Elsevier

Health Policy

Volume 94, Issue 2, February 2010, Pages 129-134
Health Policy

The preferred doctor scheme: A political reading of a French experiment of Gate-keeping

https://doi.org/10.1016/j.healthpol.2009.09.001Get rights and content

Abstract

Objectives

Since 2006 France experiences an innovative version of Gate-keeping which aims at regulating access to outpatient specialist care. We describe the reform's initial objectives, the political pathway which lead to the implementation of a reshaped reform and discuss the first outcomes after 1 year implementation. In the conclusion, we try to catch a glimpse for future steps of the reform.

Methods

In order to observe the implantation and impact on the reform, we used national sickness fund databases and a sample of 7198 individuals from the 2006 French Health, Health Care and Insurance Survey (ESPS), including health, socio-economic and insurance status, questions relating to patient's understanding and compliance with the scheme, self-assessed unmet specialist needs since the reform.

Results and discussion

2006 results show that 94% chose a preferred doctor, in a vast majority their family doctor. Impact on access to specialist care appears significant for the less well off and those not covered by a complementary insurance. From the specialist's side, new constraints on access to care seem to have been offset by rises in fee schedules.

Conclusion

Notwithstanding disappointing short terms results, the new scheme may however lead up to reinforced managed care reforms.

Section snippets

Paper objectives

Like most developed countries, France confronts escalating health costs driven by the intensive use of technology and growing consumption of services. Regulators must contend with inefficiencies in the organization, provision, and delivery of services as well as problematic financial incentives for health professionals and consumers. Although the evidence base is far from clear, advocates of Gate-keeping (GK) have promoted it as a powerful tool that regulates both the demand and supply sides so

Political context: an earlier reform

Gate-keeping has spurred intense debate in France since the early 1990s. Various experts and policymakers endorsed it, but the majority of the politically powerful specialist unions were opposed. Finally, in 1998, a first attempt at GK – the “referring doctor” approach – won the support of both the NSF and “MG France,” a union of GPs with a social democratic orientation, which thought the innovation important to its broader aim to enhance the political status of GPs in relation to specialists.

On the demand side

As of June 2007, 81% of patients had signed a contract with a PD, 99% of which were GPs [14]. Formally the scheme was not compulsory, but 81% of the sample thought that it was and offered this as by far the main reason for participating. The second most common reason for contracting, consistent with the first one, was fear of financial penalties (44%). Only 31% said they had joined because doing so would generate savings for the NSF, a mere 16% declared that they expected their participation to

The preferred doctor scheme: political success, economic failure?

Economist Jamie Robinson wrote that in the United States managed care was an economic success but a political failure. The PD scheme in France, we argue, is the reverse, namely, a short term political success, but (at least so far) an economic failure.

Acknowledgments

The authors wish to thank L. D. Brown (University of Columbia), T. C. Ricketts (University of North Carolina) and G. Bevan (London school of economics and political science) for their precious suggestions and remarks.

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