Chapter Ten. The French Doctors' Escape

~'One should strike too hard at times in order to strike just right." (11 taut frapper trop fort parfois, pour frapper juste.) Talleyrand. c H A p T E R T E N The French Doctors' Escape HETHER a sentimental human itarian or a money-minded entrepreneur, a conscientious scien tist or an artist for the sake of art-the doctor almost invariably loses in the compulsory systems. Those of the leading Latin countries of Europe, France and Belgium are exceptional. THE BELGIAN Th~ B~lgian physicians in th~ir majority ?r SET-UP ganlzatlons are "not on speakIng terms" WIth the top management of the new (1945) oblig atory set-up, in the construction of which they were not even consulted. They carry on as before, but in an uneasy state of uncertain outlook, while the major panels are building up gradually their own polyclinical and pharmaceutical facilities. The outcome will depend on political and financial constella tions, with the (recently defeated) Belgian socialists striving for full-fledged statism in the medical field. Presently, 25 per cent to 33 per cent of the official medical honoraria comes out of the panel patient's pocketbook, and more if the doctor charges above the legal rate. So far, the Belgian profession is holding the precarious line of independence and economic status, following the policy line of their French colleagues.

THE PECULIAR A near-unique situation obtains in France, FRENCH SYSTEM with very far-reaching consequences~ They affect the status of the doctors as well as the quality of the medical care. 86 87 ] THEFRENOH DOOTORS' ESOAPE As in no other country, the medical association of France established and so far has succeeded in maintaining four \principles: the patient's free choice of doctor (and the doctor's implicit right to reject the patient) ; the "sanctity" of professional secrecy, extending even to surgicalacts;! the absolute independence of the doctor in relation to ·the authorities, including his freedom to prescribe as he thinks right; and the "directness" of doctor-patient relation, with no bureau to serve as go-between (no tiers-payant). The last point is of greater significance to all concerned than meets the eye. It permits the French doctor to charge according to his position, to the service rendered, and to the patient's ability to pay.

This essential ingredient of the French scheme was already introduced in 1930 so as to avoid the pitfalls of the German sys tem which the French maintained in Alsace after 1918. It has been preserved in the new scheme. It provides for the payment direcdy to the doctor. The patient in tum collects from his panel, minus 20% of the official fee. Medical fees are regu lated in one· of two ways: either by contract between each caisse primaireand the ordr'e des medecins of the respective department (county); or by a geographically scaled tariff issued by the Minister. In about 50 percent of the depart ments, typically in the poorer ones, agreements have been reached at rates slightly above the legal minimum. But in the wealthier regions,· in Paris especially, the doctors refuse .to accept the modest concessions offered by the panels, and pre fer to work without contract, i.e., under the legal tariff which they simply ignore, charging what the traffic can bear.

In Paris, a simple consultation for a panel patient should cost at present about 240 frs., approximately 70¢, against the usual 20 frs. before World War II, while the cost of living has mounted at least 19-fold and the number of private patients has declined greatly. The caisse would be willing 'to raise the fees somewhat. But the physicians charge from noth ing more (occasionally even less, which is illegal) than the • COMPULSORY MEDICAL CARE AND THE WELFARE STATE r88 official tariff to some 200 per cent above it. Some fee be tween 300 and 600 frs. seems to be the current charge of general practitioners. And the patients pay willingly. The trouble starts when they return to their panels and find that they can collect only 80 per cent--of the tariff rate. In effect, therefore; they pay one-half or more of the doctor's bill unless it is a matter of "long" illness, meaning more than three months, or serious surgical and dental intervention. In that case they may have to do a lot of time-wasting and hard bargaining with the panel before they recover the full amount of the official rate. .

CONTROL BY Thus the French medical profession as a "DEDUCTIBLES" whole preserves its own economic level-a French level. Actually, it may be doing better, the panels claim, than ever before. And it preserves some things far more important. Monsieur Laroque himself, the director of his nation's all-round social security set-up, made the point repeatedly that his countrymen could not be trusted to observe obedience to the law as a Britisher might. Frenchmen would take too much advantage of govern mentalized medicine if they were not held back by being forced to pay a 20 per cent "deductible" out of their own pockets. It follows a fortiori that they are still more re strained if responsible for paying 50 per cent of the doctor's fee. Indeed, if the French compulsory system manages to operate ona 10 per cent visible deficit "only," if its doctors are not over-worked and its hospitals not constantly over crowded, it is so because the scheme is not under the kind of run to which other systems are exposed.

The average panel member has to think before rushing to the physician or calling him to the house and to think twice before taking the time of an outstanding specialist who charges proportionately more. A sort of treatment is available free of charge-if the member does not mind submitting to the para military, antiquated and often unpleasant polyclimc facilities for out-patients in such hospitals as those owned by the semi governmental mammoth organization called the assistance publique of Paris. That is not all. The less one goes to the doctor, the fewer cash benefit claims and pharmacy bills should arise. Industrial 89] THE FRENCH DOCTORS' ESCAPE absenteeism is tempered, too,~and the "morale" of the public strengthened, or at least its worsening is slowed.up. Above.all, the human relation between doctors and scheme patients does.not deteriorare.I.Ar1d~he .•. ~cientific standards of French .compulsory. medical practice, are maintained on high levels-apparently onrnuch higher ones than in countries with a comparable experience in governmentalization. N,or did the French system produce the acrimonious public quarrels, strike threats, bitter recriminations, etc., between panels and physicians, as did its counterparts elsewhere. What suffers is, of course, the popularity of the system. The political advan tage is largely dissipated. The' Frenchman who has. been told .that in exchange for a moderate charge on his payroll, plus a 20 per· cent "deductible" .(from low honoraria), he has the doctor at his disposal, together with all the other good things dispensed by the doctor, finds the price to be paid most unsatisfactory. Needless. to say, interested politicians and administrators share the disappointment.

SECRET OF For the ~ebeing, there is n~thing the latter ~an STRENGTH do about It beyond grumblmg and expressmg grave doubts about the legality of the profes sional behavior. Time and again, they try to call individual doctors to "explain" before the ordre des medecins, but in mat ters of fees French professional solidarity is unshakeable. What is the "secret" of their strength? Perhaps it is due to the fact that in France, the classical country of the revolutions, the middle classes'still preserve some of that old-fashioned spirit of self-reliance. In any case, the doctors' influence over the .health scheme, disregarding the some 700 confreres already on its payroll, is nil. As a group, they are treated by the scheme politicians with contempt and threatened with dire consequences. ~or is it a matter of too little supply of physicians. The some 30,000 practicing members of the French profession-for 42 million people-do not represent an appreciably lesser supply per capita, of population than.exists in England or existed 20 years ago in Germany. There are some 6,000 doctors in Paris alone.

Of the 600 young physicians graduating in Paris last year, 300 were. reported in no position to buy their own medical "cabi net." It is the type of legislative set~up that creates from the COMPULSORY MEDICAL CARE AND THE WELFARE STATE [90 outset the more advantageous climate-the fact that th~ scheme does not distribute directly benefits in kind. It merely compensates for .the patient's expenses and not for the full amount. Also, it is the cooperation of the public with the doc tors, its willingness to recognize the rationale of satisfactory medical incomes, that permits the latter to "get away with murder" as the other side sees it. The official scorn is the more poignant, since the French public puts the blame for its own dissatisfaction squarely on the scheme itself. REPER. The consequences are manifold. For one thing, CUSSIONS raising member contributions, Le., the rate of payroll deductions, is out of the question so far as the beneficiaries are concerned. Not getting what they were promised-all servicesfor no more charge than a nominal deductible-they turn the ire of their deputies and of the popu lar press on any attempt to squeeze more out of their own pay checks. Politically, nothing hurts the entire scheme more than the so-called unreasonableness of the doctors who, incidentally, seem to be very well organized and also well-versed in the devi ous ways of French politics. An organized minority among them actually "ignores" the compulsory scheme altogether.

Still, this writer has no answer to the obvious question-why, of all peoples, are the French and Belgian doctors alone able to resist the political pressure? And how long will they be able to do so? Whatever the repercussions, the result of the French doc tors' highly controversial policy is that the burden of "minor maladies" is greatly reduced. The cost of the petit risque amounted (in 1948) to about 15 per cent of the total sickness scheme outlay, apparently the lowest ratio in all of Europe. It may not pay the workingman to run to the doctor, or to call him in, on every imaginary or minor occasion. The first two sick-tickets he signs are valid for only eight days each, with no cash benefit for the first three days. The medical fee is better bearable for people in higher income brackets, who can afford half of the actual honorarium-a sad commentary, incidentally, on an institution that is supposed to provide for the poor.

The low income recipients, who must refrain from using the system unless they can expect at least an eight-day vacation out of it, naturally try to stretch each and every case to eight 91] THE FRENOH DOCTORS' ESCAPE THE PRECARIOUS days at least and to make the most of other bene~ts which the doctor can bestow. Over-staying in the hospital is a .favorite sport, resented and cornbattedby the panel administrations, but is promoted, in Paris,by the autonomous hospital system. That system needs the oCQupants·to ~o'Verits unmanageable costs per bed-50 per cent to l()O per cent higher than inpri vate institutions. Pharmacies are another "compensation" the patients enjoy. With remarkable regularity,.the average can sultationis followed by a prescription bill (in spite ofa20 per cent deductible on that, too) about 50 per cent higher than the official honorarium of the doctor. To impress on visitors how wonderful his· brainchild is, Monsieur Laroque, the chief of the scheme, likes to point out that, as head of a large family, he himself takes full advantage of it. He does not seem to realize the irony of the fact that he and his kind are the one group that really profits by ·it, ·con tributing barely one-half, in. proportion to his income, of what the average worker does, and being able to afford one-half of the doctor's fee, which may be far too much for a worker's pocket book.

The political balance is being held b)i the French ·doctors against the com BALANCE OF POWER pulsory scheme. By virtue of the legal construction of that scheme, and especially by violating the spirit if not the letter of the law, they manage to maintain something approximating the free enterprise system in medi cine. But it is a most precarious equilibrium that cannot last, and the omens are unfavorable. The scheme managers, and the politicians behind them, plan to construct, in due course, polyclinic and dispensary facilities. They pull the· strings to get hold of the hospitals. All of which would make the position of the independent doctors very difficult. Moreover,. public dissatisfaction with the scheme is mounting, and the schemers play on that. Since middle 1948, the Socialists, while still in the cabinet, have lost much of their influence, but they might regain it. With the number of doctors increasing faster than the population, and with an increase in propaganda for con tinuing the horizontal expansion of the scheme so as to elimi nate private medical practice, the conflict of the profession with the obligatory system of France might lead to a dramatic denouement.