Léna Briant, University of Nantes
In France, mental health is a public health issue and a priority, mostly because mental disorders (psychiatric illnesses, use of psychotropic drugs, etc.) represent the first health insurance’s general expenditure per pathology, before cancer and cardiovascular disease, set to billions of euros. The pandemic linked to Covid-19 have speed things up. Indeed, last month, the French National Assembly voted for health insurance to cover payment of psychological consults. This measure will be effective as of 2022 but psychologists have been protesting against it since last June.
French President Emmanuel Macron has positively responded to the ‘historic request’ for reimbursement of psychological consultations. This measure aims to simplify and streamline the path for patients using this type of care, while facilitating financial access. It is intended for all insured person who’s at least three years old. All you need is a medical prescription. Prices for these consultations are set: 40€ for the first session and 30€ for the following ones. But be careful: you won’t be repaid for 30€ or 40€ if your usual consultation costs 60€ for example. Only capped sessions at 30€ or 40€ will be taking in charge by the health insurance.
Psychologists won’t be obliged to offer consultations at capped rates. The government insisted on this measure being based on volunteering. Thus, volunteer psychologists will sign a convention with the health insurance and they still will be able, if they want, to continue to exercise their activity at their own rates without these consultations being reimbursed. As for psychologists who want to continue their practice outside the care pathways, often with higher prices, will be able to do so. The list of psychologists contracted with the health insurance will be available in an accessible and easy way to potential users. This measure concerns psychologists from all horizons: the one in private practice or in a salaried practice in a health facility or a multi-professional health center.
The government have planned to adapt the number of sessions to the needs of each patient, within the limit of maximum eight consultations a year. This package may be renewed annually if your doctor considers it necessary. Besides, following an experiment by the CNAM (National Health Insurance Found), the government have also set the length of each consultation: they estimate the first one at 55 minutes and the following ones at 40 minutes.
‘This measure is contrary to the code of ethics of psychologists’
This governmental measure’s purpose is to improve mental health care while fighting against health and financial inequalities. Then why French psychologists riot? This 28th September all psychological unions called psychologists to march against this measure, and here is why.
The biggest issue is that it is the general practitioner who makes the prescription for the patient to access these reimbursed consultations. Indeed, to benefit from these repaid consultations, the patient will have to make an appointment with his doctor first (which will cost money) and only then, the doctor will be able to guide the patient towards a psychologist according to his diagnosed troubles. To do so, the patient will have to fill up a questionnaire in order to find out if he fits in the box ‘mild to moderate depression or anxiety disorders’, which will be the only authorized reason to benefit from the repaid consults. It means that the general practitioner diagnoses the patient himself (which is the psychologist’s job) with only a questionnaire completed by the patient within only an appointment. The doctor can be the family doctor so it pinpoints a confidentiality issue.Once the questionnaire is done and the eligibility conditions checked, the prescription must be verified by the CNAM. It takes time and a lot of people intervene in this process. Besides, an individual shouldn’t have to be depressed or anxious to be able to see a psychologist, there is many more valid reasons. Even more, it is important to highlight that anyone who have been concerned or are concerned by an addiction, a psychiatric pathology, comorbidities or consumption of psychotropic drugs (during the last 24 months) or benzodiazepines (during the last 12 months) are automatically excluded from this device. This is discrimination.
Once the prescription is verified and accepted, the patient will choose among a list, previously established by his doctor, his psychologist for the first reimbursed 55-minutes-long-consultation. After which the psychologist will be obligated to make a report to the patient’s doctor so he can prescribe the number of sessions and impose their rhythm. It breaks the confidentiality between patient and psychologist and makes things complicated because it involves three people instead of two. The general practitioner chooses almost everything for the patient without leaving him a choice and without the opinion of the psychologist. Besides, the volunteer psychologists to this measure may be the young and precarious ones because it will fill their agenda. The risk is that there will be few registrants and therefore little choice for patients. In addition, the patient won’t be able to change psychologist after the first consultation because it would mean losing his reimbursement rights.
Another problem is that the imposed duration of the sessions no longer leaves psychologists free to choose their tools and this will directly impact certain follow-ups, in particular those psycho-trauma-related. Besides, the prices set are also too low to live on this alone. At 30€ per session, with a full-time and once the charges removed, psychologists will barely reach an hourly minimum wage. Unless they don’t take breaks between patients which would reduce the quality of their active listening and their skills. It can be very demanding sometimes and without breaks, they risk to feel overwhelmed more quickly. Above all that, what bothers psychologists is contempt for their profession. They have been denouncing a measure taken in a hurry ‘against the backdrop of the Covid-19 pandemic’ since June but haven’t been heard by the government since it will be settled in despite their strikes and protests. ‘Psychologists want to defend their independence vis-à-vis medicine’ explained Laurent Laporte, of the CGT (General Confederation of Work) during a rally in front of the Ministry of Health organized shortly before the presidential announcements. ‘We would like to be associated, we are not, they decide everything without us, with doctors’ adds Christine Manuel of the SNP (National Union of Psychologists). ‘While we were free of access and independent, we were placed under medical supervision, while general practitioners have much better to do, much more urgent, much more related to their core, they will have to fill out paperwork so that another person can exercise their profession’ write an angry psychologist in a manifest. ‘There is a pathologizing and medicalization of the psychologic consultation as well as a loss of freedom in the choice of the practitioner. This measure is contrary to the code of ethics of psychologists’ she writes.
Sources:
Official government website: https://solidarites-sante.gouv.fr/prevention-en-sante/sante-mentale/accompagnement-psychologique/article/vers-un-remboursement-des-seances-de-psychologues-en-2022
Official government report on mental and psychiatric health: https://solidarites-sante.gouv.fr/IMG/pdf/180628_-_dossier_de_presse_-_comite_strategie_sante_mentale.pdf
Article from a French newspaper: https://www.lemonde.fr/societe/article/2021/09/28/les-consultations-chez-un-psychologue-seront-remboursees-sur-prescription-medicale-a-hauteur-de-30-a-40-euros-a-partir-de-2022-annonce-emmanuel-macron_6096326_3224.html
Manifest from psychologist Prudence Nazeyrollas: https://www.psynancy.com/post/boycott-2022