Since 1 November, rate increases have hit a series of particularly complex, time-consuming or public health-related consultations. This is good news for patients because this means an increase in the Social Security basis for reimbursement…provided you choose the right practitioner. This is because not all practitioners can benefit from the new fee structure. Why is this?

Special treatment for public health issues.

A doctor does not devote the same amount of time or energy to a patient with a heavy cold than for a new-born baby’s mandatory visit 8 days after birth. It was this simple observation that triggered the new fees set out in the 2016 agreement with medical practitioners. Some of those fees became operative on 1 November 2017. From now on, the first appointment for contraception, how to handle an over-weight child, consultations on discharge from maternity ward and with the new-born baby are charged at EUR 46 but refunded 100% by Social Security, provided the fee charged is compliant.

Fee hikes on dozens of complex and very complex consultations

Initial consultations to provide a patient with information on particularly serious conditions (cancer, neuro-degenerative diseases, HIV, etc.) and implementation of a strategy for treatment, are very trying and so benefit from an increase of EUR 30. Dozens of other cases, mainly relating to consultations with specialists, have also undergone a hike in fees ranging from EUR 16 to EUR 30. Nevertheless, all these fee increases can only be applied by practitioners bound by an agreement with Social Security on fee levels (médecins conventionnés) or who have subscribed to the Optam or Optam-co schemes.

Refunds are biased in favour of Optam practitioners

What has changed for practitioners who decided not to sign up for the Optam, managed fee-structure, scheme? Nothing. The basis for reimbursement (BR) for their treatment is unchanged. This means that for the same complex consultation with a specialist, the SS basis for reimbursement remains blocked at EUR 23 for practitioners with their own fee structure (i.e. sector 2 practitioners). At the same time the BR has risen to EUR 46 (i.e. EUR 30 plus an increase of EUR 16) for controlled-fee (sector 1) practitioners or those in the Optam scheme. The upshot is that for the same consultation and the same fee, e.g. EUR 60, the patient who has responsible complementary healthcare insurance is left with a copay ranging from EUR 1 to several dozen Euros depending on the doctor he or she chooses.

What impact will this have on signing up for Optam?

The fee hikes, welcomed as being a common-sense move, have brought about collateral damage by putting pressure on non-Optam practitioners. Because patients with health insurance remain poorly informed as to why refund amounts are so unpredictable, surely more and more of them will be asking questions, probably of their 2nd tier (complementary) insurers, as to why their copay has exploded. At this point in time specialists do not appear to be joining Optam in any large numbers. In fact, the French Court of Audit (Cours des Comptes), in its report published in September, has estimated that the public health sector has spent EUR 10 to save every one Euro in fee overruns! The battle being waged by the system to contain expenses and curb fee overruns has not been won yet…

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