WE DO NOT TELL ALL! WHY
DESTROY WHAT WORKS!
Shock Treatment to kill the public hospital!
the Selestat, 16 March 2010-15 Chronic Sick
, France, began a strike to protest against the treatment of lump sum payment for drugs, transport to hospitals and medical visits. Perilous mode of action recalls that health can not be a market "like the others." Now financing reforms of Social Security and public hospitals are jeopardizing access to care for the sick, the work of professionals involved and the quality of medicine. By André
Grimaldi, Thomas Papo and Jean-Paul Vernant
The crisis in hospitals and the French health system owes nothing to chance. It is primarily due to the resulting shortage of medical policy followed for twenty years, continuously, by all governments. During this period, there has been the formation of 8500-3500 doctors per year (1). This Malthusian policy was advocated both by some economists and health experts from unions doctors.
For economists in question, the supply determines demand. By decreasing the first, they were going to reduce the second. This position seems all the more astonishing that she did not understand, in parallel, no adaptation of the health care system. A less naive, liberal unions of doctors felt that reducing the number of practitioners would allow them to be in a strong position in the market. In fact, this practice helps decrease excess fees, including experts, which is largely acknowledged by the social security reform introduced by M. Philippe Douste-Blazy. The philosophy behind this practice is well summarized by the statement Dr. Guy-Marie Cousin, president of the Union of Gynecologists and Obstetricians of France if the fees exceeded clinically "not suitable for patients, he believes, they have to go to hospital to be by practitioners to treat foreign degree (2) "! Consequence of this logic, the medical desertification affects not only some rural areas but also some specialties inaccessible to those who can not afford the higher fees.
Needs rising health
Against this background of scarcity, at least relative's place the recurring debate about the "hole Safely." In part, this is a false debate because the accounts for Social Security depends not only on outputs, as well as financial returns. But the deficit of the disease - 6 billion euros this year - largely due to the lack of income, unemployment leading to a decrease of those from social security contributions. This fact leads to consider new options that are less random and more egalitarian. In fact, identical sales, businesses employing many staff are affected by compared to those employing little. In addition, the government largely practical exemptions of employer contributions, without fully repay the Social Security debt induced.
Finally, many outside contributions revenue. President of the Court of Auditors, Mr Philippe Séguin has calculated that if stock options were normally subject to payroll taxes, they would provide 3 billion euros, or half the deficit of the health of Social Security in 2007 (3). Indeed, the budget of the latter does not obey the laws of the market. Dependent deficit spending but also receipts, that is to say, resources allocated by the state budget eventually results from a political decision (4).
The real question is actually one of increased health needs - faster than the gross domestic product (GDP) - and it involves social choices. Despite the assertions of some statisticians reasoning relative increase in costs, increased health needs (and therefore their cost in absolute value) explained by five major developments: the aging and diseases related thereto; the increasing obesity and its complications (in the U.S. for the first time, the life expectancy of the population has declined for this reason), the development of anxiety and depression and addictive behaviors, medical advances, more or less important but still more expensive it is incomplete, which increases the number of chronic diseases is not known cure, but treatable at costs higher and higher (AIDS, diabetes, renal failure, rheumatoid arthritis, heart failure, coronary heart disease, osteoporosis, etc.)..
France spends 11% of its GDP Health - a rate similar to that of Germany, Canada and Switzerland, less important than the U.S. (16%) than that of the United Kingdom (9%). It seems realistic to assume that the output share of national wealth devoted to health should continue to increase, reaching, France, 15% in 2025.
This is a societal choice. The proponents of liberalism were also no objection to this increase in the share of GDP devoted to this area. What they deny is that these sums are beyond the law of profit. It is from this point sight very striking that economists and politicians who criticize the waste caused by unnecessary prescriptions or abusive work stoppages have nothing to say on three important areas of spending.
First, the waste of the pharmaceutical industry, which spends about 25% of its turnover on marketing, while the health market is not a market like any other: it is largely socialized, because more than financed by Social Security. A report by the General Inspectorate of Social Affairs (IGAS) (5) estimated that the amount of pharmaceutical marketing is 3 billion euros per year, not to mention the cost incurred by the requirements of new drugs, more expensive, but not bringing any significant improvement of medical service rendered (per capita, France spends 50% more for drugs that Italy, the United Kingdom, Spain and Germany). IGAS calls for stopping the race and a promotional discount of 50% of the money allocated to the marketing industry.
Then, proponents of liberalization of services remain silent on the results of the partial privatization of care, already achieved in some areas, eg for nutritional and respiratory support at home or on insulin pump therapy. These benefits are provided by private companies belonging to large groups such as Air Liquide and Nestlé. But the cost of insulin pump therapy has been multiplied by three, and these providers tend to impinge on the care given by specialists, including hospital services.
Finally, France holds the European record of hospitalizations in private for-profit (23%). The clinics are no longer, in most cases, ownership of the surgeons who work there, as was the case in the past. They belong mostly to international companies that operate in other sectors than health. This is true of the general health (one hundred and eighty clinics), who just bought the hospital in the Red Cross in the thirteenth arrondissement of Paris. This is also the case of a newcomer, Vitalia, linked to U.S. investment fund Blackstone, whose shareholders are demanding rates of return on capital above 20%.
Vitalia, which has bought forty clinics, continues its offensive. Similarly, the investment fund 21 Centrale Partners, linked to the Benetton family, acquired Chanteclair clinic in Marseille, "based on a future hub of excellence made up of several clinics. The French health sector therefore attracts international capital waiting for a wave of privatizations.
is in this context has been implemented hospital funding called T2A (DRG's), whose declared aim is to reduce the cost of hospitals. And the objective, unacknowledged, to increase funding for clinics.
In fact, funding is not based on a "Activity" (or care) as advertised, but sensible grouping of codes like disease. But these codes are largely "biased" because there are about ten thousand seven hundred only pathologies codes defining "homogeneous" group of stays (6). Each group can actually be heterogeneous and includes several diseases. Coincidentally, within a single "homogeneous" group, simple diseases represent the main activity of private clinics, while more complex and more serious match for most of the activities of public hospitals.
Thus, chronic sinusitis is for the clinic, the tumor to the ENT hospital sciatica for the clinic, the fracture of the spine to the hospital, the pacemaker clinic, hospital for heart failure . Moreover, in the case of purely hospital, such as treatment of leukemia or resuscitation heavier, their funding has often been underestimated. Have
permanently empty beds
Just look reveals that the alleged public-private convergence set by the Government for 2012 to understand the objective réel de la réforme du financement des hôpitaux. En effet, cette notion est aberrante en raison d’une différence structurelle des coûts. Ainsi, l’hôpital doit assurer la permanence des soins vingt-quatre heures sur vingt-quatre. Cela signifie qu’il doit toujours avoir des lits vides prêts pour faire face à tout besoin aigu (épidémie de bronchiolite, canicule, etc.). Contrairement à une clinique, il ne peut donc pas viser une occupation à 100 %. Ne pas financer les 15 % à 20 % de places vides, ce serait comme payer les pompiers seulement quand il y a le feu !
Pour la même raison, une partie des hospitalisations ne sont pas prévisibles. Or, pour une pathologie identical, an unscheduled admission costs about 60% more expensive than a scheduled admission. Moreover, the habit of making private practice elsewhere complementary tests required prior to entry into clinical (blood tests, electrocardiogram, radio ...), thereby externalize their costs, contrary to the public hospital , which realizes itself exams (7).
The T2A is made to measure the quantity, not quality, standardized procedures, not the complexity, technical moves, not the intellectual act. It takes into account neither the seriousness nor the activity highly specialized hospital services, or insecurity, or psychological problems, or patient education ... In other words, it is almost appropriate or at least adaptable to the conditions relating to technical procedures and clear procedures such as radiology, but it may be irrelevant and probably unsuitable for most of the activity of health services ( internal medicine, infectious diseases, diabetes, rheumatology, geriatrics, neurology ...) public hospitals.
Moreover, even for a single disease clearly codified (intervention for varicose veins for a hip replacement), one can not compare the statement made at the hospital by a young surgeon assisted by a senior and one made in town by a senior experienced who learned his trade years ago, at the hospital, and practical actions addressed "in the chain." Finally, doctors' salaries are included in hospital costs, while the fees of doctors and surgeons as well as amounts paid by Social Security to pay part of their insurance does not belong to private clinics. Designed
clearly in favor of Clinical implementation of T2A resulted in an increase of 9% Coding activity of such establishments. Some also have a software to find the appropriate coding for billing maximum Social Security.
The imbalance is even more evident that, as regards the public service missions, it was an envelope corresponding to only 10% of total revenues provided by the T2A. As expected, therefore, 90% of public hospitals - which twenty-nine of the thirty-two university hospitals (CHU) - will be in deficit, or even bankruptcy. To teaching hospitals, the hole should be 400 million euros, including 200 for Public Assistance - Hospitals of Paris (AP-HP) and 35 for the Hospital de la Pitie-Salpetriere. This deficit will serve as an argument to try to further increase productivity.
Chief Hospices Civils de Lyon, President of the Conference of Directors General Hospital, Dr. Paul Castel recently called for a review of the administrative status of hospitals: "Only a shock treatment through a change in status will Hospital to acquire the flexibility necessary for their competitiveness in an environment competitive (8). To this end, it recommends changing to a status of public industrial and commercial (EPIC), rather than administrative (EPA), giving managers "more autonomy in hiring and personnel management" " directors pass into contracts with medical teams to assign a profit. "Clearly, this is done with the status of public service and to hire people under private law contracts, particularly in order to be able to fire more easily.
The deficit will also justify the abandonment of certain activities, other restructuring or outright closure of establishments or their transformation into retirement homes or care centers on. Some may be sold in private. If we can understand that surgical services have more activity or not providing enough security requirements must be closed, we must see that these closures will be in favor of private clinics. Surprisingly, these do not seem subject to the same requirements to maintain their activity, as was observed during the development of obesity surgery (after an investigation by the health insurance acts digestive surgery for obesity rose from sixteen thousand in 2002 to ten thousand in 2003!).
matter, can we think that patients are operated on in the clinic if the quality is sufficient, and even better if it costs less to Social Security and therefore to the community. They forget the cost to the patient himself, with higher fees become exorbitant - as IGAS they reach 2 billion euros per year (9). In Paris, it is common to have to pay for exceeding the range of 500 to 1 000 euros for a cataract to a hip, Euro 3000 pour le chirurgien et 1 000 euros pour l’anesthésiste.
Ces phénomènes ne touchent pas seulement les cliniques mais concernent également l’activité privée au sein des hôpitaux publics. Il s’y pratique des dépassements d’honoraires qui, bien souvent, ne correspondent plus à aucune règle éthique : le médecin ou le chirurgien compare ses revenus à ceux d’un grand patron, d’une star du show-business, d’un champion du ballon rond. De même, quand on a fait entrer dans les têtes que « l’hôpital est une entreprise », on ne doit pas s’étonner que les internes en grève trouvent normal de bloquer la production, that is to say to the "strike of care."
Finally, when you put your butt to the various measures - deductibles, higher fees, threats déconventionnement, development (with high rates of return) of the private sector for profit - we can see that coherence : limiting the share of funding Social Security in favor of a role more important left to supplementary insurance, and in particular to private insurers. Their participation in health financing is likely to lead not on a medicine to two speeds, but on a medicine to ten or twenty speeds. Each choose an insurance "a la carte, not according to his needs, but within its means. Who will pay for this privatization? Neither the wealthier classes or upper middle strata. But neither the poorest beneficiaries of universal health coverage (CMU). The lower middle classes, who earn between once and twice the monthly minimum wage, however, will be hit first and foremost. More than 50% of employees. Two avenues of reform
almost inexorable progression of a policy called in question a public service we envy other countries operate through a proper strategy. And its six instruments
1. "Common sense" accounting. It allows to hide the profit motive and to conceal the ideology behind the new health policy. This bible has a few key phrases: "Medicine is a commodity like others," "Only the market is effective in addressing the needs," "The employment guarantee is a luxury of another age."
2. The Trojan horse. Several administrators the highest level, as the director of the National Health Insurance (CNAM), Mr. Frederick Van Roekeghem behave as opponents of public service, and seem to militate in favor of privatization.
3. Defectors. Economists and managers from the left have joined liberal politics. This is the case of Mr. Gilles Johanet, former director of Social Security became medical director of the AGF insurance, which had offered medical insurance for excellence 12,000 euros per year for entrepreneurs. It is also the case of Mr. John Kervasdoué, director of hospitals from 1981 to 1986, now strongly supports the development of the private sector in public hospitals and change status of the latter - which would allow them to lay off for economic reasons (10).
4. Some unions. The reform benefited from the collaboration of many unions, particularly medical, attracted by the rattle of power games under the new governance.
5. Policymakers. They use the tactic of "foot in the door, hand on the arm" from the handbook of good seller. Then you push a bit to widen the crack, while victims to believe they act for their own good. It began with the excess of 1 euro on the consultation, before cover boxes of tablets and transportation. Then comes the price increase. Always, of course, on behalf of the sacred defense of Social Security, which, hand on heart, it undermines the foundations with application. Down the road, we will use private insurers to bring order into the system and stop the arbitrary excess fees ...
6. Splitting resistors. The rulers have so far been able to play categorical divisions, CHU cons non-academic regional hospitals, large hospitals cons small district hospitals, university professors, hospital doctors (PU-PH) against non-university hospital physicians (PH), internal cons elderly, patients cared for at 100% (under long-term illness) against patients not covered at 100%, etc..
To counter this policy, defenders of public service reform could oppose him based on the needs of the population and to ensure equal access to care. Solidarity, the system must be financed by social contributions and taxes. From this point of view, if we can accept, even desire, the coexistence of a public service and private non-profit, il n’y a aucune raison que le financement public continue à enrichir les actionnaires de sociétés à but lucratif telles que la Générale de santé – qui vient de décider de verser 420 millions d’euros à ses actionnaires –, Vitalia, ou 21 Centrale Partners.
Deux voies de réforme du système de santé s’opposent. L’une, néolibérale de privatisation rampante, vise à transférer les coûts vers les ménages et les assureurs privés selon la formule : « A chacun selon ses moyens ». L’autre, républicaine, égalitaire, cherche à défendre le principe du : « A chacun selon ses besoins socialement Accepted. It seeks both to renovate the public service and to challenge the excesses mercantile medical practices and those of industrial health.
Andre Grimaldi, Thomas Papo and Jean-Paul Vernant.
Pharmaceuticals, Liberalism, Social Welfare, Health, Public Service, Medical
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André Grimaldi
Chief of Diabetology, Metabolism Group Hospital de la Pitie-Salpetriere (Paris). Thomas Papo
Chief of Internal Medicine, coordinator of the division of medicine Bichat Hospital (Paris). Jean-Paul Vernant
Head of Department of Hematology, coordinator of the division of hematology-oncology (Pitie-Salpetriere).
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(1) A few years ago, Social Security early retirement financed yet to GPs because of an alleged 'medical plethora'.
(2) Le Monde, Paris, August 31, 2006.
(3) Report of the Court of Auditors on Social Security 11 septembre 2007.
(4) Cf. Pierre Concialdi, Retraites : on vous ment !, Mango, Paris, 2005, et Julien Duval, Le Mythe du « trou de la Sécu », Raisons d’agir, Paris, 2007.
(5) « L’information des médecins généralistes sur le médicament », rapport publié le 31 octobre 2007.
(6) Fédération hospitalière de France, « Hôpitaux publics et cliniques privées : une convergence tarifaire faussée ».
(7) Lire André Grimaldi et José Timsit, « Hôpital entreprise contre hôpital public », Le Monde diplomatique, septembre 2006.
(8) « Hospitals want to change status to compete with the clinics, "Les Echos, Paris, 5 November 2007 (9). Aballea Pierre, Fabienne Bartoli, Laurence and Isabelle Eslous Yeni," Overtaking medical fees, "IGAS, RM-2007 -054P, Paris, April 2007. (10) John Kervasdoué, Hospital saw the bed, Seuil, Paris, 2004.Voir also letters from readers in our April 2008 issue.
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