Abstract
Background: This presentation examines the results of a sociological study on the introduction of a flat-rate payment system for general practitioners within the PEPS pilot programme in France. The programme aims to enhance coordination between general practitioners and primary care nurses.
Approach: The study is based on an evaluative sociological analysis using a qualitative methodology, which includes around forty semi-structured interviews. These interviews capture the views and practices of health professionals at the local level. The PEPS pilot programme is managed by the Ministry of Health and the National Health Insurance, following a co-constructive approach involving health professionals through regular consultations in the design and implementation process.
Results: Over the past 15 years, integrated care policies have significantly evolved within primary care in France. A major shift came with the creation of multi-professional primary care groups in 2015, improving coordination among health professionals and introducing collective remuneration schemes. Traditionally, primary care in France has been organised around self-employed providers, compensated through fee-for-service payments. However, this model is seen by both administrative stakeholders and some providers as a barrier to interprofessional coordination, as it promotes competition between different practitioners.
From 2019 to 2024, the PEPS pilot programme offered general practitioners in about 15 multi-professional primary care groups the option to replace individual fee-for-service payments with a collective flat-rate payment per patient. The aim of this payment system was to incentivise closer collaboration between GPs and nurses.
The study focuses on two private primary care groups. Findings show that participating GPs share a distinct profile, often critical of fee-for-service payments, which in the French context symbolise professional autonomy for self-employed doctors. In these groups, the PEPS flat-rate payment initially reshaped professional practices, allowing doctors greater flexibility in patient care, such as adjusting consultation times based on needs. Additionally, the payment improved working conditions for self-employed practitioners by stabilising income.
However, the PEPS payment does not automatically enhance coordination with other healthcare professionals. In the surveyed primary-care groups, GPs were already seeking to collaborate with other professionals, but the flat-rate payment did not necessarily advance this collaborative work. Most often, collaborative projects, such as prevention programmes or patient education initiatives, are supported by other funding sources rather than PEPS.
Finally, one key challenge remains for the potential national implementation of the flat-rate payment: the collective distribution of the payment among GPs. While the surveyed primary-care groups found distribution methods that satisfied all professionals, 17 primary-care groups withdrew from the pilot programme due to internal conflicts over how to divide the collective payment.
Implications: This research provides insights into the implementation of flat-rate payments aimed at improving coordinated patient care in primary settings. While it highlights the benefits of flat-rate payments for the working conditions of self-employed doctors in France, it shows limited evidence of significant improvements in integrated care across the surveyed primary care groups. These findings contribute to understanding the interactions between payment systems and the development of integrated care.