French general practitioners have been refusing to perform on-call duty since 15 November 2001. Their action is aimed at obtaining a major increase in the fees for consultations with patients. In negotiations between doctors' trade unions and the sickness insurance funds, which began in January 2002, the key issues are the size of any increase in fees, and whether this rise should be awarded across the board or targeted on specific care.
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French general practitioners have been refusing to perform on-call duty since 15 November 2001. Their action is aimed at obtaining a major increase in the fees for consultations with patients. In negotiations between doctors' trade unions and the sickness insurance funds, which began in January 2002, the key issues are the size of any increase in fees, and whether this rise should be awarded across the board or targeted on specific care.
Independent doctors in general practice are currently seeking a major increase in the unit value of care provided to patients. The members of the National Union of French General Practitioners (Union nationale des omnipraticiens de France, UNOF) - the general practitioner affiliate of the Confederation of French Doctors' Unions (Confédération des syndicats médicaux français, CSMF), France's largest organisations of independent doctors - bases its demands on the fact that the unit value of care dispensed has not been revised for several years. UNOF is thus taking advantage of the introduction of the euro from January 2002 to demand an increase in the consultation fee (where patients visit doctors' surgeries) from EUR 17.53 to EUR 20. It is also demanding that the fee for home visits (where doctors visit patients in their own home) be increased from EUR 20.58 to EUR 30.
In an attempt to obtain this increase, UNOF successfully called on general practitioners to stop all night and weekend on-call duty from 15 November 2001 - an action which continues at the time of writing (mid-January 2002). The union has stressed that doctors are not trying to 'earn more but rather to work more effectively'. It has also suggested that sickness insurance should cover only 'medically-justified home visits'. At the outset of the dispute, UNOF estimated that the increases it was demanding would cost the sickness insurance fund EUR 300 million.
In mid-December 2001, in the wake of the collapse of talks over fees with the sickness insurance funds, the other general practitioner trade union, the French Federation of General Practitioners (Fédération Française des Médecins Généralistes, MG-France), joined the protest movement with its own specific approach. In particular, one of its demands was for doctors' consultation fees to be increased to EUR 18.5.
Problems for sickness insurance funds
In France, there are three national sickness funds: the National Employed Workers' Insurance Fund (Caisse Nationale d'Assurance maladie des travailleurs salariés, CNAMTS), which covers the majority of employed workers; the Agriculture Welfare Mutual Society (Mutualité Sociale Agricole, MSA), which covers the agricultural sector; and a special scheme for shopkeepers and craftworkers. CNAMTS is the largest of these three funds and, as such, is responsible for leading negotiations with doctors.
The demands of the independent doctors create two main problems for the funds, in particular, the CNAMTS. The fund has to figure out what the link between the value of doctor-dispensed care and the volume of care dispensed will be. It also has to grapple with the issue of whether an across-the-board increase in consultation fees should be granted, or targeted rises aimed at fostering the development of specific practices.
The previous agreements between the sickness insurance funds and independent doctors covered only care fees and not the volume of care dispensed. This raises questions such as: Do low care fees encourage doctors to dispense a high volume of care, thus leading to poorer quality care? and If care fees were increased, would doctors be prepared to make commitments on volume and quality?
For the past few years, the CNAMTS has been implementing a policy based on differentiating payment methods for doctors. This policy was designed to develop payments tied to public health goals and to boost specific types of care dispensed. Starting in 1999, the fund increased the fees paid for specific types of care, including emergency and geriatric services. In light of UNOF's demands, the fund has indicated its willingness to commit itself to a 'multi-year plan to increase fees for independent general practitioners'. Under this plan, it has pledged to inject EUR 600 million. The fee-increase measures envisaged by the CNAMTS are based on a policy of differentiation between 'commonplace' and 'more complex' consultations. These two areas would see different increases in doctors' fees. The measures are also based on the creation of or increase in lump-sum fees for on-call and emergency room duty, as well as financial assistance for doctors setting up a new practice.
Difficult dialogue between doctors and funds
Recent talks over agreements between doctors and sickness insurance funds have not always been easy. Since 1995, the CNAMTS has succeeded only in reaching agreements with minority trade unions. Much of the latest agreement was annulled by the Council of State (Conseil d'Etat).
In spring 2001, four of the trade unions sitting on the board of the CNAMTS - the General Confederation of Labour (Confédération générale du travail, CGT), the French Democratic Confederation of Labour, the General Confederation of Labour-Force ouvrière (Confédération générale du travail-Force ouvrière, CGT-FO), the French Christian Workers' Confederation (Confédération française des travailleurs chrétiens, CFTC) and the French Confederation of Professional and Managerial Staff-General Confederation of Professional and Managerial Staff (Confédération française de l'encadrement-Confédération générale des cadres, CFE-CGC) - and three doctors' organisations, including UNOF, set up the 'Group of seven' (G7). This group demanded the reconvening of talks over a new agreement between funds and doctors, based on a major increase in doctors' fees (FR0105157F).
The French Democratic Confederation of Labour (Confédération française démocratique du travail, CFDT) has chaired the CNAMTS since 1996 on the basis of a 'managing majority' made up of itself, CFE-CGC, CFTC and the Movement of French Enterprises (Mouvement des entreprises de France, MEDEF). The creation of the G7 was an initial factor leading to the weakening of this majority. This was compounded by MEDEF's withdrawal from the boards of social security funds in summer 2001 (FR0107167N). However, in the recent elections of the chairs of social security fund boards, CFDT succeeded in holding on to the the chair of the CNAMTS and managed to boost its representation on regional and département-level sickness insurance bodies (FR0111104N).
It was against this backdrop that talks took place on 10 January 2002 between, on the one side, UNOF and MG France and, on the other, CNAMTS and the other sickness insurance schemes.
In the negotiations, those trade unions which are members of the G7 were in favour of increasing fees for care dispensed. Consequently, in the opinion of CGT-FO, 'a comprehensive review of the agreement system, based on an immediate increase in general practitioner consultation and medical visit fees, is required.' In the view of CGT, 'a complete shake-up of the health and social security system and - by extension – an overhaul of agreements with doctors' is called for.
Following the first day of talks, UNOF stated that the CNAMTS proposals on fee increases were unacceptable. It also announced that it would be pulling out of the negotiations. The union asserted that it was quite prepared to discuss all the issues but that this would only be possible once fees for dispensed care had been increased across the board. It said that 'the fire had to be put out before the house could be rebuilt.'
A second round of negotiations was held with MG France on 15 January 2002. These talks led to an 'agreement in principle', which endorsed the principle of variable increases based on the type of care dispensed. Working groups will be responsible for working out the concrete figures relating to these increases. Their results were expected in late January 2002.
Commentary
What does the future hold for the dispute? Some doctors are already charging a fee of EUR 20 per consultation without any explicit approval from the doctors' unions. While the threat of the possible breakdown of the agreement system- whereby doctors would break off all ties with the sickness insurance funds – that is being mooted by UNOF, is highly unlikely since it would have serious repercussions, the potential development of unfettered fees is a possibility. Patients themselves would be hardest hit by such an approach since the 'extra' charge would not be covered by social security.
Independent doctors have long asserted that they reject 'accounting-based' restraint (based on purely money-related criteria) in favour of 'care-based' restraint based on patient needs. At the beginning of the dispute, Jean-Marie Spaeth, the CFDT chair of the CNAMTS, asked whether the increase in consultation fees to EUR 20 was 'accounting-' or 'care'-oriented ?
While the average earnings of a general practitioner are known to stand at EUR 51,000 a year, there are major disparities between them. The fact that healthcare trade unions – which are weak and scattered - have pushed the issue of care fees, shows that they are unable to deal outright with the fundamental issue of healthcare professional salaries. (Pierre Volovitch, IRES)
Eurofound recommends citing this publication in the following way.
Eurofound (2002), General practitioners take industrial action, article.
