Following the Covid-19 pandemic, which revealed the importance of the subject of mental health, a conference on mental health and psychiatry was held on 28 September 2021. The head of state, Emmanuel Macron, announced the reimbursement of psychologists’ consultations on medical prescription, as well as the creation of 800 posts in the medical-psychological centers. This announcement, which seems to suit the patients, is in fact boycotted by many psychologists because the forms of this new system seem to jeopardize a whole profession.
What are the consequences for the patient?
One of the first notable consequences stated by many professionals is the complexity of the care pathway for patients. Indeed, these measures require the patient to first meet with his or her general practitioner in order to determine whether he or she is eligible for reimbursement, yet these health professionals are generally not trained in psychopathology. If the patient is eligible, then he/she can then undergo an assessment with a psychologist. Following this assessment, the patient must return to their general practitioner (GP) with their psychological report. The latter will have to validate with the CPAM (the french health insurance fund) that the patient is eligible for reimbursement and will then determine, on the basis of this assessment, the number of psychological follow-up sessions to which the patient will be entitled (7 sessions maximum). If these sessions are not sufficient, the patient will have to go back to his GP to receive a prescription to meet a psychiatrist who will also provide a report. This report will again be analyzed by the GP who will then prescribe or not prescribe additional sessions with a psychologist.
The treatment pathway thus becomes an obstacle course for all patients who are eligible for this scheme, and constitutes a barrier to treatment for people suffering from mental illness. Moreover, the 8 sessions (the assessment session and the 7 psychological follow-up sessions) can only be renewed once a year, which means that the patient will only have 7 reimbursed psychological follow-up sessions per year (approximately 1 session every 2 months). The patient will have to choose his or her therapist from a list of professionals adhering to this system and it will not be possible for him or her to change therapists within the framework of this scheme. It will therefore be complicated to engage in a therapeutic follow-up perfectly adapted to the needs of the patients, since to do so it is often necessary to meet several therapists.
Finally, if it’s necessary for the patient to undergo psychotherapy and not a psychological support interview, this will require additional validation by a psychiatric doctor. The association ProPsy, which aims to promote the reality of psychologists and to organize reflection on the practice of psychology, interviewed psychologist Valérie Gialdini. This professional also underlines the complexity of the procedure with the CPAM and adds that doctors are not always aware of such procedures. According to her, the first prescription should be entitled “psychological assessment interview”, while the second prescription should be called “psychological support”. They also have to be careful to make sure that the date of the prescription is not the same as the date of the certificate.
Difficulties in access to care are not the only consequences that patients will encounter. Indeed, these measures will also lead to a loss of confidentiality as health insurers and GPs will have access to the reports of professional psychologists. This is particularly problematic for patients whose GP is the family doctor. The latter will then be informed of the patient’s family problems if these are the object of their suffering.
It is also important to specify that this system only concerns a specific population. Only certain mild to moderate disorders fall within the scope of this scheme. Consequently, in the case of severe disorders, patients will have to be redirected to more specialized structures. Furthermore, it would seem that patients who have suffered from an addiction or a psychiatric disorder will not be eligible for this scheme and that the use of psychotropic drugs is also perceived as a marker of the severity of the pathology.
What are the consequences for professionals?
First of all, not all professionals will be concerned by this new measure, even if they can practice in private practice, in a health institution or in a multidisciplinary house. Only voluntary psychologists who have signed an agreement with the CPAM will be involved in this scheme. Moreover, these contracted psychologists will be selected on the basis of criteria not yet established but still being defined with the representatives of the profession.
Thus, there are two major consequences for the professionals concerned by this scheme. Firstly, the reimbursement of psychotherapy sessions implies a reduced remuneration for the professionals. This will not allow them to make a decent living from their profession. Let’s take the example of a psychologist whose office rent is €800 full time. The reimbursement rate for consultations is set at €30 for follow-up sessions (and €40 for assessment sessions). All of this is for a maximum of forty minutes, with no extra charge if the time is exceeded. Thus, for a psychologist working five days in his practice and having five consultations a day, he earns about 3000€ a month. However, after deducting state taxes, rent, ancillary charges and taxes, he will only have a salary equivalent to the minimum wage. This does not correspond to the level of study of psychologists (which can range from 5 years to 8 years for some). The system does not take into account all the additional activities of the psychologist which are necessary for the good care of the patients (activities such as the writing of assessments, specific time allocated to continuing education, administrative time, etc).
In addition, there is the issue of psychological exhaustion. Indeed, if psychologists want to make a decent living from their profession, they will have to deal with 10-15 patients per day, which is impossible to achieve in practice. Moreover, this is a major threat to the quality of patient care…
The psychologist refers his or her practice to the fundamental rights and freedoms guaranteed by the law and the Constitution, by the general principles of Community law and by international conventions and treaties. He or she shall practice with respect for the person, his or her dignity and freedom. The psychologist endeavors to respect the autonomy of the person and in particular his or her right to information, freedom of judgment and decision. All persons must be informed of the possibility of consulting directly the psychologist of their choice.
What are the consequences for care?
The treatment concerned by this system seems less efficient for the patient, but also potentially abusive for him.
The treatment does not stop at the end of the session, as the psychologist continues to think about the information provided by the patient, taking notes, writing a report, etc. If the psychologist has to carry out ten or more sessions, he or she may be unable to do so. If the psychologist has to conduct ten or even fifteen interviews a day (whereas at present they receive about five patients a day), he or she will not have the same psychological availability, which will inevitably affect the treatment. Thus, the additional care time will be significantly reduced because of the addition of remote transmissions for the CPAM, reports for general practitioners, psychiatrists, etc.
Coverage will also be affected by the reduction of time allocated to continuing education for psychologists. Many professionals pay for supervisions and continuously learning after graduation in order to provide better care to their patients. However, if psychologists have to deal with fifteen patients every day, the time allocated to learning will be greatly reduced and will have a major impact on the quality of care. Finally, there is a risk of patient abuse with this scheme as it only concerns sessions of one hour maximum. Combined with a low remuneration of 30€ and a high administrative burden, the consultation time will be greatly reduced from 45mn-1h to 20mn maximum.
Conclusion
The set of measures announced by this scheme seems to divide mental health professionals. The president of the FFPP (French Federation of the Psychologists in Psychology), Gladys Mondière, seems to be unfavorable to the proposed tariff for sessions, but nevertheless notes the progress made in recent months during negotiations (Darmon, 2021). Indeed, the public concern also includes children and teenagers, since it has been extended to people aged 3 to 18. Also, the CPAM was recently taken into account to give its opinion on the notion of referral, which is a recent advance because it had often been forgotten on the question of prescription. Thus, the representatives of the FFPP are currently working on making this system official, and even on simplifying the referral system, in collaboration with general practitioners and psychiatrists. Their objective is to reduce the number of patients going back and forth between these different professionals. The President of the FFPP noted that the budget allocated to finance the sessions was not extensible and that the few sessions offered were nevertheless important for the population. Moreover, this system could encourage patients to discover psychological care, to take the plunge and consequently break the taboos associated with consulting a psychologist.
5 words/ expression we have learned and their translation :
– State of play = état des lieux
– Reimbursement = remboursement
– Obstacle course = parcours du combattant
– Scheme = dispositif
– To fall within the scope of = rentrer dans le cadre de
Bibliography :
Darmon, L. (2021). Remboursement : la psychologie a-t-elle un prix ? Le Journal des psychologues, n° 392(10), 7‑8. https://doi.org/10.3917/jdp.392.0007