Spatial and financial inequalities in access to outpatient specialist care in France. The case of cardiologists, dermatologists and ophthalmologists.

🔍💡 Inequalities in access to outpatient specialists: this document shows how where doctors are located and fee overruns deepen gaps between territories and between poorer and richer municipalities. 📊🩺 #HealthInequalities #AccessToCare

Source :     📒 Inégalités spatiales et financières d'accessibilité à la médecine de ville en France. Le cas des cardiologues, dermatologues et ophtalmologistes

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Analytical summary

Context and access challenges

The study analyses geographical and financial inequalities in access to outpatient specialist care in France, in a context of shrinking and unevenly distributed medical supply up to 2030, especially in private practice, against a backdrop of population ageing and increasing care needs. It focuses on three specialties – cardiology, dermatology and ophthalmology – chosen for their contrasting epidemiological, technological and tariff profiles, and for the frequent use of fee overruns in some territories. Spatial accessibility is measured at municipal level using the Potential Localised Accessibility (APL) index, which combines supply, age-adjusted demand and car travel times up to 60 minutes. The study highlights a core–periphery gradient in most départements, a structurally under-served central diagonal, and mountain areas or French Guiana with almost no access to certain specialties. It also shows that, in a significant share of the country, accessibility relies on secondary practices, especially in remote rural and peri-urban areas, which provide up to 40% of local specialist contacts. Finally, the financial dimension is captured through sector status (sector 1, sector 2 with or without Optam) and fee overruns, which determine out-of-pocket payments and thus effective access for low-income populations.

Operational contributions for stakeholders

The document provides a detailed adaptation of the APL index to outpatient specialists, parameterised by specialty, type of area, physicians’ age and tariff perimeter, making it possible to objectify infra-département inequalities far beyond simple département-level densities. It offers maps and indicators by municipality and by type of area (remote rural, small/medium/large/very large urban centres and commuter belts), useful for locally targeting policies on practice location, outreach clinics or cooperation with hospitals. The study distinguishes several perimeters of financially accessible supply (from sector 1 only up to all contacts including high fee overruns), which allows users to simulate the concrete impact of fee overruns on accessibility for different territorial and income profiles. It shows that dermatologists and ophthalmologists mostly work in sector 2, that access at regulated tariffs collapses in many areas when the perimeter is restricted, whereas cardiologists, who are mainly in sector 1, are more evenly distributed. Finally, the document calculates APL inequality ratios between the 10% best and worst supplied municipalities, which are much higher for specialists than for GPs, providing quantified arguments to strengthen regulation of supply and tariffs.

Key points of the document

Applying APL to specialists reveals intra-département core–periphery gradients that crude département-level densities hide, with peri-urban and rural areas heavily penalised despite sometimes seemingly adequate overall densities (e.g. the Pyrénées-Orientales) (pp. 3–5).

The APL methodology is adapted to outpatient specialist care: it takes into account actual activity (number of reimbursed contacts), secondary practices, four distance-time classes (<15, 15–30, 30–60, >60 minutes) and physicians’ age (≤ 70 years) (pp. 2–4).

Dermatologists and ophthalmologists are predominantly in sector 2 (56% and 61% of doctors in 2019 respectively), so that average APL is reduced by half or more when supply is restricted to sector 1 only or to moderate fee overruns, including in large urban centres (pp. 5–6).

Cardiologists, most of whom work in sector 1 (76%), show a more even geographical distribution and much lower sensitivity of APL levels to tariff practices, except in some highly urbanised départements (Île-de-France, Gironde) where accessibility relies more on sector 2 (pp. 5–7).

Fee overruns reinforce a social gradient in accessibility: total APL increases with municipal median income, since sector 2 supply is concentrated in richer municipalities, while APL at regulated tariffs varies little with income, thereby sharpening real access inequalities for poorer municipalities (pp. 7–8).

Action points for local stakeholders

Use APL maps and values by municipality to identify infra-département “pockets” with the greatest shortfalls in access to cardiologists, dermatologists and ophthalmologists, beyond département averages, and prioritise regulatory measures, recruitment and outreach clinics accordingly (pp. 3–5).

Target specifically remote rural municipalities and some peri-urban belts where accessibility depends almost entirely on secondary practices (up to the whole specialist supply in some areas) by securing these sites through agreements, health centres, mobile clinics and hospital partnerships (pp. 2–3).

Embed the tariff dimension in local planning: map APL under different perimeters (sector 1, Optam, moderate fee overruns) to pinpoint areas where lack of sector 1 and a strong presence of sector 2 create major financial barriers, and concentrate tools there such as the C2S scheme, practice-improvement contracts and incentives to join Optam (pp. 5–7).

Cross APL data with municipal income quintiles to target action on municipalities that are both poor and under-served by regulated-tariff supply, giving priority for example to after-hours services, planned hospital referral pathways, and mediation/health literacy activities on out-of-pocket payments (pp. 7–8).

Use specialist APL as a shared tool for territorial dialogue in CPTS, health contracts and regional health planning, by comparing inequalities in access to specialists and GPs, in order to justify combined measures on the distribution of supply and the control of fee overruns (p. 8).