The government is seeking to end the system of payment of doctors by patients, in favour of payment by the State, an approach contested by the medical profession.

Unlike most other health systems in Europe, for most patients in France medical treatment is not free at the point of delivery.

Patients need to hand over a fee for the consultation, following which they are reimbursed by the social security system, and by their complementary health insurer, provided in the latter case they have 'top-up' medical insurance.

The government argues that this is a system that penalises those on a low income, whom they consider are frequently unable to pay in advance, and who, as a result, do not seek medical treatment.

As Marisol Touraine, the Minister of Health stated recently: "Il faut que tout le monde puisse aller chez son médecin sans appréhension, même avec des difficultés financières."

Beyond improved access for patients, there is also a wish to reduce the pressure on hospitals from patients seeking emergency medical treatment, when a visit to their doctor might be all that is necessary.

As a result, the government are proposing to abolish patient payment of fees, when doctors will then be required to invoice the Caisse de l’Assurance-maladie and the complementary insurers for their consultation fees.

This system of payment is called 'tiers-payant' a phrase that really has no meaningful translation in English, but literally means 'third-party payment'.

It is a plan that has incurred the widespread opposition of doctors, many who have been out on strike over the issue.

The doctors argue that such a method of payment will be expensive and difficult for them to administer, that there will be delays in receiving payment, it will be more difficult to deal with fraudulent claims, and that by making access to the health system free at the point of delivery it will remove any sense of patient responsibility about the costs of health treatment.

They also consider that access to the health system is already facilitated for those on low income, for if they are insured through the Couverture Maladie Universelle Complémentaire (CMU-C), then patients currently have no need to pay up front, as a system of tiers-payant is in place.

Their arguments have not been entirely convincing, for a system of tiers-payant already operates amongst chemists, and without too many complaints from the professionals involved.

In their case, appropriate computer systems have been set up to ensure smooth and quick processing, an approach that should be transferable to doctors.

Many low-income households are also excluded from the CMUC due to the tough test of resources that is applied.

So to understand their grievance it probably necessary to appreciate that most doctors in France are self-employed, and that many see this change as the thin of the wedge to greater 'nationalisation' of their profession.

The fear that payment by the State will increase the level of monitoring of their work, that they will be less free to impose supplementary charges, or to set themselves up where they wish. As these supplementary charges (dépassements d’honoraires) will continue to be paid directly by the patient, they will become more transparent, and potentially more contentious.

It is a view that is more widespread amongst the specialists, for many GPs seem less tense about the measure. Indeed, one of the principal GP associations has stated that "le tiers payant est une avancée indispensable pour améliorer l’accès aux soins."

Tied up with the dispute are also other grievances by the doctors that are fanning the flames, notably that the government are unwilling to concede an increase in the regulated consultation fees, which the GPs wish to see increased from €23 to €25 per consultation.

The planned date for generalisation of the system of tiers-payant is 2017, but with the doctors unwilling at the present to concede to the new arrangements, a more gradualist approach may need to be taken. The Minister has indicated that she is prepared to talk on "les conditions de sa mise en oeuvre, notamment sur les garanties de paiement".

This is likely to mean, in the first instance, only that part of the fee reimbursable by the State will be paid directly to the doctor, whilst the 'top-up' payments will continue to be handed over by the patient.

Where the doctor imposes supplementary charges these will continue to be paid direct by the patient. Those charges that are neither reimbursable by the State or the insurers (franchise médicale, participation forfaitaire) will also need to be paid direct to the doctor.