For several weeks, anger has been mounting among liberal doctors, first against the Social Security Financing Bill (PLFSS) 2023, adopted in early December under yet another 49.3 by the government, then against the content of the medical agreement which sets the reimbursed rates to health insurance patients with freelancers. Since yesterday and throughout the week, the Medici per il Domani collective, born outside the trade unions but supported by some of them (FMF, Isni, Young doctors, SML, UFMLS), invites operators to lower the curtain of their offices to weigh the negotiation between them and health insurance and to obtain, among other things, a revaluation of the consultancy fee. Overview of the ferment of this crisis and the impact it could have on a healthcare system that has already been under severe strain in recent weeks.
Re-evaluate the consultancy at 50 euros
This is the watchword most underlined by the Doctors for Tomorrow group: the price of the consultation set today at 25 euros would not make the profession attractive, which would largely explain the disaffection of young practitioners. The demographics of current city doctors could also raise fears of a worsening trend towards medical desertification: 36% of liberals are over 60 and 20% are over 65, according to the Doctors for Tomorrow group. An age pyramid that would not be compensated for by the reopening of the numerus clausus in recent years. “Investing in health will always be more profitable than making people sick. Our goal is not to earn a better life but to develop medical practices! » says Jérôme Marty, president of the French Union for Free Medicine.
A study by the Department of Research, Studies, Evaluation and Statistics (Drees) published in March 2021 showed that liberal practice had decreased by 15% between 2012, when liberal doctors numbered among 109,000 on French territory, and 2021 , when there were only 93,000. But is the rate set by the health insurance the main reason for this reduction in the liberal workforce? “This trend not only reflects a disaffection with exclusive liberal practice and also stems from the development of mixed establishments, combining liberal and wage-earning activities”underlined the Drees study, which above all revealed a growing aspiration towards wage labor and mixed business.
With regard to health insurance, we especially emphasize the efforts already made by the social organization to provide practitioners with comfortable working conditions. “The real price of consultancy is not 25 euros but just over 35 euros once all the elements of the remuneration of private doctors are integrated, such as the different fixed prices paid by the health insurance and the responsible treatment of a large part of their contributions social security”, points out a Cnam spokeswoman, who estimates that every attending physician receives every year “over 25,500 euros in addition to the compensation for their actions (excluding Covid vaccination)”. Doubling the consultation to 50 euros would cost the Social Security 7 billion euros, while the previous increases granted by the Social Security to the liberals had already cost 2.4 billion euros.
This call for reevaluation seems all the more difficult to hear as the incomes of general practitioners and city specialists continue to rise: according to a DREES study published in March 2022, the average operating income of private physician expenses amounts to 120,000 euros a year, after a 1.9% increase in their pay in constant euros between 2014 and 2017. In addition to the revaluation of the consultation to 50 euros, the members of Doctors for Demain want the accumulation of the reimbursement of full rate deeds and billing users of unhonored appointments.
The delegation of medical tasks
While Doctors for Tomorrow’s liberals mostly say they can delegate more administrative tasks, the government has chosen to defend the option of outsourcing more medical missions to other healthcare workers, such as advanced practice nurses (IPAs). A measure that liberal doctors see as competition and a race to the bottom. This is a point of tension with patient associations. “The interest of users requires expanding the offer of treatments and not limiting it further”, he had faced France’s Assos Santé in mid-November in the face of opposition from liberal doctors to allowing PAHs access on an experimental basis to direct exercise and first prescription.
Freedom of settlement under discussion
With the creation of a fourth year of general practice in medical practice, mainly in areas with a shortage of medical personnel, the government has rekindled the fuse of freedom of settlement by including this measure in the PLFSS 2023. Strongly against binding measures to ensure coverage territorial, the Médecins pour Demain collective for its part supports the development of incentive measures, in particular financial measures, such as the tax exemption of consultancies in areas with insufficient resources.
But could these measures really curb medical desertification? In a 2019 study on the determinants of the settlement of interns in the area, the young doctors commission of the National Council of the Order of Doctors highlighted the main criteria that push medical students to choose free practice and location: 62% of interns and 57% of substitutes cited the quality of public services as an essential factor in deciding to settle in a territory, 60% indicated a desire to be geographically close to their family. The importance of reconciling work and private life was cited as a priority by over 80% of them, and the desire for a collective practice of the profession (within a company or multidisciplinary healthcare) is also appeared a more desirable perspective than liberal practice alone (3% of interns wishing to take this route). Among the interviewees, 47% believe, however, that the issue of economic aid is little or not at all decisive.
What impact for patients?
While the epidemiological situation in France remains tense with a particularly intense co-circulation of respiratory viruses (Covid, influenza, bronchiolitis, etc.) this winter, which is already putting a strain on hospitals, the question of the impact of the doctors’ strike emerges the liberal movement on emergency services. But, by the organizers’ own admission, the movement should be less important than that of early December, when there was a 30% drop in activity by health insurance companies among general practitioners, the MG France, CSMF and Avenir Spé not having called for the closure of medical studies on their part.
“For the moment it has not had any repercussions on the hospital field”, believes Nathalie Marchand, federal health officer CGT, who says she is more concerned about the saturation situation of emergencies due to the closures of beds and the continuous bleeding of public hospital staff. “We don’t want to oppose city medicine and the hospital, but we still fear that what the government is likely to let go of the Liberals, who always get raises, is so much health insurance budget that isn’t dedicated to the public hospital,” I recommend Nathalie Marchand. “For the moment we are rather conciliatory, we are asking for more mobilizations than strikes, but the movement could harden as the end of the negotiations with the health insurance nears, at the end of February”warns Jérôme Marty.
