FROM CLINICAL RECOMMENDATIONS TO MANDATORY PRACTICE The Introduction of Regulatory Practice Guidelines in the French Healthcare System

Abstract

In an effort to control ambulatory care costs, regulatory practice guidelines (références médicales opposables or RMOs) were introduced by law in France in 1993. RMOs are short sentences, negatively formulated ("it is inappropriate to..."), covering medical and surgical topics, diagnosis, and treatment. Since their introduction, physicians who do not comply with RMOs can be fined. The fine is determined by a weighted combination of indices of harm, cost, and the number of violations. The impact of the RMO policy on physician practice has been questioned, but so far few evaluations had been performed. At the end of 1997, only 121 physicians had been fined (0.1% of French private physicians). The difficulty of controlling physicians, the large number of RMOs, and the lack of a relevant information system limit the credibility of this policy. The simultaneous development of a clinical guideline program to improve the quality of care and of a program to control medical practice can lead to a misunderstanding among clinicians and health policy makers. Financial incentives or disincentives could be used to change physician behavior, in addition to other measures such as education and organizational changes, if they are simple, well explained, and do not raise any ethical conflict. But these measures are dependent on the structure and financing of the healthcare system and on the socioeconomic and cultural context. More research is needed to assess the impact of interventions using financial incentives and disincentives on physician behavior.

Choice of second‐line disease‐modifying antirheumatic drugs after failure of methotrexate therapy for rheumatoid arthritis: A decision tree for clinical practice based on rheumatologists' preferences

“…Some physicians consider such clinical practice guidelines and related algorithms to be an attempt to reduce medicine to simple equations for solving medical problems. This perception is even more confirmed when guidelines are used by regulatory authorities to impose mandatory practice (51). Several guidelines have already been published at the national and international levels.…”

Legal thoughts on the implications of cost-reducing guidelines for the quality of health care

“…They are based on clinical guidelines which are characterized by the Agence Nationale pour le Développement de l'Evaluation Médicale (ANDEM) as systematically developed statements, aiming to assist medical decisions about the appropriate health care in specific clinical circumstances [17]. The underlying clinical guidelines are drawn up by the Haute Autorité de la Santé (formerly known as ANDEM and the Agence Nationale d'Accréditation et d'Evaluation en Santé (ANAES)) and based on scientific evidence and expert opinion [18][19][20][21]. The Références Médicales Opposables are selected from the clinical guidelines by representatives of French insurance funds and doctors' unions.…”

“…If the results show that the physician did not comply with the RMO, the physician can be sanctioned. The fine is determined by a weighted combination of an index of the RMO's redundancy or harm, an index of its cost and the number of violations [19][20][21][22].…”

“…They resent financial penalties. A study in 1998 showed that 60% of French physicians feared the ability of RMOs to affect the quality of care [34,19,20]. The impact of binding guidelines becomes important.…”

Guidelines in lower‐middle income countries

“…There is evidence in the literature to suggest that successful implementation of guidelines reduces mortality and morbidity (Lindsay et al, 2014;Griesdale et al, 2015;Lee et al, 2015). It has also become more prevalent for guidelines to influence government spending on health (Durieux et al, 2000).…”