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168 Health systems in transition France that did not counterbalance the negative issues faced by doctors choosing to live in areas that may be less attractive in terms of schooling for children, job opportunities for spouses, and so on. Alternatives to financial incentives: quality of life, new practice models and task transfer Innovation in regard to addressing geographical disparities has come from local policy-makers, who face tremendous pressure to find solutions to this critical situation. Local initiatives focused on improving the workplace quality of life of doctors, rather than providing financial incentives, have flourished. Such initiatives include providing practice structures so that doctors are not faced with the high start up costs in establishing their practices; offering the opportunity to work in group practices connected with other health professionals and so eliminate the need to find replacement cover when they go on holiday, which is often a problem for solo practitioners; paying doctors fixed salaries in lieu of the traditional FFS arrangement; and covering their liability risk. Other initiatives to address medical deserts focus on new methods of health care organization that redistribute the role of different health care professionals and improve their coordination or efficiency in order to decrease the need for some categories of professionals and thus ameliorate accessibility problems. Experimentation with task transfer between professionals was permitted from 2004 and some such transfers have already taken place (e.g. between ophthalmologists and vision therapists). In 2008, a recommendation regarding the professional skill mix between doctors and other health care professionals was issued by HAS and the National Observatory of Health Professions. The proposed changes included a transfer of certain tasks from physicians to other health care professionals, an improvement in the education and training of nurses and a regulatory and financial framework for developing cooperation. In 2009, the transfer of tasks and cooperation between categories of health professionals was further encouraged, with protocols of cooperation being provided under the supervision of the ARS. Health professionals may design their own protocol or join an existing protocol that defines the nature of the cooperation, the services involved and the place and scope of the professionals’ interventions. Task transfer has developed more slowly than expected for two main reasons. First, there is opposition to task transfer because physicians are paid on a FFS basis and so a reduction in the tasks for which they have a monopoly reduces their revenue potential. Second, this approach also raises a question of logistics: in the same zones in which an insufficient supply of physicians is found, there are also fewer nurses and other health professionals to perform the transferred tasks.
Health systems in transition France 169 The use of information technologies was also perceived as a tool to reduce the need for health professionals, and the implementation of tele-health has been encouraged since 2010. Tele-health solutions have been developed mainly by the ARSs with the strong support of the Ministry in charge of Health, which announced a national strategy for telemedicine, including a methodological guide and recommendations on developing telemedicine projects (Ministry in charge of Health, 2012). The ARSs have a specific budget to develop these projects (€15 million in 2013), and since 2012, eight pilot projects have been financed and monitored in order to better understand the factors facilitating or limiting the development of telemedicine, to test financing models and to produce practice guideline. By the end of 2011, there were 256 telemedicine projects in France. While there is great enthusiasm for the possibilities of telemedicine to address access problems in underserved areas, it is too early to say whether it can live up to this promise. SHI is studying the financing options, with a particular focus on fixed-price reimbursements. The HAS has developed a framework for undertaking health economic evaluations of telemedicine projects. Following the change of government in 2012, medical deserts once again became a priority on the political agenda, and in December 2012, the Minister in charge of Health presented the “Pact on Health Territories” (Le Pacte Territoires- Santé), which repackaged a number of previously announced measures rather than developing innovative measures. The 12 proposed measures focused on the training and practice establishment of young physicians, the development of alternative practice settings, and targeted goals and practice adaptations for isolated areas. To date, several measures have been implemented: • a designated person in each ARS to facilitate the establishment of practices by new doctors; and • experimentation with new methods of remuneration for multidisciplinary teams of health professionals until 1 January 2015 as a precursor to a new agreement (subject to arbitration in the event no agreement can be reached). Finally, the proposed Health Law (see section 6.2) includes measures to reduce geographic disparities, including interim medical personnel and a corps of substitute professionals and new modes of cooperation between health professionals.
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Contents Contents Preface
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Preface Preface The Health Systems
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Acknowledgements Acknowledgements T
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List of tables, figures and boxes L
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Abstract Abstract This analysis of
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1. Introduction 1. Introduction The
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3. Financing 3. Financing Health ca
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