By Jules Morel. Originally published on 2012/12/15

While protests and demonstrations have never been unusual in France, one currently taking place might just be standing out. As of November 12th, French doctors in clinics have engaged in an illimitable strike to express their anger against the healthcare reform concerning top-up medical fees (les “dépassements d’honoraires”) in sector 2, signed on October 25th.  Many surgeons have since refused to perform any more surgeries until an agreement can be reached, while some med school interns are also refusing to work anymore. Protests and marches have been initiated all around the country, affecting more than 70% of the French healthcare facilities.

Clearly this is a complex issue that involves numerous actors, and very often it is insufficiently explained by the media. Therefore it might be worthwhile to unfold its complexity and break down the variables before drawing a formal opinion;  the stakes might be different from what they seem.

Context and facts

 In France the medical sector is divided into two main categories: public and private. The first encompasses hospitals and every other healthcare institution financed by the state, where doctors are salaried and work a predetermined amount of hours per week. The second refers to clinics, where doctors are liberal workers, remunerated according to the amount of work they put in the job. It is very important to note these are entrepreneurs in the full extent of the word, taking on high levels of debt in order to have the right to establish themselves in a city and build a clientele (“patientele” in this case).

In order to prevent a brain drain to the private sector however, the French State has granted the public doctors the possibility to devote 20% of their time to liberal practice, either qualified as “sector 1” or “sector 2”. In this situation, hospital doctors can round off their revenues by earning payments proportional to the number of patients they take in. On the other hand, full-time liberal doctors (doctors in clinic) have the choice to declare their activity as either sector 1 or 2.

Sector 1 stipulates that the practitioner must comply with a “price nomenclature of medical acts”, which he cannot transgress to demand more than the official price. In return, the state agrees to take care of a chunk of the social contributions. Sector 2 doctors stick to this grid, but have the right to add “top-up fees” to it.

Why doesn’t everyone perform in sector 2 then? Simply because of the price elasticity of demand: a fees increase might just lead to a decrease of patientele. Those doctors charging sector 2 fees usually have the academic reputation to justify the price; however this is a financial relief about to disappear. It is those fees that have become the core of the debate.

Current issue

These top-up fees have become Marisol Touraine’s – the healthcare minister – principal target when she enacted “amendment 8”. In fact, her bill aims to get rid of these extra fees in the long-term, by first advocating their demise in sector 2. At a first glance, this seems like a fair deal for a country that promotes “the guarantee to all – especially to the child, to the mother and to the old worker – to benefit from the healthcare protection” (written in the French Constitution). From the context of a socialist presidency, it seems even more logical that the State seeks greater involvement in healthcare.

However, here is where the first interrogation comes into play. Sector 2 concerns mostly doctors having to deal with “heavy technical acts” – those professions relying on the use of costly medical devices and the employment of nurses and assistants – namely the surgeons. And the costs of performing surgery are numerous: employee wages, cost of material, social fees, rent, subscription to “civil and professional insurance”, and they are most of the time directly paid from the surgeon’s own pocket. Moreover, social allowances (family, age, illnesses and maternity) are much higher in sector 2 than in sector 1, and it came with quite a necessity that the government allowed the “dépassements d’honoraires”. Doctors even refer to those fees as « complementary fees ». 

As a matter of fact, Valéry Giscard d’Estaing’s prime minister (Raymond Barre) froze the prices of medical acts in the 1980s. The rational was that reimbursing those growing expenses cost too much to the French “Sécurité Sociale”. On the other hand, the reform gave birth to sector 2, enabling French doctors to charge top-up fees – priced with “tact and measurement” – in order to compensate for the rise of inflation and cost of living. However the Sécurité Sociale does not redeem the patient these top-up fees.

From an economic point of view, the reform surely comes as a stab in the back for most liberal doctors. With an average annual inflation of 2% per year for thirty years, cost of life is doubled. It is easy to understand that, with the price nomenclature of medical acts remaining the same in the meantime, medical profits have reduced by two. Not to mention the rise of wages, the increase of the raw materials costs, the overall better quality of healthcare (new material, state-of-the-art techniques), all three far greater than inflation … Quite surprisingly, studies revealed it is hospital practitioners that charge the most excessive extra-fees. When devoting their 20% time allocation to sector 2, they can charge up to 700 euros per consultation (official price: 23 euros).

Along with “Le Bloc”, various doctor unions have joined in the protests against the government’s reforms. The Facebook group “les médecins ne sont pas des pigeons” (doctors aren’t pigeons) now counts around 40,000 members, gathering not only doctors, but nurses feeling threatened by this reform, med school students frightened by a labour market no longer full of promises and sympathizers to the doctor’s cause.

Dis­claimer: This art­icle was ori­gin­ally pub­lished as “French medicine: somebody please find a doctor! (Part 1/2: “Les dépassements d’honoraires”)” on December 11, 2012 on The Polit­ical Bouil­lon, EST cooper­a­tion partner.

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