Arnaud Montebourg: Integrating the quality of care in the financing of hospitals

After the success of the Primary of the right and the center (4.4 million voters in the second round) which crowned François Fillon, it is the turn of the French left to elect – on January 22 and 29 – its candidate for the 2017 presidential election. And a notable change has taken place compared to the previous election, health is at the center of the debates. Health insurance, hospital … the French wanted to hear about it, they are served.

Our series of interviews with the seven candidates for the Primary of the Belle Popular Alliance continues this Wednesday with Arnaud Montebourg, former Minister of the Economy, Productive Recovery and Digital. Does the “Alternative Project” he claims to have for France also concern the health system? Reply.

The community will no longer be able to cover the cost of innovative drugs. Should we devote a specific budget to the support of these therapies, and how to finance it?
Arnaud Montebourg : Research and innovation in the field of health are now producing spectacular results which make it possible to significantly improve the daily lives of patients suffering from serious pathologies. However, the cost of certain molecules can contribute to calling into question the sustainability of our health system based on solidarity and access for all to quality care. In the PLFSS for 2017, a Fund for the financing of pharmaceutical innovation (FFIP) in the amount of 220 million euros, was created for this purpose. However, I think that there is currently a lack of a mechanism for regulating the prices of certain medicines at European level, or even in connection with the WTO. It is not normal that some laboratories impose unreasonable prices. The example of Harvoni, a drug against hepatitis C sold for nearly € 48,000 for twelve weeks of treatment in France, € 39,000 in the United Kingdom and $ 900 in India is particularly significant. This regulation, resulting from negotiations with the pharmaceutical industry, and which exists in France via the CEPS, would make it possible to maintain the sustainability of the system without calling into question the economic model of these particularly dynamic industries. Harmonization would avoid the risk of competition in access to innovation. Indeed, the pharmaceutical industries could be tempted to “serve” first the countries which would accept higher prices.

Big and small risk We would move from a solidarity system to an individualisation of risk with contracts with multiple and varied cover, sometimes illegible for citizens.

To ensure the coverage of health expenses, should mandatory reimbursements be limited to serious and / or chronic illnesses (care basket), or rather act on funding by broadening the base of levies (for example with the CSG )?
Arnaud Montebourg : Unlike the initial positions of the candidate nominated by the right, I am not in favor of calling into question our social security system. The candidate François Fillon, inspired by liberal theses, wishes to keep chronic OR serious pathologies in a basket of care reimbursed by compulsory schemes. Take the example of some long-lasting illnesses (ALD). In May 2011, we had a precedent with the removal of severe hypertension from the list of these ALDs, by Xavier Bertrand. Some of you rightly protested against this decision. As François Fillon conceives, one could imagine that a diabetes balanced by treatment remains a chronic disease but … without a serious nature! According to a survey by the DRESS carried out in 2015: 36% of the metropolitan population aged 18 to 64 say they have given up healthcare for financial reasons during the last twelve months. This rate was 16% in 2010. We must therefore keep our current system.
It is important to remember that the French make their health system solvent through social contributions, the CSG, subscriptions to complementary and the rest at charges. The more we disengage the compulsory schemes from reimbursement of health costs, the more the complementary organizations automatically take over the “relay” with the risk of seeing contract memberships increase. We would therefore move from a solidarity system to an individualization of risk with contracts with multiple and varied cover, sometimes illegible for citizens. To ensure a solvent health service, it is necessary to accelerate the optimization of the existing (relevance of prescriptions, deployment of the DMP …) which avoid redundant prescriptions and acts, better organization of the care of 1^er appeal…

The hospital must simultaneously reconcile medical excellence with its social missions. In view of the budgetary constraints, does activity-based pricing (T2A) appear to you to be suited to this dual requirement?
Arnaud Montebourg : T2A was designed with the aim of optimizing the management of hospitals. This pricing fulfills its role for certain specialties, but is not adapted to those which require more support and care such as geriatrics, psychiatry or pediatrics. The funding of the hospital must therefore be redirected to become more pragmatic: neither full pricing per activity, nor opaque general budgets. I think it is appropriate to integrate the quality of patient care in the funding model of hospitals. For lack of organization or presence of primary care, patients, it is logical, turn to the hospital (CHU, local hospitals). Hospitals are sometimes called upon for care that should not be their responsibility (example: the attendance of emergency services increased by 20% from 2003, date on which liberal doctors were exempted from the obligation to provide guards). To use Anglo-Saxon terms, “cure” is taken care of while “care” is too often not considered. Concerning the personnel, the policy of the figures carried out until now must be called into question to readjust the means up to the needs and give new life to the hospital. This is the meaning of my proposal: to restore 5,000 doctor and paramedical positions per year to the public hospital for the duration of the mandate. We must move from mistrust to trust.

Medical deserts I propose to create public dispensaries where there are no houses or health centers.

One in four general practitioners will not be replaced by 2025. How do you plan to fight against medical deserts?
Arnaud Montebourg : Our country has nearly 200 medical deserts – in the countryside and in the suburbs in particular – where some 2.5 million people live. The situation is that of a real health divide: on one side there are over-endowed areas and on the other, forgotten areas. The trend is downward in the number of attending physicians throughout our territory due to a vocations crisis and too difficult daily life. I propose to create public dispensaries where there are no houses or health centers. They will be installed wherever it is needed. Town halls and departments will be asked to provide available premises to install this new local public service. The care of patients at the end of their hospitalization will be based on this network of dispensaries which will supplement the existing one when it is lacking in certain territories and will ensure the coordination of care outside the hospital for the patients.

France is the European champion of cannabis consumption. It is also the country which has the most prohibitive law. Should we decriminalize use and should the State organize the production and distribution of cannabis?
Arnaud Montebourg : You are right about your assertion. This is a real public health issue, especially since there is often poly addiction (tobacco, alcohol, cannabis, etc.). Before naming the solution (decriminalization, contravention, legalization), I would like to bring together the whole of society on a shared diagnosis. I’m not going to teach doctors that the best treatment is the one prescribed after a proper diagnosis.

In a manifesto, French doctors admitted having helped lesbian couples and single women to resort to assisted reproduction abroad. Can we continue to reserve it for heterosexual couples?
Arnaud Montebourg : The left was united on marriage for all, where the right has once again sought to pit the French against each other. Today, the extension of assisted reproduction involves complex bioethical issues, but is already a solution adopted by a growing number of same-sex couples. What matters to me is above all to preserve the legal situation of the children of these same-sex couples, which must firstly involve facilitating their administrative return to France and the establishment of their filiation, in the spirit of the Taubira circular validated by the Council of State in October 2014. This is what I will try to do as a priority before assessing, as clearly as possible, in conjunction with professionals, conditions which will make it possible in France to open this possibility to all couples of the same sex.

Environment Measures to limit the use of diesel must be intensified while at the same time, the marketing of electric vehicles at a lower cost must be encouraged …

What would be the first concrete measure you would take to limit the harmful effects of pollution on our daily lives? And when?
Arnaud Montebourg: According to the WHO, in France, pollution is responsible for more than 48,000 premature deaths each year. It is therefore urgent to act in the long term to limit its effects on health. First of all, I think that the measures to limit the use of diesel must be intensified while at the same time, the marketing of electric vehicles at a lower cost must be encouraged by reinforcing the automotive industry in this new promising niche. . But the fight against air pollution is also a fight to be waged on an international scale. I will therefore be particularly vigilant to ensure that the Paris Agreement is respected by all its signatories.

Thursday January 12, find our interview with Manuel Valls

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