The distribution of tasks, a mirage in the medical desert?

Distribution or delegation of tasks, the vexing topic? Or how to find solutions by avoiding the coercive impasse of the regulation of the installation… By experimenting with direct access to masseurs-physiotherapists and speech therapists? By expanding access to dispensing according to protocol, which enables the pharmacist to supply the patient with one or more compulsory prescription drugs without a prescription? Several measures are tested within the framework of formal cooperation protocols. Long hampered by a discouraging administrative burden, however, they have been simplified by the Health System Modernization Act of July 2019. Every year, 4 to 6 national protocols are developed to respond to public health issues and, on the other hand, local protocols. This more flexible formula gives e.g. midwives the opportunity to benefit from a delegation for the treatment of chlamydia with a simple declaration to the ARS.

medical assistants

The solution of hiring “city carers” as a priority in under-resourced areas by removing the group training condition for payment of recruitment assistance from CNAM1 is cited by many observers. A study carried out by the BVA for Health Insurance (March 2021) describes invaluable assistance to doctors, especially through the performance of administrative tasks that “cannibalize” medical time (to use the CNOM formula): receiving patients, management telephone contacts, updating the patient’s journal, invoicing, protocols, scanning of the results of the assessments. According to the BVA survey, medical assistants perceive their missions as “challenging and attractive due to the proximity of patients”.

CNAM estimates that physician assistants have increased the active file by 1,077,156 patients (patients seen at least once a year in the hospital or in consultation). 1 o’clockeh In February 2022, 2,809 medical assistant contracts (of 1,486 FTE) were signed with health insurance funds by 2,150 general practitioners and 560 specialists, including 1,406 contracts signed in areas with underdensity. A result below the targets that the government has set for 4,000 assistants in 2022. A recent report from the Senate2prepared by the Regional Planning Commission, on combating medical deserts, suggests raising this hiring target “at 10,000 dby 2024, to overcome the difficult course at the lowest point in terms of GPs, in particular by facilitating the management of their funding in under-dense areas where their leverage on the patient base is the strongest.”.

Lack of readability of advanced practice

Other structural solutions are not yet showing the expected results. With expanded competencies, nurses in advanced practice (IPA) who follow patients for their chronic pathology(s) can, within the framework of a trial protocol, prescribe additional examinations, request follow-up and preventive actions, but also renew or adapt any , certain medical prescriptions. Not to mention, note the senators in the aforementioned report2that this is an attractiveness factor in desolate areas: ” A team of involved paramedical professionals is the guarantee of good working conditions.facility for young doctors who are increasingly aware of the quality of the health and care ecosystem. »

They are just under 1,000 IPA graduates in March 2022 (plus 1,425 professionals in training at 27 universities). The stabilized chronic pathologies, prevention and common pathologies in primary care make up more than half of the workforce, followed by oncology-hematology, nephrology-dialysis and dialysis reviews… well ahead of the newer reviews, psychiatry and emergencies. When 5,000 IPAs will be trained (this was a goal for the end of the President’s term, by the way), they will represent only 0.7% of all 764,000 nurses.

They are just under 1,000 IPA graduates in March 2022 (+1,425 professionals in training at 27 universities)

In January 2022, a report by the General Inspectorate of Social Affairs (IGAS) was published on the mechanisms for sharing skills between professionals and cooperation protocols. In terms of advanced practice, he describes a ” growth thwarted both by the reliance on the doctor it establishes for access to patients and an unsuitable and undersized economic model.”.

One of the main recommendations of the mission is to distinguish between two types of advanced practice: that of “specialized” APNs and that of another intermediate profession, “practicing” APNs, health professionals in primary care and in the general population of common and benign pathologies. .This, of course, provided that certain conditions, which are still lacking, are met: a “coherent regulatory framework” which provides direct access to the population and the first prescription of APIs4 and the revision of the economic model as well as the financing, in liberal (in the conventional way) as in the hospital. IGAS also suggests evaluating direct access to certain nonmedical professionals, including APNs, in coordination with attending physicians.

However, the report does not consider it appropriate in the current context to create a new health profession ex nihilo as RPNs are already an intermediate profession and are considered as such, although ” their position in the Public Health Act does not currently recognize this status “.

Sources:

1 Amendment 7 to the medical agreement of 20. June 2019 clarifies that the help for the recruitment of a medical assistant concerns doctors who (with some exceptions) practice together, in a practice with at least 2 doctors or already practice in a coordinated way.

2 https://s3-eu-west-1.amazonaws.com/static.hospimedia.fr/documents/220225/7831/r21-5891.pdf?1649424702

3 New special bonus for IPAs in the public hospital system will be paid from 1eh April 2022.

4 Correcting the texts that currently prohibit patients from consulting an APN on their own initiative, and APNs from first prescribing certain treatments or services for their patients, deleting the mention of trusted patients who “compromise the development of ​​the training and goes against the free patient’s choice”.

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