Surgical practice in the French private sector

The hall mark of the French health system is the juxtaposition of a flexible and active private sector with a public hospital sector that is plethoric, comprising top reference teams in major cities and regional hospitals throughout the country.Emulation between these two sectors is a quality factor.In the so called profit making private sector, surgeons work as licensed professional and the following considerations only apply to those.The private sector is essential, comprising 570 clinics, mostly chain owned, but this supposedly for profit sector barely makes any profit as 46% of the units are in deficit while employing 45000 physicians – one third of them surgeons of all specialties – and ensuring 58% of surgical hospitalizations, 52% of surgical oncology and 70% of outpatient treatments.What reasons can bring a 40 year old surgeon to venture out of the comfort of team work in a public hospital, to change medical institution and take the challenge of building a new patients’ base?There is only one, it is the spirit of entrepreneurship, but here lays the snag, such spirit no longer is a feature of our young colleagues.Practicing in a private structure alleviates from hospital hierarchy but it is a much more solitary practice.The beginnings are hard work and the liberal professional starts from scratch even though he held a certain reputation in public hospitals. He must build his practice conditions, choose his assistants and though he may be trusted for so called common surgery, things are much more difficult when he sets on major and/or more specialized surgeryFor such intent he generally needs to ask the institution to acquire equipment and sometimes modify its organization; he must achieve working hand in hand with the existing anesthesia-intensive care team, he must bear alone the continuity of care if he wants to build his own patients’ base, and he must join in continuing care with other practitioners who might be of different generations and may share neither his skills nor his objectives.All these constraints are rarely compatible with everyday living conditions.Concerning liability, the surgeon’s move to a private professional practice brings about a complete paradigm shift. He has been trained in public hospitals in an administrative environment where the hospital bears sole liability while the personal legal responsibility is very limited. As an independent professional, however, the surgeon works in an environment ruled by civil liability and is therefore personally liable for all his actions.Such liability impacts every professional decision and imposes utmost attention to administrative formalities as well as professional reference systems and recommendations defined by state health authorities and medical societies.And finally, but foremost, the liberal surgeon is an entrepreneur and he quickly realizes that he has never been trained for that role during his training. He bears multiple tasks, he is an employer, indeed, you can’t do without secretarial staff to abide by all the administrative rules, and he employs a pivotal figure but an Achilles heel, his assistant, without whom nothing is possible.There are multiple vital tasks to run his practice (rent, equipment, IT, etc.).And finally, he must proceed to retransfer to his institution, to settle his professional insurance policy, health care and pension plans, transportation and last but not least his accounting, for which he will need the help of a professional.To this list must be added dealing with the multi headed social security monster (URSSAF, CSG, CRDS…).In the face this outstanding burden, liberal surgeons are paid by fee for service within a rating system that leaves much to be desired, in spite of a reform in 2002, as the service fees have remained nearly unchanged over the last 30 years (+6,5%). For a practice to yield some benefit in this system of frozen fees and never ending social costs increase, there remain only two adjustment variables: fee increase by non-reimbursable increment and activity increase.The first was encouraged in the 80’s, when the state decided not to increase the official reimbursement value, but is now blamed for hindering access to care.The second variable leads to multiplying surgical procedures, a permanent danger pertaining to this logic and which the surgeon needs to fight back in spite of an environment pushing in that very direction: weak fees for each procedure, surgical procedure quotas required by the health authorities to allow continued practice (e.g. oncology authorizations), securing time allocation for surgical procedures, and, furthermore, the common state of the surgeon’s image. We can only hope the recommendations on procedure relevancy that are presently being drafted will take all these elements into account.Practicing surgery in a private environment is indeed a path full of pitfalls, the lonesome aspect of the practice is giving way to joining up in teams but the financial constraints of surgical enterprise, with skyrocketing social security costs could lead such professional practice to extinction to the benefit of other remuneration patterns, i.e. by means of wages paid by private institutions, as already planned in the current HPST law (Hospital, Patients, Santé, Territories).