2023-12-21 13:40:46
Emmanuel Macron was the guest of the show “C à vous”, Wednesday evening on France 5. LUDOVIC MARIN / AFP
The Head of State assured Wednesday evening on France 5 that it was necessary to move towards remuneration of doctors “at the capitation, …, rather than at the isolated act”. A statement that strongly reacts to professionals.
After the resounding resignation of the Minister of Health Aurélien Rousseau opposed to the tightening of state medical aid (AME), new excitement among doctors Wednesday evening listening to Emmanuel Macron on France 5. While they are currently in full negotiations with Health Insurance on the price of the consultation, the president indicated that he wanted to put an end to payment by service and favor flat-rate remuneration. “ It is undoubtedly necessary to go more towards remuneration, what we call capitation, etc., rather than the isolated act, that is the right method. » declared Emmanuel Macron, during his show Wednesday evening on France 5. A sentence which is reminiscent of the President’s words, already in 2018, during the presentation of his health plan: “I want isolated exercise to gradually become marginal, become an aberration and be able to disappear by January 2022».
Strong reactions
In the midst of conventional negotiations, resumed in October after the failure of a first round last March, the President’s comments reignited the situation. “Emmanuel Macron wants a liberal medicine system with capitation. That is to say, doctors will be encouraged to follow even more patients, therefore with less time per patient.», laments Rudy Vannobel, general practitioner in Avranches. “Hold the poll tax! Always closer to the English NHS system, which has proven all its flaws and excesses», Reacts a general practitioner. “Capitation leads to degraded consultations and an increase in active files abroad (Italy, Germany, Great Britain): you have to know what you want», observes another. “Capitation in the morning and traditional medicine in the afternoon, Spanish style. Dispensary then real medicine», quips the town doctor ironically. “Liberal doctors care more than anything about fee-for-service payment…he can keep his performance-based payment and his capitation, we will never accept it“, fumes a rheumatologist.
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On the side of medical unions, the reactions confirm those of field doctors. “Hearing the president announce that capitation is the future is very surprising when we know the enormous difficulties in accessing care in England, which has made capitation the basis of its care model.says Franck Devulder, president of the CSMF. The attractiveness of private medicine requires a revaluation of the medical procedure taking into account its complexity and a valorization of the treating physician package.“. For Agnes Giannotti, president of MG France, there is nothing new. “The president has said this every time he speaks on the subject for two years”, she notes. For Sophie Bauer, president of the SML, this scenario “could only worsen the situation of access to care».
A fundamental principle of the profession
Because although the subject may seem technical, it constitutes a profound modification of the current model of liberal medicine. Since the 19th century, French private doctors have been paid on a fee-for-service basis. They vigorously defended this method of remuneration against attempts, particularly those of mutual societies, to introduce fixed-price or subscription formulas, what the President calls capitation. In the 1927 charter, they made direct payment for services between patient and doctor a fundamental principle of the profession. City doctors thus want to remain liberal entrepreneurs and refuse a nationalization of medicine which would transform them into civil servants.
But for several years, public authorities have introduced fixed rates into doctors’ remuneration, in order to guide their practice and encourage them to respect a whole list of indicators. There are mainly three packages:
Remuneration based on public health objectives (Rosp), a sort of annual bonus granted to promote good practices (systematic screening, prevention, limitation of the number of boxes of medicines, etc.), amounted on average to 5,113 euros per general practitioner and 1,837 euros per specialist in 2022. The “structure» (4,044 euros on average in 2022) is granted depending on the organization and computerization of the medical office (software, prescription assistance, electronic care sheets, secure messaging, etc.). As for the package “treating doctor patient» (€2,759 on average in 2022), it pays for the overall care of patients on the administrative and coordination levels.
But the packages, complex with long lists of indicators to complete, are sources of paperwork and loss of administrative time. Above all, they are in the hands of public authorities who can modify them at any time, which is why doctors are wary of them and see it as a step towards “nationalization» of medicine.
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