haro on doctors deemed too prescribing

In early June, Dr. Aurélie Dah, a doctor in Givors (Rhône), received a phone call from her primary health insurance fund to announce the start of a “targeting” procedure (MSO). In question, the too many sick leaves that it would prescribe: 16.6 days compensated per patient of working age, according to a letter arrived a few days earlier.

“This procedure only applies to extremely atypical prescribers, who represent less than 2% of general practitioners, around a thousand”, explains the National Health Insurance Fund (Cnam). The organization selected “those prescribing at least twice as many work stoppages per patient of working age as the average, taking into account the structure of their patient base”. They will be set “a reduction target which can be modulated according to the context in which each one exercises and its specificities of activity”.

“On the phone, my contact from health insurance seemed quite embarrassed and had difficulty explaining to me the concrete consequences of setting a target,” says Dr. Dah, who nevertheless fears having to “select” her patients. In the long term, penalties could indeed be applied to him.

“We throw the general practitioners into the food”

“It’s pure communication, indignant Luc Duquesnel, president of the generalists of the Confederation of French medical unions (CSMF). The very fact that it is the Minister of Finance who is announcing this campaign against sick leave clearly shows that the concern is above all to reassure the rating agencies. »

In fact, it was during the public finance meetings on June 19 that Bruno Le Maire, in search of 10 billion euros in budgetary savings, launched hostilities. “Does anything justify that sick leaves have increased by 30% over the last ten years? It represents a total expenditure of 16 billion euros per year, ”he was indignant.

“We are throwing general practitioners into food when the profession is of less and less interest, regrets Doctor Duquesnel. However, we know very well that it is telemedicine platforms that are the cause of abuses in terms of work stoppages. »

“I don’t feel like I’m prescribing more than others”

In the report detailing each year its budget proposals for the coming year, health insurance also announces that it “will act with the socially insured who have the most recourse to work stoppages obtained following a teleconsultation carried out with different doctors and not known beforehand”, and that it will reinforce the controls towards the patients who multiply the stops with different doctors.

But it will not release the pressure on doctors deemed too prescribing, like Aurélie Dah. “However, I do not have the impression of prescribing more than others”, estimates the young doctor installed in 2017 and who describes a worker patient in factories or handling, easily subject to musculoskeletal disorders (MSDs).

“When, in a patient, the analgesics no longer work and he is in so much pain that he no longer sleeps at night, what can I prescribe if not sick leave? “, she asks. She notes the difficulty in obtaining appointments with a specialist or for an MRI.

“People come because they are sick”

For Doctor Thibault Barbier, a doctor in Château-Gontier (Mayenne), and he too under the threat of a “targeting”, the lengthening of waiting times would be one of the causes of the explosion of work stoppages . “Here, it’s a medical desert: you have to wait a month and a half for an X-ray or an ultrasound, a month for a physiotherapist, six months to see a rheumatologist”, he describes.

“People don’t come to see me because they want to stop working, but because they are sick,” insists the doctor. He describes “country people, tough on things, who tend to come quite late and therefore with more advanced pathologies, which require longer stops”.

Refusing the put under objective proposed by his CPAM, he asked for a “put under prior agreement” (MSAP) which means that each stop prescribed must be validated by the social security medical adviser. “It does not bother me: I know the merits of each of my judgments, and none has ever been invalidated”, he assures.

“The phenomenon cannot be attributed to doctors alone”

This solution is advocated by the medical unions MG France and CSMF. It makes it possible to transfer to Social Security, whose doctors are already short of time, the responsibility for stopping. “But also that of the possible return to work: faced with patients in psychological difficulty, when it comes to suicide, the consequences can be serious”, warns Doctor Barbier.

The question is all the more significant as “depressive syndromes”, “stress-related suffering”, “anxio-depressive disorders” have become the leading cause of work stoppage: more than 3 million days of work stoppage work in 2022, in the face of musculoskeletal disorders, winter gastro or seasonal flu. However, these judgments weigh all the more on the Social Security accounts as they are longer on average and more often affect executives, with higher salaries…

“The complex phenomenon of work stoppages cannot be blamed on doctors alone,” says Anne-Sophie Godon-Rensonnet, director of services and the social performance observatory of the social protection group Malakoff Humanis, which publishes an annual sickness absenteeism barometer. On the contrary, it pleads for a “multidisciplinary” approach.

Reflect on the causes of unhappiness at work

“We need to better train the human resources teams of companies so that they detect earlier and better support those who need it,” she says. As for small structures that do not have an HR department, occupational physicians or complementary health professionals, who have social action resources, can also intervene. »

To reduce the cost of work stoppages, Bercy has also turned to employers, even imagining, according to the Confederation of Small and Medium-sized Enterprises (CPME), an extension from three to seven days of the waiting period – period during which the employee on sick leave is not compensated – before triggering the reimbursement of daily allowances. But if this can deter so-called “comfort” absences, it would have a negative impact on those of companies – one in two – which pay daily allowances during the waiting period.

“Passing the expense back to companies is not the right method,” warned Geoffroy Roux de Bézieux, a few days before handing over the presidency of Medef. But he admitted that companies must “think about managerial practices”, and the “reasons why, in certain cases, this feeling of unease is increasing”.

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A steady increase in sick leave

Reimbursement of daily allowances (IJ) work stoppages for sickness or accident at work has increased by 3.8% each year since 2010 (compared to +0.3% for maternity leave).

This increase is explained by several factors according to Social Security:

– the increase in the active population (23% of the contribution to the increase in expenditure);

– the aging of the working population (13%);

– salary increase (18%);

– the increase in the average duration of outages (23%);

– the increase in the rate of recourse to judgments (14%).

In 2022, the health insurance deficit stood at 21.6 billion euros, city care (36.5%) and public hospitals (32.8%) weighing very largely in the 232.8 billion euros of expenditure, far in front of the IJ for sick leave (5.2%).

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