Introduction

In the five years up to 1996, expenditure on healthcare in France increased at an average yearly rate of 4-5%; by 1996 it amounted to about 10% of the gross domestic product.1 2 Various cost containment programmes have been proposed and implemented, many assuming that high costs are a result of unnecessary tests and treatments. We describe and make a preliminary assessment of the latest of these, introduced in France from 1994 onwards, which combines mandatory practice guidelines on procedures and drug prescribing with a system of fines for doctors who do not comply.

Background

Two thirds of French doctors are in private practice and are paid on a fee for service basis. The French social security administration provides medical cover for 99.6% of the population, and 80% of the fee the patient pays to a private physician is reimbursed by social security. Private insurance companies reimburse the remaining portion for most people. The social security administration and the doctors' unions have negotiated contractual medical fees and these are paid to most general practitioners and to 60% of specialists. Basic fees per consultation in 1997 were F110 (£11) for a general practitioner and F150 (£15) for a specialist but additional fees could be claimed for medical or surgical procedures performed during the consultation. Thus, physicians receive most of their income from social security.2

The French healthcare system has historically provided freedom of choice for patients and doctors. Patients can see any general practitioner or specialist they choose, with no limit to the number of doctors seen or the frequency of visits. Doctors have been free to request any investigations or procedures and have prescribed as they pleased—with the exception of a few drugs restricted to hospital use. This combination of freedom of choice, the high proportion of medical expenditure …