several avenues for development proposed in a draft amendment to the medical convention

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The director general of the National Health Insurance Fund (Cnam), Nicolas Revel, had announced in early December 2019 that he was in favor of a relaxation of endorsement no. 6, notably regulating teleconsultation, in order to take into account "all relevant clinical situations".

Endorsement n ° 6, signed in June 2018 between the National Union of Health Insurance Funds (Uncam) and the five unions representing liberal doctors, was approved in August following in the Official Journal.

It sets the framework for teleconsultations carried out by registered doctors in order to allow their reimbursement, by including it in the course of coordinated care, while providing for some exceptions.

If the amendment project reaffirms the need to respect the coordinated care pathway, and to include teleconsultations in a territorial framework, flexibility is envisaged, as well as an experimental framework allowing additional derogations.

It is thus planned to modify the field of application of teleconsultation which would no longer be reserved only for doctors "exercising a contracted liberal activity" but also for doctors practicing "in a contracted structure", for example those of health centers.

The general framework would be maintained, by reaffirming the principle of an initial orientation by the attending physician, the patient being already known by the consulting physician (physical consultation in the previous 12 months), with alternation with physical consultation over a period of 12 months.

To the two existing exceptions (absence of designated attending physician and unavailability of the latter within a period compatible with their state of health), would be added the emergency situation within the meaning of the social security code, the condition of residential care for dependent elderly people (Ehpad) or accompanying adults with disabilities, and detained persons.

"The territoriality of the response by teleconsultation to a need for care constitutes a general principle applying as much to teleconsultations organized on the guidance of the attending physician as to teleconsultations without orientation of the attending physician", it is stipulated in the project.

The stipulations of endorsement n ° 6 listing the structures concerned would be maintained (professional regional health communities -CPTS-, primary care teams -ESP-, multiprofessional health houses -MSP- health centers -CDS- and "any organization "notably proposing to organize a telemedicine response in a coordinated manner open to all healthcare professionals in the territory).

It would however be specified that "the methods of recourse to teleconsultation acts put in place by these coordinated territorial organizations are necessarily defined with a local territorial anchoring" in order to respect these principles and to "ultimately allow patients who request them to benefit "physical consultations" and to be able to return to the course of care in the long term ".

It would now be clearly stated that a "territorial organization cannot cover the entire national territory", no doubt in response to the deployment of specialized platforms to which health insurance disputes the reimbursement of services provided.

The compulsory validation of these joint committee structures bringing together doctors and health insurance at local (CPL) or regional (CPR) level would be replaced by a referral by the primary health insurance funds (CPAM), after simple advice from these bodies.

The validation process in CPL / CPR would however be maintained for territorial organizations other than CPTS, ESP, MSP or CDS, "in order to verify that they meet the principles defined in this agreement as regards the conditions for taking charge of acts teleconsultations ".

Finally, the endorsement project aims to allow the carrying out of experiments, by departing from the framework set for reimbursement (initial orientation by the attending physician, prior knowledge of the patient and alternation over 12 months of face-to-face consultations and teleconsultations, territorial nature of the answer).

Project leaders could submit a request to the National Joint Commission (CPN), detailing "the precise outline of the organization envisaged, the exemptions provided for in relation to the methods of organization and taking charge of teleconsultation acts" and the reasons justifying them, the territory envisaged and the methods for evaluating the experiment.

The experimentation would be authorized by the Director General of Uncam, on the assent of the CPN.

These relaxations should allow an acceleration of the development of teleconsultations, the number of which would have exceeded 60,000 in 2019, according to the Cnam.

The negotiation of this endorsement project takes place in a context marked by the development of platforms offering teleconsultations at the national level, sometimes bypassing the course of care.

Thus, the Council of State is seized of a litigation between the health insurance and DigiSanté / Livi, and engaged jointly with the order of the doctors a summary against a website promising the delivery of sick leaves at the end a teleconsultation.

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