In the current debate on the freedom of establishment of doctors in France and the “medical deserts”, experiences abroad are used in very different ways by defenders and detractors of stricter regulation than that which exists today. today.
Concretely, at present, a liberal doctor in France can settle wherever he wants. Nevertheless, the “Potential Localized Accessibility” or APL (established according to the number of general practitioners up to 65 years old, the access time for patients, etc.) is beginning to be taken into account within the “Territoires vie- health” that connect the country (see map).
There are thus financial incentives to promote settlement in an area “under-dense” in terms of medical personnel. At the same time, the idea of ??restricting installation to “over-dense” areas is developing and fueling proposals that are sometimes very controversial. The most recent controversies concern the addition of a fourth year to the general medicine internship, together with the obligation to carry it out in a private practice. In an under-dense Life-Health Territory, a resident has access to less than 2.5 consultations per year; 3.8 million people were affected in 2018, compared to 2.5 million in 2015.
Germany, the closest neighbor geographically, has one of the strictest installation regulation systems in the world. However, it is very little mentioned in the French debate. Beyond the language barrier, the low dissemination of the evaluation of the policies in place across the Rhine does not facilitate the exchange of experiences. This article deciphers the current German system, and its history, and gives an overview of the effects. Furthermore, it discusses the transferability of these teachings to France.
The foundations of “needs planning” (Bedarfsplanung) were laid in 1976 with the introduction of statistics on the distribution of practitioners in the territory. A major change took place in 1993 with the division of the country into 395 planning zones and the setting of “target densities” for 14 categories of doctors (general practitioners, neurologists and psychiatrists, etc.). The objective is to avoid areas that are over-dense with doctors. Installation is only possible if this density threshold is not exceeded by more than 10%.
Since 2013, the calculation of the threshold has been more detailed and takes into account the demographic structure (age and sex) of the population. The objective is now also to avoid under-dense areas. In 2021, a final evolution of the calculation method is launched. Are gradually integrated the state of health in the territory (based on the administrative data provided by the doctors), the distances (by car) between population and surgeries, then the multiplication of the zones of planning, in particular for the generalists (currently approximately 883 areas).
An important point to note is that this binding policy is widely accepted by physician organizations. It should be noted that, within the regional steering committees (associations of contracted doctors and health insurance funds) and at the level of the federal framework (a committee essentially bringing together doctors, funds and hospitals under the legal supervision of the Ministry of Health), these organizations contribute to the development of the system.
Since 1999, the regulation of the installation has also been extended to psychologists practicing as psychotherapists within the framework of their agreement with the Health Insurance. Like doctors, in exchange for the benefit of reimbursement of their care, psychotherapists accept certain constraints, including the limitation of the installation. Concretely, in 2021, 31,300 psychologist-psychotherapists and 152,000 contracted doctors were concerned in Germany by this installation control system.
This system has so far given good results which, if they do not benefit from scientific evaluations, are based on fairly robust data as to its effects. The discussion around this policy is in fact essentially based on reports drawn up by private institutes and financed by the various stakeholders.
An in-depth, independent expert report published in 2018 concluded that access is very good for most people in Germany: 99.8% of the population is within ten minutes’ drive of a GP, and 99.0% less than 30 minutes for most specialists. This is, of course, a purely geographical indicator of access, assuming that a car is available. When it comes to doctor availability, the majority of respondents said they get appointments within days.
In France, a 2017 study found relatively close figures for GPs: 98% of the population is less than ten minutes away by car. In the absence of an identical method, the other data from these two studies are not comparable. Nor should we overlook the systemic differences between the two countries, which prevent us from concluding that the sometimes divergent results are due solely to the regulation of the installation.
It should also be pointed out that, if the limitation of the installation is not disputed, it is the German doctors themselves who implement it.
They have broad skills to manage the organization of their practice: from training (definition of courses for medical studies, etc.) to the permanence of care, through the distribution of the ambulatory budget. They are in almost permanent negotiation with the Health Insurance and are well represented at the political level. The institutional integration of doctors, through the bodies representing them, is therefore strong.
However, this integration entails great complexity so that the scope and skills of each partner (associations of contracted doctors, health insurance funds, common federal committee, etc.) are clearly defined.
In Germany, remuneration is essentially based on a capitation system: a fixed sum for each patient cared for by a doctor, per quarter. In addition, there is a fee-for-service fee, the amount of which decreases according to the number of procedures provided. This is called “degression”: the more procedures, the lower the price per procedure. As mentioned above, it is the doctors themselves who manage this so-called “half-closed” envelope.
Conversely, in France, fee-for-service still dominates, which is non-declining, and therefore at a fixed price.
A priori not, because there are all the same many similarities making the two systems comparable to a certain extent.
Unlike other systems such as that in force in England, France and Germany offer relatively unrestricted access to many specialists outside the hospital. In France, however, the “care pathway” financially incentivizes patients to go through a GP first – excluding gynecologists, ophthalmologists, psychiatrists and stomatologists, who are accessible directly without financial penalty.
The two countries are also introducing more and more similar devices, which are reshaping the organization of the healthcare system: homes or health centers bringing together several professionals, more coordinated care for patients with chronic diseases, the use of reference to improve quality, etc.
In the organization of the healthcare system, we also note, in Germany as in France, that the State is increasingly in charge of these policies. This is linked to the notion of budgetary control, which has become a primary concern and a means of framing changes in the health system.
The German example shows that limiting installation is an effective policy… but which can only be put in place at the cost of a fairly thick administrative layer. Each new modification, as in 2021, adds (more) variables to an already very complex planning model. It is therefore necessary to increase the collection, reporting and analysis of data, consultations, etc.
But it should be remembered above all that this tool was put in place (and has long been used) to “correct” over-dense areas in a country rather well endowed with doctors and hospital beds. This planning was designed in order to control costs and avoid excessive competition between doctors who operate with the half-closed envelope system. This trajectory still structures debates and actions in Germany.
However, it is the under-dense areas that are at the heart of the debates in France. For example, the density of general practitioners is 46% higher in the most endowed region (Paca), compared to the least endowed (Centre), in 2021. In order to remedy “medical deserts”, it is it would be better to look at incentive tools. Those that exist are also quite similar in the two countries: financial assistance for settling in, opening of training sites or university branches in rural areas, incentives to recruit interns, etc.
The approach across the Rhine therefore provides lines of thought that deserve to be analysed. However, in order to carry out an informed debate, it is essential to distinguish the notions of under-dense versus over-dense zone, and to take into account the specificities of the system of our neighbor – close… but not quite similar.
