Friday, April 29, 2011

Ridiculous Stubbornness

France is now going through the process that fixes physician fees under what they call the “convention”. This is a formal negotiation that involves the health insurance system, l’Assurance-Maladie, and the unions, or “syndicats” of physicians. That process hasn’t happened in three years and both sides are itching for an update.

A big issue in US health policy is how physicians are to be paid under the Medicare program. The fee scale for doctors is determined by a complex process that weights each billable activity according to its “relative value.” That process is adjusted annually. But the overall cost to the system from the physician payment component, or Part B, is to be controlled by a global expenditure target that is intended to keep growth in proportion to change in all prices. This “Sustainable Growth Rate” or SGR, has proven to be difficult to apply as its formula has required larger and larger cuts which are resisted by physicians and “fixed” by the US Congress which can override the formula. Because the SGR law stays in place, there is a constant struggle to adjust rates based on negotiations, mostly with physician groups pressing Congress to allow for payment rises.

We have become a little like France in that the process is a continuing dance of negotiation, but the US leaves it to the general political process with Congress acting as the regulator of relatively detailed policy.

For France the issue of physician payment is now tied to problems of “medical desertification” as well as the continuing problem of excessive billing. Geographic maldistribution of doctors, or medical deserts, has risen on the policy agenda of late and there is an interest in creating incentives to entice doctors into rural and urban underserved areas. A group at IRDES (Institute de Rechereche et Documentation d’Economie de la Santé) is exploring how other countries do this in the hope that there are effective mechanisms out there that might help adjust the balance if applied in France.

The negotiations over rates in France hit a glitch earlier this week when the head of the Confederation des Syndicates Medicaux Francais, CSMF, which is supposed to coordinate the negitations among the physician groups, objected to the number and types of negotiators from some of the physician groups. He complained that the Medecins Generalistes and groups representing anesthetists, surgeons and obstetricians brought in “representatives of interns and young physicians into their delegations.”

The House of Medicine in France is becoming fractured the same way as in the US as specialists and generalists, surgeons and physicians, see the process of payment negotiation in different ways.

For the French it looks like the negotiation for the new “convention” will be delayed for “eight to fifteen days while the syndicates figure out a new negotiating group” as the newspaper Figaro put it. The CMSF issued a press release April 27th saying they “find ridiculous the unnecessary stubbornness” of the minority syndicats.

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