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Cervical cancer: Is screening management worse?


HEALTH PROTECTION – Implementing a large-scale screening for cervical cancer is one of the priorities of the government's cancer plan for 2014-2019. In France, 3,000 cases of invasive cancer have been detected, and 1100 patients die every year. However, within two months, some gynecologists condemn the devaluation of the cervical screening by the National Health Insurance Fund.

On January 22, the first day of the 11th European Week of Cervical Cancer Prevention, the National Cancer Institute (INCA) launched an active information campaign to warn of the importance of screening. With brochures, posters and brochures, INCa invites practitioners to feel interested and better inform their patients. This third national screening program, announced by Health Minister Agnes Buzin in the spring of 2018, is a priority for the cancer plan for 2014-2019. By allowing all women between the ages of 25 and 65 to have access to regular cervical screening, the goal is to reduce the incidence and mortality of this cancer by 30%, of which 1,100 women died. Every year.

However, on May 11, 2019, billing for medical procedures for screening cancer of the cervix was fixed, which, according to gynecologists, made it more difficult for them to reach social welfare. Several practitioners quickly condemned this contradiction, in particular because of the voice of the FMF, the Federation of Physicians of France.

When screening for cervical cancer, the first test is a cervical gonadotype, more commonly known as a swab. In the case of abnormal smear, colposcopy, a cervical examination using a dandruff – colposcope – should be performed after the application of two dyes. If there are abnormal cells, they absorb these dyes and become visible. After that, the practitioner may perform a biopsy that involves getting small fragments of colored tissue for microscopic examination to determine if abnormal cells are cancerous or pre-cancerous.

Each medical act performed by a professional is represented by the code listed in the General Classification of Medical Procedures (ACMK), in order to better identify the invoices and social security benefits. Until now, the JLQE002 medical procedure that applies to colposcopy can be cumulative with the JKHA002 Act concerning cervical biopsy. Two additional studies: colposcopy identifies the problem, and the biopsy allows you to diagnose. But since May 11, practitioners can no longer make sheets of burns that accumulate two acts. The procedure is blocked on the electronic procedure sheets, and on paper care sheets all reimbursement is rejected by health insurance in a few days.

Computer upgrade

Dr Hocquemiller, a colposcopy gynecologist, exposed in sector 1 in the Paris region, is one of the first to have this information. He understood the change of account after the abandonment of several dozen care sheets. "There was no consultation, no warning, no communication," says a practitioner at the Fournier Institute, which joined the ICS. "My patients could not be reimbursed, we had to rework all the steps, all for what? To save money," he mourned.

Dr. Hoinh, vice president of FMF, is a bad signal that is being sent in the middle of the campaign. "This is the decision of the bureaucrats, they do not deal with the consequences in reality, neither the method of reimbursement of patients nor the result of the regularity of their impressions," condemns the gynecologist from the ICS.

Consequence of "mistakes by some practitioners"?

For its part, the National Health Insurance Fund (CNAM) provides the LCI that this "simple computer upgrade" is a consequence of the "repeated mistake of some doctors who have billed abnormally these exams." According to CNAM, "the colposcopy formulation JLQE002 indicates" with or without: biopsy and / or collection, "and the price of" colposcopy with a biopsy "was set at 49.82 euros." Thus, before the update, when practitioners combined the colposcopic code – with a biopsy included under medical insurance – and biologically independent of the code, CNAM believed that they were charged twice for a biopsy.

During the annual inspections, health insurance "would indicate these accruals, inform healthcare workers and request the collection of unlawfully paid amounts as a result of double-counting of biosphere bills" in accordance with their services. Then, in order to put an end to this "false encoding," CNAM consulted the healthcare professionals three times to find a solution. "It was decided by mutual consent to block the possibility of simultaneous evaluation of colposcopy and biopsy." This update, effective from May 11, 2019, does not affect the management or treatment of patients. reimbursement to patients, "says health insurance.

However, in the official description of the general classification of medical procedures (Ccam), a biopsy is never mentioned in the editorial, description, or notes of colposcopy. In-house software practitioners also have no traces of this accuracy. "The truth is that they completely devalued the medical procedure of the cervix biopsy," says Dr. Hockemiller. "The colposcopy has always been estimated at 49.82 euros, so they believe the biopsy is free?"

Are doctors less paid or patients less reimbursed?

Unfortunately, a biopsy is far from an inexpensive medical procedure. Usually at a price of EUR 21.45, she was paid EUR 10 for patients, as the second medical act, performed on the same consultation, will be charged at a rate of 50%. "Even before the update is not profitable, given the cost of tweezers to make samples, and the cost of their sterilization." What consequences should be feared for the proper conduct of organized screening, which the state wants?

For practitioners in the 1st sector, tariffs are regulated, they can not charge a fee beyond the limits of Ccam rates. For patients, care is the same, physicians blame the blow by performing two actions at the price of one. On the other hand, for practitioners in Sector 2, the rates depend on the excess of the fee, the impact will have consequences for the patients. The frequency of consultation, colposcopy and biopsy will remain unchanged, but they will be less reimbursed, as the colposcopy will now be available on the help pages.

Even assuming that all gynecologists are guided by their professional consciousness and that this does not prevent them from undergoing additional examinations in case of abnormal smears, this, according to practitioners, remains a problematic condition of the medical profession. Medical insurance during a national campaign for screening for cervical cancer. Dr. Huynh reports that the problem was presented to CNAM in the National Joint Committee in June, without reaction from them until today, two months after the computer upgrade. "Do they think or hide? We do not know," said the gynecologist. – But it is serious, screening [de cette ampleur] should take the professionals to bring results, and this is not an extended hand. "

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