Supervision and control of outpatient medicine – comparative administration study: Germany, England, United States, Netherlands

This report provides a summary comparison of the systems used to monitor and control outpatient medicine in different countries and, based on observations from other countries, proposes ways in which France’s system could be changed. The initial focus of the study was “medical control”, which in France is primarily carried out by the medical services of the various health insurance schemes. This proved to be too narrow a scope, given the lack of an identical structure in the countries studied. A functional rather than institutional approach was therefore adopted. The mission examined the way in which other countries ensure the supervision of medical and prescribing practices and the management of costs within the outpatient sector of their health system. Four countries were analyzed: Germany, England, the United States and the Netherlands. This decision was based on several factors:

• Germany, because its outpatient care system shares similarities with the French system, and so that the numerous measures it has adopted in recent years, particularly with respect to quantitative regulation, the accountability of doctors and, more generally, self-management by the profession, can be studied.
• England, because innovative management methods have been in place there for a number of years within a very constrained budgetary framework. It would not be fair to simply sum up the English model as the result of a series of fatal errors.

Despite its obvious shortcomings in terms of waiting times and results, it has made significant progress in terms of public health. Ambitious reforms are currently being carried out, characterized primarily by a very significant increase in budgetary resources, a shift towards a far more decentralized system for managing funds (which does not distinguish between community healthcare facilities and hospitals) and increased focus on the qualitative approach.

• The United States, the inclusion of which seemed essential, although its healthcare system differs greatly from our own both in terms of its principles and its results: firstly, due to the amount that is spent on healthcare, and secondly, due to the advances that it has made, some of which are already long-standing, in the organization of healthcare and pursuit of quality. Despite the profound inequalities that characterize disease management in this country and seem a far cry from European aspirations, the American system offers the most innovative mechanisms. The mission focused on the latter.
• The Netherlands, as relative competition between insurers is being gradually introduced there. This country is also distinguished by a moderate increase in its healthcare spending and by the importance attached to improving quality, thanks in part to the investment that has been made in the medical profession. Each of these countries is the subject of a specific report which presents the main data relating to its health system, the ways in which health cover and outpatient medical services are organized, and the various tools designed to improve the quality of practices and regulate the costs of these.

This report summarizes the lessons learned from our observations of other countries and, without making a systematic comparison with the situation in France, seeks to identify possible ways in which community healthcare in our country and its relationship with the public authorities, and, more specifically, with the medical services of the various health insurance schemes, can be improved. The main lessons and areas of similarity identified by studying foreign countries Despite the different approaches to financing health risk, the institutional framework highlights the consistency of the principles on which European systems are based: solidarity and quasi-universal coverage, which sets them apart from the American system at a fundamental level.

With countries across Europe seeking to manage expenditure, state intervention is increasing everywhere. It is clear that the situation in France is no different. The characteristics of outpatient care bridge this deep divide. The existence of a well-established, structured and recognized profession, and relationships based on trust, are historical and cultural characteristics shared by the countries that were visited. Nevertheless, the way in which English and even Dutch doctors work is more similar to that of their American counterparts than that of their German or French counterparts, with Germany differing from the other three countries in a number of respects. Several of the following characteristics of outpatient care in the United States, Great Britain and even the Netherlands appeared to be key factors in facilitating achievement of objectives concerning improvement of practices and thus efficiency of spending: the regulation of access to specialists (gate-keeping), the running of medical practices based on a far more collaborative, multi-professional and multi-disciplinary approach, forms of remuneration that are geared towards diversity and incentives, and close links between community doctors and hospitals. In these contexts, regulatory tools, when they focus on practices, rely heavily on the profession itself. The provision of support, agreements or contracts for these tools has meaning and value for practitioners.

A recent trend towards the individualization of contracts – an inherent feature of the American system – has been observed in Europe. On the other hand, in the three countries that invest in tools to ensure the quality of practices (United States, United Kingdom, Netherlands), penalties for medical practices requiring improvement are rarely implemented. The wide range of tools designed to ensure quality, the close involvement of the profession in defining these tools beforehand, and the way in which medical practices operate are just some of the factors that help to explain this observation.

Although there is an internal “control” mechanism, it has more to do with support, partnership and advice. A “medical control service” is in fact a feature unique to France. Germany is the only other country with a highly institutionalized system for monitoring private practitioners, responsibility for which is delegated to the profession, and an effective “hard” monitoring policy. For the sake of convenience, the tools were presented by the mission in three parts. However, a key lesson of the comparative study is that the various tools must complement one another. Prioritizing a single approach comes with risks: in Germany, the very quantitative approach to regulation has undoubtedly hindered the introduction of more quality-focused and organizational tools. England’s numerous innovations in these last two areas have been unable to mitigate the impact of the system’s chronic under-funding (hence the recent decisions to compensate for this by increasing the planned budget). The pursuit of quality of care that characterizes the most successful American networks must go hand in hand with a controlled financial framework, market and competition permitting: but the prices accepted by insured Americans are high by European standards and the costs of managing the system are high. Regulation through monitoring of the supply and cost of care has highlighted the appeal of competition in Europe. This covers various concepts: competition between insurers (Netherlands, Germany), competition between healthcare providers (England, United States). Beyond some improvements in terms of efficiency and the service provided to insured individuals (the Netherlands), more in-depth experimentation in Europe is still required.

Another tool used is the regulation of medical demographics; the German system of imposing limits on how many practitioners can operate within a particular geographical area is now an interesting, key element of the way in which it regulates healthcare provision. Of the many existing fiscal tools, Germany’s collective floating-point system for regulating the fees of private practitioners has, in the mission's opinion, many drawbacks. The same can be said of Germany’s collective penalties (for prescriptions), a measure that has just been abandoned. On the other hand, allocating individualized budgets to different practices for prescriptions is a recent and undoubtedly more promising tool, which has been tested in England and Germany. Another commonly used tool, with which the medical control service in France is well acquainted, is the use of statistical profiles and activity monitoring. In this regard, it appears that while the quality of the information system is an important aspect (Germany), it is primarily the way in which the system is used and the complementary measures put in place to support doctors that make it effective (United States, England).

The prescription of drugs and incentives to use generic drugs are accompanied by various micro-economic regulatory mechanisms in all countries. The cost-effectiveness of prior authorization, which is also required in France, is now being questioned in the United States. Tools designed to improve the quality of professional practices are easier to delegate or share with the profession than mechanisms with a decidedly quantitative focus that put the profession in a difficult situation (Germany). Three areas of similarity can be identified when it comes to tools designed to ensure quality: diversity, similarity of tools and a strong driving force. However, Germany and France are lagging behind in this movement, which is a central component of the framework for outpatient medicine in the United States, England and the Netherlands. American, English and Dutch community doctors are supported in their individual practice by schemes involving an obligation of means (ongoing training, Dutch recertification, etc.). They are also increasingly required to have their professional practice evaluated and their results analyzed. The “penalty” is, put simply, a personalized support plan. In these three countries, the profession has also invested heavily in tools designed to improve collective practices.

With respect to recommendations and standards for best practice, three factors are recognized as being decisive: participation in their development by those who are responsible for implementing them, a flexible incentive-based approach in place of rigid application (they are rarely “enforceable”), and circulation of information to facilitate their adoption. Peer exchange is another widely used tool. Lastly, although quality assurance programs are not designed to control costs, they do play their part in a wider public health objective that aims to improve the efficiency of the healthcare system. In the United States, these programs are closely interlinked with those concerning resource use optimization. It is here, and in England, that these measures are most successful. This review highlights the paradox that the doctors with the greatest obligations in terms of quality of care – the Americans and the English – operate within systems that are diametrically opposed at both a philosophical and organizational level. Tools designed to ensure quality of care and to control costs can only be fully effective if the way in which the healthcare system is structured allows these tools to be monitored and implemented consistently. Once again, it is in England and the United States that the most notable advances have been made.

Comprehensive patient care is the main characteristic of the most extensively integrated healthcare networks (United States). This logic underlies England’s approach to clinical governance, introduced in 1999, which also calls into the question of the relevance of complete separation of funding (outpatient/hospital). Accreditation and evaluation of network performance is an American tool that England has adapted to its own needs. There is another American practice within the context of Medicare that is of interest: the Peer Review Organizations, which offer free technical, methodological, clinical and biostatistical support to practitioners in each state to help them implement quality improvement programs.

Lastly, the use of electronic medical records is a topic of discussion at a national level in all of the countries due to the challenges this entails. Only some American networks have access to this tool – along with the software built around it – which is remarkable considering the objectives being pursued (control of unnecessary expenditure; quality, continuity, coordination of care). Courses of action in the French context In terms of areas of consideration and proposals, the main recommendations relate to the general framework for outpatient medicine, desirable improvements in the professional practice environment and some new emerging requirements for doctors that the profession ought to be addressing.

Finally, proposals are made regarding changes to the medical services of the various health insurance schemes to reflect these developments. It is clear that pursuit of quality goes hand in hand with regulation or optimization of costs. Three other basic principles must also be observed: the coexistence of incentives and penalties, the provision of (possibly individualized) support measures and transparency regarding the rules of the game and the results achieved. In terms of a general framework, certain methodological elements should be reviewed: there needs to be greater coherence between priorities and multi-year public health programs and the actions taken by those working in the field on a day-to-day basis, particularly in the context of risk management; more must be done to ensure the continuity of actions taken involving professionals; the actions taken must be evaluated in a more systematic way. The way in which outpatient medicine is organized needs to evolve. General practitioners should play a greater role in our health system. Their tasks could be redefined. The conditions in which they practice, which all too often still involve working in isolation, should be reviewed, and coordination between the various disciplines and professions should be encouraged. The future of management should also be given consideration. In this respect, greater peer involvement is needed in the management of regulation based on quality of care and, more generally, in professional guidance.

Finally, the respective roles and aims of those involved should be clarified with regard to penalties. Proposals are made to improve monitoring of doctors and their work. They include redefining the scope of the contract and the agreement. They are based on systems which already exist (statistical profiles) or which still need to be put in place (classification of procedures, which needs to be released). More problematic, but even more important, is the progress that must be made in how practices and the certification of professionals are evaluated. Each doctor should be subject to an annual evaluation of their practices. A procedure for regular requalification of professionals should be put in place. These changes seem inevitable, but there still seems to be a notable lack of action in our country when it comes to these matters. Progress cannot be made unless these changes are accompanied by measures to help facilitate professional practice. From a technical standpoint, these are quite easily achievable and, in many cases, good progress has already been made in other countries. They primarily concern tools to aid decision-making, which can be accessed in particular through information systems, quality-improvement measures and dialog between professionals. The introduction of a single medical record will also be a key factor in bringing about improvement, by enabling coordination and continuity of care. But there is also a cultural aspect to these necessary changes. They will require the extensive involvement of and in-depth consultation with professionals. Finally, these developments should go hand in hand with changes to the medical services of the various health insurance schemes. The mission considers it appropriate to enhance the role of the doctors working for these services in providing advice and monitoring activities. It recommends that their direct involvement with community doctors be expanded, their advisory role strengthened, their monitoring activities made more targeted, and also recommends that they be given new regulatory powers that would allow them to initiate, if so required, measures that would be binding on medical practitioners (such as an obligation to undergo additional training or assessment).

Although direct action involving certain insured individuals, in the context of quality-improvement measures, for instance, is something worth discussing, the medical service’s relations with professionals must remain a priority. To this end, the mission recommends that the medical officers assume an advisory role, for which they would be assigned responsibility for the doctors within a geographical sector and/or particular specialty, depending on local set-ups. Other managerial and organizational changes are worth exploring further, whether to strengthen monitoring capacities, such as the creation of a mobile second-level control team, or to help open up the medical officer community, such as ensuring greater mobility. Lastly, although the status of the bodies belonging to the different systems and the question of how these should be integrated into the hierarchy were not specifically analyzed by the mission, it is the mission’s view that the recognition of professionals, which would reinforce their independence, must take precedence over the system of management. Summary of recommended changes to the framework for community medicine The framework is not neutral: -

Ensuring actions are multi-disciplinary :

• Ensuring the continuity of actions taken involving professionals 
• Developing the system of evaluation 
• Strengthening the role of general practitioners 
• Encouraging the grouping of professionals 
• Considering possible transfers of duties 
• Identifying the right level of management 
• Involving peers 

Clarifying aims and roles with regard to penalties Improving the professional practice environment: 

• Consolidating the recommendations for good practice 
• Developing the information system’s functionalities - Establishing systematized exchange between peers 
• Implementing quality
• improvement measures and programs 
• making the transition to a single medical record 

Focusing on coordination Rethinking how doctors are monitored :

• Redefining the scope of their contract -
• Releasing the classification of procedures and drawing up a classification of diagnoses - Enhancing statistical profiles -
• Making each doctor undergo an annual evaluation of their practices 

Introducing professional re-qualification The future of medical control : 

• Strengthening the role played by doctors in providing advice and monitoring practices 
• Developing direct work with community doctors 
• Strengthening the supporting role of medical officers 
• Targeting control activities - Granting powers to impose obligations on practitioners 
• Participating in the evaluation of practices and the re-qualification of doctors 
• Building the relationship with certain insured parties 
• Having medical officers assume an advisory role 
• Creating a mobile team for second-level control - Promoting openness among and the independence of medical officers