“I think it will be more than… five years that I have not had a doctor”. Five years that Chloé*, 26 years old, wanders from practitioner to practitioner. She seems to be the first surprised. “I did not change general practitioner when I arrived in Paris for my studies, she recalls. And when my family doctor retired, I admit that I did not try to find another.” Why ? The young woman, who gladly laughs at her “administrative phobia”, especially ensures that she is “never sick”. Never, except a few times. “Of course it could have played tricks on me,” she admits.
Like most recently when, after being declared positive for Covid, she had to wait two days before being able to obtain a consultation with a practitioner. “I ended up finding an appointment in Val-d’Oise … by videoconference!” she exclaims. Or this moment when, last year, she ended up turning to SOS Médecins, the home medical service. “It was for an emergency, and I paid the price.” Assessment of the races for this consultation at home: 60 euros, against 25 euros, the usual price of an office consultation with a doctor. “I found it a bit expensive. I don’t have a precise amount, but I know that I haven’t been reimbursed in full,” breathes Chloé.
The quest for the attending physician
This is normal: in the office as for a home consultation, the reimbursement of health insurance usually amounts to 70% of the basic rate (i.e. 16.50 euros out of 25). But only when the visit is carried out by the attending physician. If the person consults a practitioner outside of their “care pathway”, they are only reimbursed up to 30% (i.e. 6.50 euros) by Social Security. An additional cost that is not covered by mutuals either. Chloe pauses, visibly disappointed. “So I’m probably less well reimbursed than I thought for all these years,” she concludes. At the time when the reimbursement of health costs was invited into the debate between vaccinated and non-vaccinated, a category of population is today less well reimbursed than the rest of the French: those who do not have a doctor. According to estimates, between 5 and 9 million people would be affected in the territory.
Chloé is therefore not alone, far from it. Ophélie, 26, did not have a doctor for several years either. “I moved from my parents, I went to another country… and when I came back to France, I had nothing left: no doctor, no health insurance.” Once back in France, the young woman put off her search for a long time, discouraged. “It was complicated. Many doctors do not take new patients or even refuse to see those who are not in their practice. So I waited.” Young, without a medical address, Ophélie postpones her visits to a practitioner. “As I didn’t have a doctor, it was a little more expensive, she recalls. If it’s a one-time thing, we could say too bad, it’s not much. But I had a problem which meant that I had to go back to see my GP for regular monitoring. Faced with this medical problem that she was silent about but described as “not urgent”, Ophélie postponed her care until later. “It was the same for the other specialists,” she says.
End of the family doctor
The lower reimbursement does not only concern visits to general practitioners: not having an attending physician also penalizes consultations with other practitioners, such as dentists. Your reimbursement rate thus drops from 70% to 30%. Ophelie will finally take care of her problem only a few months later, once a doctor and complementary health insurance have been found. “The fact of no longer having this obstacle, both practical and financial, allowed me to take stock. I finally consulted for things that I had left lying around that I should have taken care of. much earlier, and which would perhaps have had less serious consequences on my health”, she believes.
Until 1998, patient-doctor relations were governed by the charter of liberal medicine proclaimed at the end of the 1920s. Freedom of choice of practitioner, freedom of prescription… The profession imposed its liberal identity for a good part of the 20th century, until the principle of the referring physician was introduced. The goal is then to enhance the role of general practitioners with their patients, while the principle of the family doctor, omnipresent sometimes over several generations, is running out of steam. In 2005, the reform of the attending physician generalized this time the course of care, introducing “a principle of hierarchization of access to the care system, explains Julien Mousquès, researcher at the Institute for Research and Documentation in Health Economics, to Doctor’s Daily. This is an important turning point since it potentially places the practices of general practitioners in a population logic.
Consumer choice rather than coercion
The 2005 reform places the general practitioner at the center of the care pathway: he is the one who must be seen in order to be redirected or not to a specialist – with the exception of gynecologists, ophthalmologists, dental surgeons or stomatologists, you can go to consult directly while being reimbursed normally. “The objective was to give the attending physician the role of guardian at the entrance to the health system, so that he could direct the patient as well as possible”, specifies Jean-Paul Domin, lecturer in economics at the university. of Reims Champagne-Ardenne and health economist. A way to streamline health insurance. “The reform was also made to limit the overconsumption of care, to save money, points out Marine Crest, general practitioner. The initial idea was good, but we can regret today that some patients want to see general practitioners only in order to to be referred to a specialist.
However, the system pushes patients in this direction: when a patient goes to see a specialist without a letter from his attending physician, his reimbursement rate again drops from 70% to 30%. The same applies if he chooses to see a general practitioner other than his referring practitioner. “We have attached to this reform an incentive device at the financial level, to encourage the patient to respect the course of care”, deciphers Jean-Paul Domin. The High Council for the future of health insurance did not say anything else at the time of the adoption of the reform. This “system is therefore based on the consumer’s choice rather than constraint: we can choose to keep total freedom of movement in the healthcare system, but we pay for this absence of constraint. It is undoubtedly, given the habits , of the value attached to the freedom of choice, the only way possible in the French context”, he wrote.
Retirements
The goal was then clearly to empower the French in their course of care. “But this system remains fairly poorly controlled, especially in regions like Île-de-France where the number of specialists is not lacking, believes Jean-Paul Hamon, general practitioner and honorary president of the Federation of Doctors of France. I saw disease sheets where the specialist had written ‘sent by doctor Hamon’, when I know very well that I had not sent this person to him”, he assures. A circumvention strategy that Paul *, in his thirties, knows well. “If I need to go see a specialist, I will ask friends if they know practitioners with specific prices, which will allow me to pay less,” explains the young man, who says he no longer has any attending physician for three years. “My former general practitioner retired and gave me another address, he says. But this doctor had no more room, and after having made attempts with a dozen other practitioners, I gave up.”
In good health, Paul believes he can afford this absence of a attending physician. But if he is not one of the people launched in a frantic search for general practitioners, his experience raises a pitfall experienced by more and more French people: finding a referent practitioner when his good old family doctor retires. In an interview conducted in January 2020 in the professional journal The Generalist, Nicolas Revel, Director General of the National Health Insurance Fund, argues that “more than half of our fellow citizens without a doctor are in real search of a regular practitioner, often because they have not been able to find one at the time of the retirement of their GP”.
The “double jeopardy”
A situation that is not going to improve: according to the population projections of the Department of Research, Studies, Evaluation and Statistics (DREES), the number of general practitioners should continue to decline until 2026, before rising again in 2030. “The new generations of doctors will only arrive not on the ground for a few years. By then, we will spend ten very difficult years, “confided to L’Express Elisabeth Hubert, former Minister of Public Health and Health Insurance. A state of affairs that risks affecting the less well-off, while poor people are “three times more likely to give up care than others”, according to a study of the Drees. “French people do not visit a general practitioner, in particular because they are in medical deserts or white areas, and they therefore have less good access to care. In addition, they are penalized financially. It’s a bit double punishment”, regrets Jean-Paul Domin.
However, solutions do exist. “Health insurance is careful not to penalize patients,” says Dr. Jacques Battistoni, president of the union of general practitioners MG France. Faced with the shortage of doctors, the National Health Insurance Fund has recently set up a system so that patients who have lost their doctor, or are looking for one, “are identified and their consultation is well reimbursed without application of penalties”, indicated Nicolas Revel in his interview with Generalist. This reimbursement amount of 70% rises to 100% for people with long-term illness or pregnant women. A way to stop the bleeding. “Other solutions exist, such as allowing the attending physician to have staff around him, from the secretary to the medical assistant, or even nurses, list Jacques Battistoni. It can help to share part of the load and patient follow-up. A way for GPs to have more time to provide care. And to allow more French people to finally find a general practitioner.