Doctors' organisations opposing current health insurance policy make election gains

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Since 1995, the French government and health insurance system have been actively promoting a policy of curbing health spending and improving the quality of healthcare. The results of the recent elections of representatives among independent doctors, published in June 2000, demonstrated relatively widespread hostility to the approach adopted by the government and health insurance system.

The outcome of elections to renew the Regional Independent Doctor Associations (Unions régionales des médecins libéraux, URML), which are organisations representing independent doctors (médecins libéraux) in dealings with the government and the health insurance system, were unveiled in early June 2000. Observers feared that many doctors would not vote but, although turn-out for these elections was down (see table below), it nevertheless remained high for this type of ballot.

Election results

The results of the election demonstrate a major rejection by independent doctors of the policies of the government and the health insurance system. In France, relations between independent doctors and the health insurance system are regulated by "collective agreements". In the case of general practitioners, only the French Federation of General Practitioners (Fédération Française des Médecins Généralistes, MG-France) trade union signed up to the most recent "collective agreement". Although, this union had emerged as the majority union at the the previous round of elections in 1994, with over 55% of the votes, it garnered only 31% this time around. Specialist doctors were unable to reach any collective agreement in the most recent negotiations. The College of French Specialists and Surgeons (Union collégiale des chirurgiens et spécialistes français, UCCSF), a very minor union in 1994 with 11% support, was the only one to have signed an agreement, but this was subsequently thrown out by the courts. This union also experienced a drop in support in the 2000 elections. However, the major independent doctors' union, the Confederation of French Medical Unions (Confédération des syndicats médicaux français, CSMF), which openly opposes the current policy and which is calling, in particular, for a return to the former principle of a single collective agreement covering all doctors - specialists and general practitioners alike - garnered 41% support. It thus became the largest union in the general practitioner branch and strengthened its majority in the specialist section, with 59% support. The table below gives the results of the 2000 URML elections.

Results of the 2000 and 1994 elections to Regional Independent Doctor Associations
. General practitioners Specialists
. 2000 1994 2000 1994
Turn-out (%) 54 65 52 57
Support by union (% of votes cast)
MG France 31 55 . .
UCCSF - - 7 11
CSMF 41 26 59 54
Others 28 19 34 35

Since the last URML election in 1994, relations between doctors and the government and health insurance system have undergone a major upheaval. In 1995, the "Juppé plan" (named after the then conservative Prime Minister) ushered in a major shake-up of the French health system. A major pillar of this upheaval was a restrictive health insurance spending package voted by parliament on an annual basis (FR9712184F). In 1997, the health insurance system signed a "collective agreement," covering only general practitioners, with the MG-France union, which stipulated that health professionals could be remunerated on a per-patient basis in addition to the traditional diagnosis-based payment (FR9704139F). In 1999, the major health insurance fund, the National Employed Workers' Sickness Insurance Fund (Caisse nationale d'assurance maladie des travailleurs salariés, CNAMTS), unveiled a "strategic plan" to cut health insurance spending by over FRF 60 billion over three years, of which FRF 30 billion were to be absorbed by the non-hospital-based medical sector (FR9907197F). The results of the URML elections must be interpreted against the backdrop of these reforms.

Reaction from unions and employers' associations

In the opinion of the president of the CSMF union, negotiations should be restarted and current policies should be revisited: "the government and health insurance managers have to realise that the collective bargaining policy has reached a dead end and that they have to listen to the representatives of the majority of health professionals." The head of the general practitioner branch of CSMF was even more categoric, saying that "we now have to admit failure. [The results of this election can be considered a] major rejection for three reasons. First, it is a rebuttal of current policy. Second, doctors are in favour of unity. Third, general practitioners reject any type of government-dictated healthcare."

The representative of the CGT-FO union confederation on the CNAMTS board shares this point of view and sees the outcome of the elections as "a triumph for those who in 1995 decided to fight and resist, as well as a nail in the coffin of the inevitably doomed post-1996 collective bargaining policy". In his view, "the majority coalition in the CNAMTS management body must alter its policy by convening talks with doctors' unions in an attempt to reach a single collective agreement. The health insurance fund can no longer be managed on the strength of one very minority union."

However, the president of CNAMTS, a representative of the CFDT union confederation, has a different view of the election results, stating that "those unions which ran on a very clear and strong opposition ticket either in 1994 or this time around, are those that won these elections. It would seem that those doctors who, individually, support collective bargaining relations with the social security system, systematically rebuff those unions supporting these agreements." He went on to refuse to change the current CNAMTS policy and explained that "just to draw a parallel, I would point out that a change in the majority union(s) at the SNCF workplace elections does not mean that French railways policy should also change."

Commentary

The response to the unions' and independent doctors' demand for the reconvening of negotiations by the current CNAMTS "management coalition" - made up of CFDT, CFTC and CFE-CGC representing the unions and the Movement of French Enterprises (Mouvement des entreprises de France, MEDEF) for the employers - will come against a wider, multi-faceted backdrop. CNAMTS is under pressure from two quarters - the Ministry of Employment and Solidarity and health professionals. The Minister for Employment and Solidarity, Martine Aubry, clearly stated, when the 2000 social security funding bill was voted, that for her, CNAMTS' ability to bring family doctor fees under control was a litmus test to ascertain just how the health insurance fund would perform in the whole issue of curbing health spending. Health professional spending rose more quickly than forecast during the first half of 2000. In the opinion of the CNAMTS "management coalition", opening negotiations with a union hostile to the curb-on-spending policy would weaken CNAMTS' own position in terms of the Ministry. However, taking unilateral measures to curb spending would be an outright attack on already sceptical doctors. Those nationally representative trade unions which are not part of the CNAMTS management coalition, CGT and CGT-FO, announced that the negotiations they had begun with the majority independent doctors' unions, such as CSMF, the Union of Independent Doctors (Syndicat des Médecins Libéraux, SML) and the French Doctors' Federation (Fédération des Médecins de France, FMF), were moving along and that they would be able to table an alternative proposal for a collective agreement in September 2000.

On a more general level, the URML elections took place against a backdrop of the complex issue of the "overhaul of the French industrial relations system (FR0002143F)". Given MEDEF's threat to pull out of all jointly-managed agencies, the ability of CNAMTS effectively to control health insurance spending is obviously an important test. The Ministry for Employment and Solidarity, in allotting FRF 10 billion extra to hospitals, whereas the CNAMTS strategic plan provided for FRF 30 billion in savings for this sector, has totally negated the impact of the strategic plan on the hospitals sector (FR0004156F). Any failure to reach an agreement with healthcare professionals on out-patient healthcare would have serious consequences that would reach beyond the health insurance system itself. (Pierre Volovitch, IRES)

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