Ethical issues raised by the introduction of payment for performance in France.

CONTEXT: In France, a new payment for performance (P4P) scheme for primary care physicians was introduced in 2009 through the 'Contract for Improving Individual Practice' programme. Its objective was to reduce healthcare expenditures while enhancing improvement in guidelines' observance. Nevertheless, in all countries where the scheme was implemented, it raised several concerns in the domain of professional ethics. OBJECTIVE: To draw out in France the ethical tensions arising in the general practitioner's (GP) profession linked to the introduction of P4P. METHOD: Qualitative research using two focus groups: first one with a sample of GPs who joined P4P and second one with those who did not. All collective interviews were recorded and fully transcribed. An inductive analysis of thematic content with construction of categories was conducted. All the data were triangulated. RESULTS: All participants agreed that conflicts of interest were a real issue, leading to the resurgence of doctor's dirigisme, which could be detrimental for patient's autonomy. GPs who did not join P4P believed that the scheme would lead to patient's selection while those who joined P4P did not. The level of the maximal bonus of the P4P was considered low by all GPs. This was considered as an offense by non-participating GPs, whereas for participating ones, this low level minimised the risk of patient's selection. CONCLUSION: This work identified several areas of ethical tension, some being different from those previously described in other countries. The authors discuss the potential impact of institutional contexts and variability of implementation processes on shaping these differences.

The preferred doctor scheme: a political reading of a French experiment of gate-keeping.

OBJECTIVES: Since 2006 France experiences an innovative version of Gate-keeping which aims at regulating access to outpatient specialist care. We describe the reform's initial objectives, the political pathway which lead to the implementation of a reshaped reform and discuss the first outcomes after 1 year implementation. In the conclusion, we try to catch a glimpse for future steps of the reform. METHODS: In order to observe the implantation and impact on the reform, we used national sickness fund databases and a sample of 7198 individuals from the 2006 French Health, Health Care and Insurance Survey (ESPS), including health, socio-economic and insurance status, questions relating to patient's understanding and compliance with the scheme, self-assessed unmet specialist needs since the reform. RESULTS AND DISCUSSION: 2006 results show that 94% chose a preferred doctor, in a vast majority their family doctor. Impact on access to specialist care appears significant for the less well off and those not covered by a complementary insurance. From the specialist's side, new constraints on access to care seem to have been offset by rises in fee schedules. CONCLUSION: Notwithstanding disappointing short terms results, the new scheme may however lead up to reinforced managed care reforms.