“I sent my letter last Friday. In a few weeks, this general practitioner from a small town in the North of France should officially be deregistered by Social Security. No more the usual sector 1 which allowed its patients to see their consultation at the capped rate being reimbursed at 70%, before the contribution of any mutual insurance companies. Place in “sector 3”, where each practitioner is free to set the amount of his intervention, it almost entirely paid by the patient. The National Health Insurance Fund (CNAM) only pays here more than 0.61 euro…
“At home, the consultation will be 50 euros,” continues the doctor, who thought carefully before taking the step, thirteen years after his installation. Why such a choice ? “The pressure put on by social security has always bothered me. We are increasingly paid according to our prescriptions, with lots of criteria to respect. Some are smart, but not all. I prefer to remain free in my decisions”, he explains, without denying that the financial aspect also weighed: “My expenses have been increasing for several years and the price of the act little or not at all. I certainly make a good living, I’m not saying the opposite, but I have to work more to continue having roughly the same income. »
Or, on average and according to a study by the Department of Research, Studies, Evaluation and Statistics (Dress), around 90,900 euros, all charges included, before tax. It was then an average noted among general practitioners in 2019. Against, for example and the same year, 146,200 euros for specialists. This places the two categories among the 2% of the highest paid national population, according to the Observatory of Inequalities.
So would the deconvention be above all a story of money? ” No way. We want to do quality care, not earn more,” Jérôme Marty gets carried away. The generalist media based in Fronton (Haute-Garonne) is at the head of the French Union for Free Medicine (UMFL), a union which organized the “Assises du déconventionnement” last March. Since then, he has encouraged doctors to submit their letter of intent to deconvention. Not far from 2,800 have already sent it to date, “and it will continue”, insists the president who… does not however plead in favor of such an extreme.
“We have to wield this atomic bomb”
“The goal is to show politicians that doctors are ready to take the plunge. When we have 15,000 of them (out of the 110,000 general practitioners and liberal specialists in activity), we will go see them and say, you have two months to draw up a major general medicine plan. To obtain it and weigh it, we are obliged to wield this atomic bomb which is deconvention. We have to stop: either we decide to pay caregivers as it should, or we continue to watch our health system fall. »
Among the demands of the UMFL is nevertheless the increase in the price of the consultation with a general practitioner to 50 euros. “In order to reach the European average”, pleads Jérôme Marty. A fact that is disputed by the researcher at the Center for Economics at the University of Paris 13, Nicolas Da Silva. “Comparing ourselves with other neighboring countries is not justified, quite simply because they do not have the same working conditions. In England, it is a mode of distribution by capitation, with large practices which divide their profits according to the number of doctors. And in Germany for example, health insurance pays a floating annual envelope, the value of the consultation can therefore vary from year to year. I would add that in France, the remuneration is not only linked to the act. Social Security pays numerous bonuses which can represent up to one month’s salary. »
“An unbelievable threat”
For contracted doctors, it is logically their primary funder, up to about 80% of their income. “That’s why I think that deconvention is an unbelievable threat”, summarizes the lecturer. “They can’t do without so much input. Except for a minority of doctors, those who are able to find a wealthy patient base, as is already done in some beautiful neighborhoods. »
According to the figures of the Cnam communicated to 20 minutes, non-conventioned practitioners now represent “0.7% of all liberal doctors in France”. Or precisely 743 out of the almost 111,000 in exercise. The Cnam also speaks of “a few dozen doctors” who would have come out of trouble in 2023. Even if it means forcing certain patients to go elsewhere for lack of means…
“That’s not true,” argues Dr. Marty. All those who have already taken the plunge say it, they have not lost a single patient. Those who benefit from Universal Health Coverage (CMU), they do not charge them and that’s it! “A commitment that the future unconventional general practitioner from the North of France, who always prefers to remain anonymous, takes on half-words. “I will respect my Hippocratic oath to treat everyone, I will not close my door. “He does not deny it, however: since he announced his upcoming move to 50 euros per act, “some patients told me that they would no longer come. »
“A problem of access to care”
A speech also heard by the mayor of Orschwihr, in Alsace, where the only installed general practitioner also decided to move to “sector 3”. “People ask me how they are going to do with their little retirement… others that they are going to stay because they have no choice. Because beware, all the doctors in the area are overbooked and often no longer take patients, ”explains Marie-Josée Staender, who was nevertheless very proud to have succeeded in attracting a practitioner to her town. “It was a coincidence, he was looking for building land… We gave him premises for a small rent, paid for work. We have every interest in what remains. »
Especially in a department, almost like all those in the territory, already under-staffed in doctors… President of the Haut-Rhin Order of Physicians. We do not encourage them to do so but we cannot forbid them. And it still reflects a real current trend: fewer and fewer young generalists are settling as liberals. »
“The game is no longer worth the candle”
“Because it no longer attracts at all”, according to the president of the UMFL, who today estimates that “15,000” the number of practitioners have turned away from it when they leave boarding school. “They prefer to take university degrees, do replacements etc. I repeat, our profession is exhausted with a suicide rate more than twice that of the population. The game is no longer worth the candle. »
According to Dress, the number of general practitioners practicing in private practice has fallen by 5% in ten years, from 2012 to 2022. This does not yet prevent a few from settling. Like this 30-year-old, graduated in 2020 and partner in the Cher. “It is certain that I have many friends who are substitutes and want to remain so because it has become complicated to settle down, she testifies. The job is difficult, the expenses increase while you are paid the same rate regardless of the act and there is always more administration. In addition, you have to juggle to maintain a balance between work and family life. Afterwards, we work with an “Asalée” nurse (to whom tasks are delegated) and we try to educate the patient a little to adapt to emergencies. But we know why we do it, to treat. »
This is why the practitioner would not see herself asking for her deconvention tomorrow, “because that would create an injustice with the patients. An argument that does not convince his colleague from the North. “The problem of access to care? I think it’s already there… The French don’t need to be reimbursed, they need to be treated. »