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. “We must undoubtedly go more towards remuneration, what we call capitation, …, rather than the isolated act, that’s the right method” declared Emmanuel Macron, during his show on 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, to become an aberration and to be able to disappear by January 2022.
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 that 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 queues abroad (Italy, Germany, Great Britain): you have to know what you want,” observes another. “Liberal doctors insist more than anything on fee-for-service payment…he can keep his performance-based payment and his capitation, we will never accept it,” fumes a rheumatologist.
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 of access to 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 an upgrading of the medical procedure taking into account its complexity and an enhancement of the treating physician package. For Agnes Giannotti, president of MG France, there is nothing new. “The president has said that 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”.
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 the remuneration of doctors, in order to guide their practice and encourage them to respect a whole list of indicators. There are mainly three packages:
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 a “nationalization” of medicine.
