Quelles solutions pour la garde en médecine générale? - KCE

120
8.4.4. After-hhours
care in Frrance
Items
Expert(s) interviewwed
Emgan QUERRELLOU
Isabelle Aubin-Auger
(Secrétaire générale
CNGE; i.aubin@cnge.fr)
Literature base
National and international publications
on the topic of aftter-hours
care in Francce
Characteristics off
the Population off
63.8 million in metrop politan France
health system with
France has a social insurance syst tem financed by emplooyer–employee
payrolll
taxes and central taxxes.
relevance to after-
2007: total exxpenditure
on health in n France was estimateed
at €208 billion or 111%
of gross domestic product (GDP), of whhich
79% is publicly funnded.
hours services
Expenditure oon
personal health care
accounted for 88% of total expenditure oon
health and represennts
an average of €28995
per person.
Statutory insuurance
covers all resid dents for hospital and ambulatory care, presscription
drugs, and, too
a lesser extent, denttal
and optometry caree.
Cost-sharing requirements apply to o all publicly covered sservices,
although these
are waived for patients
with any of 30 chhronic
diseases.
Roughly ninee
of 10 residents have complementary privaate
insurance that coveers
most cost-sharing charges under the puublic
system; they eithher
obtain
this insurancee
themselves (usually through employment) ) or, if they have low inncome,
have it provideed
by the government.
Since 2000: in order to ensure tha at measures increasinng
patients’ co-insurannce
would not increasse
social inequities in access, public compleementary
insurance (coomplementary
univers sal health coverage ( (couverture maladie uuniverselle
complémeentaire,
CMU-C)) is offfered
on a voluntaryy
basis to
lower socioecconomic
groups. It cov vers 7% of the population.
Ambulatory ccare
is provided mostly
by self-employed pphysicians
paid fee-forr-service.
Tariffs are nnegotiated
in pluri-annnual
agreements betwween
SHI
and represenntatives
of health profe essionals.
Since 2004: rregistration
with prima ary care physicians whho
act as gatekeeperss
has been encourageed
through higher coppayments
for self-referrrals,
and
roughly 90 peercent
of the populatio on is now registered.
A further primmary
care reform has been the 2009 introduuction
of pay-for-perfoormance,
with GPs abble
to earn up to €5,0000
for achieving qualitty
targets
on preventionn,
chronic disease management,
and drug pprescriptions.
Responsibilityy
for capacity planning
is shared by the central
and the regional level. At the regionall
level, the ARSs weree
implemented in Apriil
2010 to
coordinate ambulatory
and hospit tal care and health aand
social care for the
elderly and disabbled
through a regionnal
strategic health plan
(plan
stratégique réégional
de santé; PRS S) that is based on population
needs. Each sector’s planning proccess
will have to comply
with the PRS. Thiss
is a first
attempt at reggional
planning of the ambulatory care sectoor.
Quality of carre
is regulated at the national n level.
122 500 self--employed
GPs (2009)
Most French patients have chosen a preferred doctor (855%
in 2008) which is aalmost
always a GP (mmore
than 99%).
40% of self-eemployed
physicians are a involved in group practices. Physicianss
involved in group praactice
never share a common patient list bbut
aim to
ensure continnuity
of care (through shared s electronic recoords)
and mutualize exxtensive
capital investtments.
Situation before After-hours care
was historically or rganized by the local ccentre
of the Physicianns
Association, which scheduled on-call rouunds.
reform
Drivers for systemm
- Self-employyed
GPs, whose numb ber is scarce in certainn
areas and whose woorkload
was increasingg,
became increasinglly
reluctant to participaate
in the
reform on after-hoours
rota system.
care
- Hospital emmergency
departments s dealt with an increaasing
workload. The ooverload
of these deppartments
has been reelated
to the lack of aaccess
to
primary care ambulatory services as a well as to a lack of available hospital bedds
for emergency admissions.
System reform sinnce
and type of reformm
Affter-Hours
Primaary
Care
Resullts
Remark: Theere
is widespread conc cern in France about tthe
excessive use of tthe
SAMU in circumsttances
that prove not tto
be warranted.
In thheory,
if a
patient calls oout
the SAMU and it proves p not to be a real emergency, the doctoor
or hospital receivingg
the patient may be uunwilling
to sign off a ttreatment
certificate, ass
a result of which the patient will be expecteed
to pay the costs.
Between 20003
and 2005:
Developmentt
of ambulatory care centres (les maisonss
médicales de garde;
MMG) that are acccessible
during nightts
and weekends, in order to
guarantee coontinuity
of access to care. c This attempt hass
been only partly succcessful,
mainly becauuse
of difficulties in hiring
physicians for nigght
shifts.
KCE Reportss
171