Kairos: Can you tell us about the history of medical homes in Belgium ?
Christophe Cocu(1) : Medical centres appeared at the end of the 1970s, as « late children » of May 68, in the same crucible as family planning and mental health centers. It is the meeting of two movements: on the one hand, practitioners who decide to collaborate together and, on the other hand, a more theoretical aspect with the Group of Study and Research in Medicine (GERM), left-wing intellectuals who reflect on the issue of equality in health and bring a scientific validation to the experiments. Then there are landmark events, such as the 1979 strike by general practitioners to retain their right not to be contracted(2). The doctors in the medical centers broke the strike by providing on-call and emergency services because the objective was maximum accessibility, supervised by the state, of « front-line » medicine. This was a major political event. What to do with the aftermath of the strike? What would be useful to obtain to continue the fight? A fixed price financing was proposed. This device already existed in the law, but had never been applied before. It works as a tripartite contract between a patient, a medical home and a mutual insurance company: the patient commits to attend only the medical home, the mutual insurance company pays a fixed monthly fee to the medical home, which provides primary care without asking the patient for money. This package is paid whether the patient consults or not. The first medical center appeared in 1983 and they have multiplied, 80% of them apply the fixed price.
At the beginning, the package was in the minority, right?
Yes, then it was re-evaluated to be financially cost-effective. In 2013, the latest changes were tipped the reluctant medical homes over the edge. We still needs accessibility for patients. We went from a few units in 1983 to 112 on the and about thirty in Flanders.
Do we see at this time a split between different visions of the medical act?
At a convention, it was said that medical homes were doing left-wing medicine in a traditionally right-wing area. This sums up our relationship with other practitioners and with the politician, in this case Maggie De Block. The way of working is quite similar, except that in a medical house, we work as a team around a patient, with various disciplines having the same weight. The medical homes are self-managed for ideological reasons and also for the equality of the patient, who must be taken care of as well as possible. There is no hierarchy between the doctor, the physiotherapist and the nurses, decisions are made collegially.
Where is the opposition?
These are the same physicians who may or may not work on a fixed-price basis. The philosophy and the means are different. In a medical center, almost all the workers are salaried, because paying social contributions means redistributing money in a supportive manner. With this money, practitioners do both preventive and curative work. By working on a fee-for-service basis, they would earn more…
It seems to me that there are two advantages to medical homes, that of community and proximity medicine, and that of teamwork. Could you elaborate on these aspects?
The main advantage is at the level of health itself: having a multidisciplinary structure with several views of the patient, including psycho-social, curative and preventive. We take into account the determinants of health, because biological factors only account for 30% of pathologies. The rest is related to the environment in the broad sense (housing, food, social contacts, work, unemployment, etc.). If we want a healthy population, we must act on these determinants by working on the living conditions in the neighborhood, in conjunction with other institutions, so that we don’t just treat the symptom but act on the causes. A typical example is a patient who arrives with chronic bronchitis. If you don’t improve the quality of your home, there’s no point in giving it aerosols. One advantage of the package is that it eliminates the money relationship between the caregiver and the cared for. The care is better. For caregivers, there are also benefits, including a more comfortable work environment, as opposed to the former family physicians who worked long hours. In a team effort, we can replace each other, the pressure on each other decreases, and it works.
Wouldn’t a beneficial effect of group medicine be that practitioners would be more motivated to preserve the good health of their patients, while on the other hand, fee-for-service medicine is accused of having perverse effects: multiplication of procedures, and therefore of the doctor’s fees…
Not quite. Let’s take an example. When a person arrives with a fever in a medical home, they will tend to return three days later to check on the persistence of their symptoms before possibly prescribing antibiotics. At the procedure, the doctor will certainly prescribe antibiotics directly, which will be ingested immediately by the patient. In a medical centre, we manage to save money in terms of prescriptions, while achieving better overall health, since we are doing prevention.
The social cost of health care seems to be equivalent between socialized and individual medicine…
Since 2013, the share of the flat fee is identified in the social security budget in the first line, which was not the case before. There is a continuous and steady increase in the fixed price budget. De Block reacts by wanting to curb this fee-for-service medicine, which might seem logical… except that there is also an increase in the number of people being treated on a fee-for-service basis, which drives up the budget. In the end, since there is a transfer between the budgets for fee-for-service and fixed-price care, there is no overall additional cost.
Are patients ever chosen?
Yes, even though it is forbidden. But it’s undetectable. In the medical homes, we refuse this logic. There has been some drift in the flat fee system, but in 2017, two studies showed that flat fee practices did not cost more than procedures. Our hypothesis is that medical homes generally put in place safeguards to prevent them from slipping. It is therefore unfair to lump all flat-rate practices together. In 2016, De Block was at the height of his popularity and the government decided to make 900 million in savings on health care alone, and he made his move. In the meantime, De Block has plummeted in the polls and has retreated to her commune. It organized both an audit and decided on a moratorium on the opening of new medical homes, with the aim of saving 7 million euros. The results of the audit are not yet officially known, but it is rumored that the conclusion was that a fixed-price practice would cost one and a half times more than fee-for-service medicine(3). Would De Block have achieved her goal? Another study shows that flat-rate medicine prescribes fewer antibiotics and more generics, which saves money for the social security. But the minister seems to be stubborn… One could accuse him of defending liberal medicine, but the medical centres do not represent a threat to it, since it is only 3% of the population using it.
Medical homes would not be good for growth and profits?
The answer lies in what happened in the past: there are doctors who still don’t believe that the medical centers broke their strike in 1981 and ideologically the doctors in the medical centers are left-wing in a right-wing sector. Nothing else about the motivations, in my opinion.
The fear would be that medical homes would be more successful than private practice?
It is only an ideological struggle, in which misinformation about medical homes is rampant. Liberals see us as competition, whereas the medical centres have never replaced anything, they completed the offer in a context of shortage of general practitioners.
What are your relationships with other general practitioners, specialists and mutual insurance companies? Do you have allies there?
Mutual insurance companies, associations and trade unions support the logic of the package because it allows financial access to care for people who would otherwise be deprived of it. For mutual insurance companies, reimbursements in medical homes are stable, budgets are predictable, while each individual act must be reimbursed, which is unpredictable. We have objective allies. As a non-profit organization, the medical centers do not seek profit, even if the remuneration levels are satisfactory.
What is your relationship with the unions of general practitioners?
There are two of them. ABSyM(4) is the union for specialists and the GBO for general practitioners. We have a good relationship with him. On the other hand, the former, which has the ear of the Minister and is in the majority, tried to destroy the inter-mutual study.
The unions deplore the fact that there are no longer any dialogue between politicians and society…
Our base sometimes reproaches us for our position with the minister, but she has never received us in her office!
But on the other hand, she listens to the liberal doctors!
Obviously, she has an attentive ear for them.
Are there any others that are in line with Maggie De Block?
Yes, the part of the society that aligns with it, such as the free mutualities, FEPRAFO(5), ABSyM. It is the « piliarization » of the Belgian society in all its splendor! They behave as Catholics and socialists did in their time.
When I see your study on Colfontaine and the health impact of the Bell factory in the area(6)don’t you think that you are seen as a nuisance by certain political parties?
I believe in the freedom of association, in the freedom of expression. We must not change our speech to please the politicians.
When you point out the weight of the environment on health, you go against a certain ideology that is very much in evidence today…
It is scientifically validated and we are envied worldwide for our effective and well-funded model. Then, this whole argument can be set aside for political reasons.
Isn’t it radically more difficult to negotiate with the latter government? So far, it’s been going pretty well, right?
It’s obvious. The other aspect is the multiplication medical homes. When there were only 4 or 5, it didn’t bother. But our ambitions to reach 10% of the population by 2025 are frightening to some.
However, as there is a shortage of general practitioners, medical centres should not be seen as competition…
Of course. While the shortage of general practitioners is caused by the numerus clausus at the federal level and by setting sub-quotas at the regional level.
The numerus clausus would be the product of lobbying of private physicians. Do you confirm?
In the old days, when you graduated from medical school, you would look on a map for villages with a few hundred inhabitants and no general practitioner, and you would move there. Then there was an overabundance of doctors and the decision to introduce a numerus clausus. The idea was that the more doctors there were, the more it would cost social security. The social security system ensures a comfortable income as long as a state monopoly is established, and doctors are free to charge their own rates, leaving it up to the patients to make their choice. This is particularly true for specialists, some of whom earn €500,000 per month. So, let’s stop looking for lice in general practitioners!
The drifts of liberal medicine are passed over in silence, the fact that ophthalmologists ask for 2,000 euros per act, sometimes « with envelope ».
We know that it exists, but not so much in Belgium, in any case.
What is your relationship with the mainstream media?
When the medical homes were created, it was hard. There was a consensus among us to keep a low profile: no external communication to avoid making waves and provoking liberal physicians. This fear became entrenched until Minister De Block had us in her sights, which forced us to come out of the woodwork. Her goal was to break the medical homes but she achieved the opposite by giving us media visibility. On the one hand, we have organized ourselves to better communicate with the media, which are fond of this information; on the other hand, the list of people registering with us is growing, and the patients already registered are mobilizing to defend us. We took advantage of the curiosity of the media. The associative sector, in the wake of this, also supports us.
Is the networking of associations not not the solution? Medical homes are moreover present in the collective d19/20…
Our challenge is to work across the board and in a network, locally and more widely with ONE, Médecins du Monde and family planning organizations, for example. We are trying to create common structures to make economies of scale. Politically, we participate in the Action santé solidarité platform, a structure that denounces the commodification of health at the European level. We are simply looking for more leverage.
As for Medicine for the People, do they don’t you sometimes do yourself a disservice?
When it comes to health, they are our ideological allies, anyway. We also share the same games at the package level. Where we differ is that the medical centers aim at social transformation, whereas Medicine for the People has, in addition, electoral aims, which sometimes go beyond the theme of health. When they boycott the audit, it is to make it a political position to be relayed in the press, while the medical homes accept the principle of it since they have nothing to reproach themselves with. Unfortunately, Medicine for the People takes up all the media space at the expense of medical homes. Some patients mistakenly think that we are affiliated with the PTB, since Medicine for the People speaks on behalf of medical homes, without making the distinction. They have 11 medical homes and a good communications department, we have 10 times that number, but without the communications. But we are learning from this and are now improving our communication.
Do you have members of the middle classes in medical homes?
Yes, our audience is mixed. Personally, as I am never sick, my package serves as a solidarity with others. Others are following my example, more and more.
So De Block doesn’t care about the well-being of the poor patients ?
Yes, this is budget reduction ideology, for only 7 million euros!
Interview by Alain Adriaens and Alexandre Penasse, January 15, 2018.
Transcribed by Bernard Legros.
- Secrétaire général de la Fédération des maisons médicales depuis 2016.
- « Un médecin conventionné adhère à la convention médico-mutualiste et s’engage ainsi à respecter les honoraires de référence fixés dans la convention », www.partenamut.be.
- L’audit commandé par le cabinet de la Ministre De Block à la firme privée KPMG a révélé ses résultats le 22 janvier. Fortement favorable au secteur des pratiques forfaitaires, il a conduit à lever le moratoire sur les maisons médicales, qui durait depuis trois mois.
- Association belge des syndicats médicaux.
- Fédération des Pratiques médicales de première ligne au forfait