The preferred doctor scheme: A political reading of a French experiment of Gate-keeping

Rethinking primary care’s gatekeeper role

“…38 In France, incentives that promote gatekeeping worsen access to specialists, particularly for poor and uninsured people covered by complementary insurance. 39 However, evidence from European countries shows that gatekeeping helps reduce healthcare inequalities, [18][19][20][21][22] provides decision making support to disadvantaged groups, and lessens unnecessary specialist use by advantaged groups, 40 who tend to use specialty medicine more often. 18 22 …”

“…45 In France, the 2005 health financing reform law introduced a voluntary gatekeeping scheme termed "the preferred doctor," aiming at regulating access to outpatient specialist care and providing patients with financial incentives to see their preferred GP first rather than consult a specialist directly. [39][40][41][42][43][44][45][46][47] Although the scheme has shown disappointing short terms results, 39 it may have contributed to the reduction in the health system deficit. 47 Constraints on access to specialists were offset by rises in their fees.…”

Gatekeeping and provider choice in OECD healthcare systems

“…Our literature review indicates that gatekeeping has the potential to increase efficiency and reduce costs, but savings are probably smaller than political expectations. One reason for low cost savings is that many people in free access countries have already voluntarily followed a gatekeeping patient pathway, as indicated by the high number of persons with a family doctor who also usually forms the first point of contact in free access systems (Dourgnon and Naiditch, 2010;Himmel et al, 2000). As a result, most people in free access systems see no problems in the development towards gatekeeping.…”

Advancing Primary Care in France and the United States

“…11 The scheme was abandoned, as only 10% of physicians and slightly more than 1% of patients enrolled and cost projections showed an average increase of 30% in overall payments from the CNAM to participating physicians without any significant gains in access or outcomes. Subsequently, a new preferred physician program, the médecin traitant, was passed into law in 2004.…”

“…This is essentially reverse gatekeeping, and the specialist is given the responsibility of coding the visit as an appropriate referral. 11 The system did allow CNAM to link physicians to their patient lists using administrative data. The addition of this information backbone provided the framework for development of a pay-for-performance program called "contract for the improvement of individual practice," which is now viewed by stakeholders as a promising vehicle to control costs, 13 much as pay for performance (P4P) is seen in the United States.…”