The approximately 1,500 health insurance medical advisors, who play a key role in the fight against fraud or in the granting of benefits and reimbursements, are at the heart of a reform project which raises fears for their independence and worries the unions.
The management of Health Insurance wants this medical service, which has long enjoyed a certain functional independence, to be integrated into the general organization of Health Insurance.
According to his project, presented Thursday to the central social and economic committee of the Cnam, the 16 regional directorates of the medical service would disappear and the 7,200 people who make it up – practitioners and agents – would be distributed among the hundred primary health insurance funds (departmental ).
“Tomorrow, the body which controls work stoppages (among others) will be absorbed by the primary funds: reason to fear a management of opinions made more accounting and by algorithms than medical”deplores an inter-union CGT/FO/CFE-CGC.
At a time of probable new tightening on health spending, the unions fear that the medical advisors, now attached to the primary funds, will lose their independence and end up being influenced by the management of the funds on the granting of the status long-term illness, the granting or extension of work leave, disability or retirement for incapacity. Crucial decisions for users.
They also fear the consequences for non-medical staff who will have to be distributed throughout the network of primary funds.
“The sudden announcement of this elimination at very short notice, from April 1, 2025, is astonishing and creates great anxiety among employees”underlined the inter-union.
The administrative agents who surround the practitioners and share with them medical confidentiality, fear losing a specificity of their missions “listening to the patient”, explains Cédric Bertet-Pilon, an elected CGT agent of the regional directorate of the medical service of ‘Auvergne Rhône-Alpes.
“We know that this or that patient we welcome has cancer or multiple sclerosis, we share medical confidentiality. This is all that patients risk losing.”complete M. Bertet-Pilon.
Liberal doctors wonder
The CSMF union of liberal doctors also expressed its concern.
The Health Insurance medical service must give its opinions “in complete independence and with respect for medical confidentiality”he underlined in a press release on Thursday.
“At a time when the Cnam is considering an awareness policy concerning work stoppages, medical transport prescriptions or dual-zone prescriptions (for ALD patients), seeing the medical service disappear in the very short term raises questions”he indicated, asking the Cnam to « clarifier sa position ».
The management of the Cnam, for its part, indicated to AFP that the independence of the medical advisors “would be guaranteed on a daily basis thanks to a double evaluation system” practitioners.
The medical aspect of his activity will not be evaluated by the director of his home fund but by another “professional medical advisor”she said.
Et “to take into account the specificities specific to medical practice, the national collective agreement for consulting practitioners of the general social security system is fully maintained, as well as the national management of this body (in terms of recruitment and mobility)”she added.
“This logic, which brings together medical and administrative teams, already exists in many organizations (agricultural social mutual funds, ARS, health agencies)”she added.
The call for a strike launched on the day of the presentation to the social and economic committee was widely followed within the medical service, according to Cédric Bertet-Pilon who mentions participation rates “from 40 to 100%” depending on the region.
The central social and economic committee of the Cnam will be called upon within a few months to give an opinion on the reform project. In the meantime, elected officials have requested that an expertise be carried out on the project, indicated Mr. Bertet-Pilon.