Interview with Dr. Louis-Jean Calloc’h, Auditeur au Conseil National de l’Ordre des Médecins and Secrétaire-Génèral de l’Association Médicale Française and Director of International Affairs for the Chamber of Medicine of France
In France, “a ‘G-P Specialist’ is a G-P who practices and has a quite exclusive and verified good and permanent practice in general medicine. Not an other not referenced opposed verified practices: homeopathie, acupuncture, psycological-consultations. The others are simply G-P.”
Economic pressure is forcing physicians to become specialists. In the past in France you were able to go to any physician but there became restrictions on access to cost restrictions. The GP is still the gatekeeper. A patient is not allowed to go directly to a cardiologist or other specialist without using the gatekeeper function. This is a recent change.
Training is changing. In the past, it required approximately 8 or nine years of training to become a GP. It took two or three years after that to become a specialist. But now GPs are becoming specialists: I think he’s saying here that a GP can get additional training at the University to get further qualifications. It’s not clear to me the difference between GPs with a traditional training versus true specialists. It sounds like it might be that one becomes a GP specialist in cardiology and therefore sees more patience with party logic problems but they are still not true cardiologist specialists. And they still perform a gatekeeper role before the patients get to the true specialist. It sounds like the GP and the GP specialist both are in charge of handling the ministerial and medical record-keeping work in the system. Keeping the dossier, as Dr. Calloc’h says.
Dr. Calloc’h notes that patients can be put on the list, for example, of diabetics who require more advanced care. These patients can then go see an endocrinologist directly several times a year. There are limits to how many erect visits the patient can get. The idea is apparently to make the primary interface with a primary care physician can not a specialist. He specifically said that specialists such as cardiologist and endocrinologists do not perform primary care functions.
The GP is the person who interfaces with the single-payer entity. The GP also develops a care plan. This plan may specify a number of visits to a specialist. If the patient exceeds the number of visits they then have to pay out of pocket. There is a list of from 20 to 22 diseases that are specifically supposed to be managed with a plan by the GP. He gave several examples including hypertension and diabetes obesity and some others that I didn’t catch. It sounds like these patients that also signed a contract with some details of their management plan including specialist visits. Now here Dr. Calloc’h indicates that a specialists may actually act as a GP for some of these patients. He called it the “Reseau,” which is a kind of managed care contract. The réseau is a contract that the GP or specialist also signed with the single-payer and agrees to manage the patient. The Medical Society, Chambre Du Medicine, seems to be advocating for this approach, but the trade unions do not. The chamber also would rather see multiple players for more competition. It’s not clear to me what the competition would center around.
Dr. Calloc’h: “The “Assurance Maladie or CNAM” is so powerfull in France that, today, there is quite no economique competition with other public or prived medical care insurance. Only one entity to negociate with.”
Trade unions. It took a little while for me to figure this out, but the physicians have trade unions. So, when he was talking about trade unions, he was asked a talking about the physician trade unions who sound to me to be the advocates for the physicians on economic matters. As opposed to the chamber of medicine, whom he represented, who were more the professional watchdogs and ethical watchdogs. For the trade unions, the single-payer is a big problem because there is only one entity to negotiate with. This seems to be why they would like to see multiple payers.
Generally people pay the physician. Poor people get a card to excuse them from payment. If the patient is without means and has complicated multiple illnesses, apparently one has to appeal to the single-payer for credit on the card for more frequent visits etc. For the people who do pay, currently the fee is €22 but this will be rising this coming year. Interestingly, it sounds like the complexity or time of the visit is immaterial. He said a 4 or 5 minute visit gets the same fee is a more complicated visit. However the more you do, such as EKGs or blood work, the fees accumulate. He said something in here about the patient’s then getting reimbursed by the single-payer, but only about €17 for a visit. So this functionally works out to a five euro co-pay. Some patients buy supplementary insurance so that even that small co-pay is taken care of.
He makes the point that GPs are expected to be able to do everything except the most dangerous of procedures. He feels that this is asking too much and that some physicians make the mistake of being too proud and believing that they can do anything. And this is something that the chamber of medicine handles, and it’s role as what we would call a state Board of medicine. France has civil sanctions, administrative sanctions and penal [criminal?] sanctions. The Chamber of Medicine is responsible for the professional sanctioning. It is akin to a state Board of Medicine however it is run from within the profession and not from the state or national government. Complaints can come from patient to patient organizations or from other doctors. Apparently the complainants and lawyer decide whether something can be handled through sanctions or through civil law, which sounds like medical liability action. He says that he feels this is having a chilling effect particularly on young physicians who are now more worried about liability. He also indicates that this is slowing the activity of the Chamber of Medicine because of concerns with the civil liability aspect of the case. So where they might act quickly in the past they now are more circumspect and take more time to make a decision. Dr. Calloc’h feels the France is about 15 years behind where the US is regarding medical liability. He indicates that France now has lawyers who specialize in finding medical liability cases much as we have here in the US.
[Dr. Calloc’h has updated me that he thinks they have nearly caught up due to their new lawyers.]
Half of physicians in France are GPs. There are limited number of specialists. This is due to specific decisions made by the single-payer, apparently. The decision was made that too many specialist made care too costly and that this had to be stopped. Apparently the thinking was that too many doctors led to many prescriptions and too many prescriptions increased the cost of care. “So stupidly, they decided 15 years ago to make the big selection(?)”– not sure if he meant here about cutting training or something else.
And what of the most pressing concerns of physicians under the French system? The pressure of lawyers and prescription restriction. The first is obvious, the second simply refers to pressure to prescribe generics and formulary restrictions on expensive medications. And the patients are specifically asking for the newer, better medication. The single-payer keeps statistics on each physician and they know when you prescribe to many antibiotics for example. They will then send someone out to talk to you. If this keeps happening you can get an administrative sanction. This can then turn into an economic sanction where they single-payer will refuse to reimburse patients for their visits to you. Obviously this is fairly severe. It sounds like much of this takes place in the context of your position neighborhood and what others in your area are prescribing or not.
The Chamber of Medicine is apparently not allowed to advocate politically. Political advocacy therefore takes place either through the universities or the trade unions (and maybe the specialty societies?). There are trade unions for GPs and for specialists also. It sounds like you typically belong to your specialty’s trade union and its academic society.
I will keep updating this as I receive clarifications from Dr. Calloc’h.
