France seeks to curb health costs by fining doctors

Heavy handed and expensive

In happier times of economic growth, most Western governments had a light touch in controlling health care costs. But as the growth of health care spending has outstripped the performance of most economies since the 1970s, health care payers have realised the need to act more firmly. They face powerful groups with an interest in resistance: health care providers, who gain from increased income.

Fortunately some tools are available to help targeting costs at health care, doctors, and patient level. At the “system” level the most effective is a limit on overall annual expenditure. Britain is a good example of this: health care spending has grown less than in almost all other Western countries since the 1970s. But while this method controls overall costs, it does little to relieve pressures on the budget. Other tools are needed, such as controlling the number of doctors; paying providers capitation fees rather than fees for service; and having primary care providers acting as gatekeepers to secondary care.

At a more micro-level are tools to change the behaviour of the chief spenders—doctors. The carrots include guidelines, peer pressure, and financial incentives to operate within a budget; the stick is sanctions when rules are not followed. Tools to influence patient behaviour include user charges. If all these do not work fast enough governments can relieve pressure on budgets through other means—for example, in Britain by redefining services off the NHS menu (such as eye tests) or allowing waiting lists for care to grow.

Governments are constrained by the combination of tools they inherit and their ability to introduce new ones. In this respect the French have some strengths—notably, almost universal coverage of health benefits paid for mainly by government. This provides the government with leverage over health care providers, and it has been used successfully to cap hospital expenditures. But, as Durand-Zaleski et al explain in this issue, outside the hospital sector their leverage is weaker: there is no global budget; doctors get fees for service; there are no curbs on prescription drugs, diagnostic tests, or procedures; there are no gatekeepers; and patients can shop around to their heart's content (p 943).1

Faced with the unsurprising growth of costs in this area, the French government offered various carrots to change clinical behaviour (guidelines) and user charges for patients. It ducked fundamental reform of the system, such as paying doctors on a capitated basis; giving them a fixed budget; encouraging patients to register with a primary care doctor; or controlling the numbers of doctors. But since the carrots have not worked, France has now taken up the stick. Durand-Zaleski et al describe a system introduced in 1994 in which doctors practising outside hospital must either follow national rules for prescribing, ordering diagnostic tests, and carrying out procedures, or be fined.1

These rules have had some impact. The growth in costs for services outside hospital slowed from 6% to 2.3%. Savings on prescriptions alone were estimated at £34m. Of 13 000 doctors surveyed, 75 were eventually fined.1 However, the impact on health has not yet been evaluated. Furthermore, the cost of policing doctors in this way is likely to be expensive and may even outweigh the savings made: a reviewer took over 300 hours to check prescriptions ordered by one doctor over two months.

Are there lessons for the NHS and other health systems? A fundamental issue in controlling costs is how far various methods should be targeted on the health care system itself, doctors, or patients. A secondary question concerns the best tools to use. Historically in the NHS the system has been targeted—for example, through the use of a global budget, controls on staff numbers, and through the gatekeeper arrangement in primary care. These have proved highly effective, but while there is still more to do at this level,2 attention has increasingly been focused on changing doctors' behaviour.

First came professionally led activities such as guidelines and clinical audit, but these have not yet had much effect on, for example, drug costs.3 Next came government incentives such as giving doctors budgets to manage. These have not had great success either,4 5 possibly because both incentives and sanctions are weak or because considerations of cost currently conflict too obviously with the professional ethos.6 As yet few initiatives have targeted the behaviour of individual doctors directly using rules and sanctions, as in managed care organisations in America.7 The French experience described in this issue suggests that this is likely to be expensive.

Finally, should patients be targeted through user charges? User charges are costly to administer and penalise the sick. Furthermore, until adequate steps have been taken to tackle the health system and clinical behaviour, it is unfair to penalise patients, whose decisions are largely not responsible for health care costs. This message should ring loud and clear from all organisations (like the BMA) whose members are advocates for patients. Either way the main lesson from France is for the medical profession: take more responsibility for costs, or be increasingly managed until the sticks become unavoidable.