From clinical recommendations to mandatory practice - The introduction of regulatory practice guidelines in the French Healthcare System

In an effort to control ambulatory care costs, regulatory practice guidelin es (references medicales opposables or RMOs) were introduced by law in Fran ce in 1993. RMOs are short sentences, negatively formulated ("it is inappro priate to..."), covering medical and surgical topics, diagnosis, and treatm ent. Since their introduction, physicians who do not comply with RMOs can b e fined. The fine is determined by a weighted combination of indices of har m, cost, and the number of violations. The impact of the RMO policy on physician practice has been questioned, but so far few evaluations had been performed. At the end of 1997, only 121 ph ysicians had been fined (0.1% of French private physicians). The difficulty of controlling physicians, the large number of RMOs, and the lack of a rel evant information system limit the credibility of this policy. The simultaneous development of a clinical guideline program to improve the quality of care and of a program to control medical practice can lead to a misunderstanding among clinicians and health policy makers. Financial ince ntives or disincentives could be used to change physician behavior, in addi tion to other measures such as education and organizational changes, if the y are simple, well explained, and do not raise any ethical conflict. But th ese measures are dependent on the structure and financing of the healthcare system and on the socioeconomic and cultural context. More research is nee ded to assess the impact of interventions using financial incentives and di sincentives on physician behavior.