No great national debate for health reform, an area which nevertheless concerns the French in the first place and where there would be a lot to say in terms of inequality and access to care. If we cannot increase the budget, it would nevertheless be necessary to define in a transparent and consensual manner what we are going to delay or sacrifice.
Suicides, burn-out or resignations of hospital staff, non-replacement of retired doctors, medical desertification, lack of nursing staff in hospitals, incredible delays in appointments, nearly 15% of French people without a doctor… the crisis of health is only accelerating, in the hospital as well as in the city.
We expected a general mobilization to organize a “great national debate” involving learned societies, teachers, professional communities, unions, patient associations, civil society, but we don’t see anything coming. We looked closely, health is not in the 35 questions of the letter from the President of the Republic nor in the 4 themes. Even if some mayors have mentioned the subject.
Doctors and nurses cry out their suffering but not many people hear them. Or maybe once in a while when you have to travel 50 kilometers to give birth or wait more than 3 hours in overcrowded emergencies. At that time, it’s a problem, but as it only happens once in a while… We need yellow vests.
40 years of bad choices
The starting point of the problems dates back to the 1970s and 1980s, when health expenditure increased too quickly at the whim of the public authorities. One day, someone had a brilliant idea: “to lower prescriptions, and therefore expenses, all you have to do is reduce the number of prescribers…”. And we have put in place a drastic numerus clausus which has dried up the exit of young doctors, a choice all the more pernicious as there is a 10-year gap between the decision and the effect: the time necessary to train a doctor today.
At the same time, the French population has increased by 10 million inhabitants and it has also aged, consuming more and more care. Add to that the 35 hours for hospital employees and the moral impact that resulted from it in the city: we end up with a reduction in working time in the hospital and a discouragement of the facilities in the city, too time-consuming and not profitable enough. A formidable scissor effect in relation to the increasing workload.
The reforms did not stop there. This is evidenced by that of drugs: to reduce drug-related expenses, financiers have pushed for the use of generics. A universal choice, but the problem could have been managed through a reduction in price in proportion to an extension of the patent term. The drug patent is of the “industrial” type, lasting 15 years with 7 years for the development of a drug, since it is more difficult than that of a machine tool (at the same time, the patents on lines of software code last 88 years). In the end, we have incredibly expensive new drugs and generics that are manufactured elsewhere, in India or China, with repeated contamination by non-compliant, even potentially carcinogenic products.
The French health system is not so expensive
The public authorities have repeated it to us in all tones: health expenditure is too high in France. However, if France is 4th in the OECD in percentage of GDP devoted to health, it is only 11th in euros spent per capita (OECD data). The French health system is therefore not so expensive, it is in the low average of developed countries.
Compared to this moderate expenditure, there are not enough general practitioners in town because they are not very well paid (26th in the OECD for income) and their installation is expensive. Nurses are lacking in the hospital and they are also poorly paid. Of the more than 1,000 French hospitals, the number of beds has fallen significantly since 1981, with the elimination of one bed in four in the public sector and one bed in five in the private sector. Ambulatory surgery did not compensate for this drastic drop.
Some economies have gone too far
It seems difficult to do more at the hospital which is, in the opinion of all, “on the bone” with problems of non-medical personnel which lead to bed closures while the emergency doctors spend too much time of their time looking for a hospitalization place for emergency patients. The problem of the Assistance Publique in Paris is separate and corresponds to an unacknowledged desire of the public authorities to consolidate services and close beds there.
Some have proposed lowering reimbursements for transport costs, which cost 4.8 billion euros in 2018 (+4.4%). But is it logical to lower this budgetary envelope when, at the same time, we are moving medical resources away from the countryside in certain regions? It is now sometimes necessary to travel fifty kilometers to find an open maternity ward and, at the same time, there is an almost complete absence of public transport in many small towns.
Reductions in drug reimbursements have been the budgetary martingale of recent years. But French prices are among the lowest. This is also shown by the number of stock-outs which increase each year: manufacturers prefer to choose other more profitable countries to supply them as a priority when demand is tight: France is served among the last countries and often when there is no ‘there’s more.
There are savings that can be made
Some have proposed saving money by eliminating the double management of reimbursements which costs 7 billion euros for the CNAM (76% of reimbursements) and 7 billion euros for complementary health insurance (for 13% of reimbursements). But it is a reform that does not look easy.
Activity-based pricing (T2A) has pushed physicians and surgeons to generate revenue with seemingly “profitable” acts and gestures, but to the detriment of other activities, which may raise questions in University Hospital Centers ( CHU). The T2A has clearly not been adapted to chronic diseases and it is by nature inflationary because it pushes to multiply the acts. According to the OECD, 20% of acts and prescriptions are still unjustified. However, this does not allow the hospital to compensate for the resulting deficits because it is regulated with an iron fist, unlike the city, and it treats many chronic diseases. A reform of the pricing of chronic diseases is under discussion, it is a hope.
Another figure that we never talk about is the second place of France (behind the USA) for the total sum (or the share of GDP or the share of health expenditure), devoted to the administration of health… The most immunized professional body in the hospital is the administration, since it is they who hire: we devote in France 6% of our health expenditure to administration, whereas most of the other developed countries oscillate between 1 and 3 %… In view of the current results, this is a serious way to save money.
Does the reform meet expectations?
The forthcoming health reform remains, however, a tinkering with what no longer works with a lot of patches (for example, the ridiculous number of 4,000 medical assistants compared to the 88,000 general practitioners…). It was decided in the midst of the French high administration, whose main advisers say that she is autistic. It will be applied in extenso by a disciplined French administration (it has no choice). It risks leading, like the other reforms, to a clash with the reality principle, but the people who proposed them will be gone.
Forty years of contradictory reforms have resulted in an over-administration of medicine and a loss of influence of those who exercise it on a daily basis in the choice of decisions that are made. Even if the diagnosis that was presented by the President of the Republic is not meaningless and even if the tools that are proposed to remedy it are not completely illogical, it would have been good to make it a national debate to agree collectively on the real expectations of the population and the type of health organization desired in France.
The sovereign French people
Everyone, or almost, has understood that the budgetary envelopes are not extensible and that one would prefer to lower taxes and social charges to revitalize society and reduce the debt. But each year, the national representation does only a small part of the work on health: it is content to vote for a budget increase for health expenditure according to inflation and a certain number of criteria, but it absolutely does not define what the health priorities are and for whom.
Since there is not enough money to do everything, and the latest drugs are too expensive, French society as a whole must define more precisely what must be delayed or sacrificed and assume it in a transparent. But this is where we get into the hard part: what are the diseases that we are no longer going to treat as we could? Should we, as has been done in Great Britain, stop resuscitating certain patients according to an algorithm calculated according to the budget? Should we delay access to the market for medicines that are too expensive but which save lives?
These are somewhat excessive questions but which are not so far from reality (we already do not reimburse certain anti-diabetic treatments or certain anti-cancer drugs which reduce mortality because they are too expensive). It is not logical not to put everything back on the table according to the priorities which will have been discussed and accepted in conscience by the Nation. The national debate on health would have been relevant since it is one of the first budget items. But I think he will invite himself into the discussion.
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