Op-ed written by Philippe Leducdoctor and health journalist, originally published on the Les Echos-Le Parisien website.
Liberal doctors have been fighting for almost a century once morest what they believe to be the loss of the principles of liberal practice. The public authorities and the health insurance pay them back. The result is worrying. A particularly low consultation fee and public health that is going down the drain. The situation is tense in the face of the exasperation of citizens and elected officials. The trap closes. How to get out?
It has been going on for nearly a century. The law of April 5, 1928 created health insurance for all employees. It is supplemented by the law of April 30, 1930. “Social insurance covers the risks of illness, premature invalidity, old age, death and includes participation in family expenses, maternity and involuntary unemployment due to lack of work. »
“All employees of both sexes whose total annual remuneration, whatever its nature, excluding family allowances, does not exceed 18,000 F, are compulsorily affiliated to social insurance.
This is a real turning point for the French and also for liberal doctors. The Funds begin to negotiate medical rates and intervene in fact in the activity of city practitioners. These rear up, get together and unionize to defend the liberal exercise: freedom to choose its practitioner, freedom to fix the tariffs and direct payment, freedom of prescription, freedom of installation.
Since then, it’s been a kind of guerrilla warfare. The Executive has, during the previous century, strengthened its influence. The Liberals have increased their power to block (or harm, some would say). The acme intervenes with the Juppé plan of 1995 fought by city practitioners, who would have caused the ruling party to lose the 1997 legislative elections. Later Roseline Bachelot will be exfiltrated because of her bad relations with the liberals. Similarly Marisol Touraine, wanting to establish the third-party payment and the control over feeswill be harmed.
Faced with this opposition, the Health Insurance and the public authorities react and construct many safeguards which complicate the organization of the liberals: fixed price, control, incentive pricing, supervision of overruns of fees, etc. The freedom to set the price of the consultation no longer exists. Neither does the prescription one. There remains the free choice of his doctor and the freedom of installation.
At one time (or almost) the doctors (some) and the public authorities met. To reduce the “medical plethora” and establish the closed number in 1971 at theentrance to medical studies. The former to limit competition, the latter to control health expenditure. Today we are paying the consequences harshly.
No one is satisfied
Result: no one is satisfied.
Nor the doctors who feel, as they say on the banners of the demonstration of last February 14 in Paris, “despised” and “humiliated”, astonishingly shifting the debate towards affect. Because they are sincere. They live badly this situation which escapes them. Beyond the tariff demands, they do not manage, fed as they are to the liberal (in the medical sense of the term), to project themselves into a new world. And yet the current system is leaking from all sides. The old people are exhausted. Young people increasingly prefer wage employment, decent hours and teamwork.
Neither Health Insurance nor the public authorities who are unable to meet the needs of the French.
Neither the elected officials, stuck between the two, who are trying somehow to close the gaps.
Nor of course the French, even if the patients, worried regarding the degradation of the health systemkeep a important mark of esteem for doctorswhether liberal or hospitable.
Certainly, considering the liberal medical profession as a homogeneous whole would be a mistake. Both by the difference in remuneration (from 60,000 euros to almost 300,000 euros), and by the methods of exercise (from the essentially clinical generalist to the specialist who handles sophisticated technology). But the liberal spirit is widely shared.
The circle is complete
Faced with this blocked situation, the trap closes. The public authorities have decided to no longer compromise in the face of the gap that separates them from practitioners, but to now respond above all to the demands of patients. With a lever that usually works well here as elsewhere: financial leverage.
The President of the Republic said this very clearly on January 6 during his wishes to health actors by distinguishing between “doctors who are exhausted” and those who are not playing the game. end to a divergence that has set in… we need to better reward, better incentivize those who want to work together”.
The Minister of Health and Prevention, on January 30, also insisted on theengagement territorial just like the Minister of Territorial Organization and Health Professions on the Territorial Pact. And finally the Director General of Health Insurance negotiates the ” Territorial commitment contract » with the liberal doctors within the framework of the renewal of the Convention which binds them with this one. Even if it means dividing up the medical offer a little more, the contract having to be individual. The circle is complete.
The trap initiated almost a century ago and maintained in a vacuum is closing in on liberal doctors who have failed to create the conditions for a constructive dialogue with the public authorities and the Health Insurance by not taking enough convincingly takes into account the difficulties of access to care, medical deserts, excessive overruns of fees, the relevance and quality of care, prevention, the population approach in a territory.
What future
It would be a shame if in ten years, liberal doctors would be reduced to the bare minimum. Their responsiveness in case ofepidemic, their availability, their expertise, their creativity, their love of their job are precious assets. Is there still time to renew the threads of dialogue?
The liberal doctors would be well advised not to shut themselves up in concepts from another time and to prop themselves up on considerations of “humiliation” or “contempt” but to say how concretely they propose to respond to the difficulties of French in terms of health.
It is up to them to take the initiative. They have more interest in it than the public authorities. The French too.
Philippe Leduc hosts and directs the Health Economics Think Tankdeveloped by Les Echos Le Parisien Evénements.
