Hospital Healthcare Reform
The reform called “Hospital 2007″ is taking place smoothly, without any real opposition or even national debate, even though it is preparing the privatization of public hospital services.
What is it? It is a reform of hospital funding. Previously, hospitals were equipped with global budgets declined then service budgets. Each year, this budget could be revised based on results from the previous year and forecasts for the current year. In the absence of evaluation and political will, these estimates tended to freeze the acquired status and did not allow adaptation to changes in business activity. That, at least that argument has prevailed to replace the overall funding by financing activities told T2A says, by assigning each patient and each activity of a funding code.
Now such a patient is more profitable than another, such activity becomes more profitable than another. Thus, the patient receiving a technical act or surgery involving a short hospital stay is highly profitable. The patient with complex chronic illness with social and psychological problems, and requiring prolonged hospitalization, is not profitable. In diabetes, so provocative and factually accurate, we can say that dialysis or amputation of a diabetic is more profitable than preventing dialysis or amputation. Therapeutic education units, which provide for such prevention and are inherently more consumers personal techniques, have their development hindered. Keeping them is even threatened.
So doctors are placed in the center of an ethical conflict: on one hand they must ensure that each patient the best care, the other they are for mission effectiveness, a condition of maintaining their activity. Each specialty, individual hospitals, each service began feverishly to reflect changes and tricks necessary to become “profitable”. The hospitals have hired full-time hospital practitioners become expert coders. The services were attended consultations to transform them into day hospitals. Here and there, we overcharged or activities are carried out little or no useful but profitable. Indeed it is as if, to ensure the survival of his or her hospital service, it should increase the billing of Social Security. Suddenly, it began to develop controls. The commodification of health is out with his triptych productivism, competition, control.
Furthermore, legislators, and more generally the parliamentary majority even against the advice of the Minister of Health in the minority, decided that henceforth the financing of the hospital would be similar to that of private clinics with a total convergence to 100% in 2012. It is obviously to encourage private hospitals to profit, so all the more improbable that if hospital costs include the salaries of doctors, surgeons and doctors’ fees of private clinics are not part of the cost care. Moreover, behind the same encodings are very different activities.
Much of medicine is made to the hospital, most of the surgery is performed in the clinic. Chronic sinusitis or chronic ear infections in clinical tumors ENT and stomatological are for the hospital. Hip prosthesis are in clinical spine injuries are complicated for the hospital. Surgery of the hand for the clinic, diabetic foot surgery is for the hospital. Remember that nearly 80% of French people die in hospital and more accurately to the public hospital. Patients are sometimes transferred before dying from the private clinic to the hospital. Let us add that the hospital is the place of training for all caregivers, the senior professionals have gained their expertise at the hospital before clinical practice. An expert surgeon in private practice will much less time for the same operation as the operating surgeon beginning in hospital supervised by a senior helping and guiding. In short, it has scheduled a special envelope called “MIGAC” for these public service functions, but it remains unclear subject to the vagaries of economic-policy decisions to come. We want to send the public hospital in the wall that it would not have made otherwise.
The second aspect of this reform is to weaken or even eliminate, the structure of hospital services by removing the nursing managers (supervisor (s)) and department heads responsible for the organization and the recruitment and allocation para-medical personnel. The head of service is no longer a vague medical officer. The goal is to “pool” means between paramedics and medical services, that is to say handle staffing shortages by removing some to give to others. And some nurses work one day or a week in service, and one day or another week in another. It takes all the ingenuity of communication or language of certain Wood reform advocates to find a consistent medical center surgical nephro-pity, consisting of nephrology, vascular surgery, endocrine surgery, gastrointestinal surgery, urologic surgery, maternity, orthopedic surgery. The former Director of Public Hospitals did not hesitate to explain that the poles increased the “readability” for patients. Thus, a pregnant woman returning to the maternity of MERCY will surely be better informed when she learns she gives birth in the pole nephro-surgical hospital!
The goal is actually to submit the medical power in the power of administrative management. Indeed, if we think that medicine is a commodity, the doctors just technicians or healthcare providers, it is logical that the power back to the “managers” true entrepreneurs. Thus, while we lack in hospitals so dramatic sometimes doctors and nurses because of a numerus clausus excessive, they hire managers from the private poles or reclassified from old privatized utilities (France Telecom, etc. …). The liberal reform thus takes the immediate form of a huge bureaucracy to the French, providing greater levels of decision. If we take the example of Mercy – SALPETRIERE, there is a level of service, the level of the pole, but for the huge poles level “sub-pole” or pillars of poles, then there is the level of hospital, then there is the group level university hospital (GHU East, West, South and North), finally, there is the seat of the Assistance Publique. Obviously, each level has its secretariat, justifies its existence by surveys, reports, each committee meets and makes decisions … Result, the physician who treats patients still in his department is overwhelmed with bureaucratic red tape to check, check, code, transmit … Sometimes the medicine is what happens to the rest of the economy: production costs low, most of the prices is the enormous machine of marketing and management. Already there are hospitals in communication directors. It seems clear that hospitals will soon be advertising in the media …
Finally, the key should be for health expenditures paid by national solidarity, the right care at the right price when there are three forms of waste:
- The first form is the irresponsibility that promotes funding without limit, without consequence to the prescriber and the user. Whatever we redo unnecessary examinations and the patient have one or two more days in hospital, because the social security payroll!
- The second form, which is familiar in private practice, is the increase in acts profitable, not necessarily justified. Modern imaging, noninvasive, sometimes unnecessarily and often unnecessarily repeated requested, provides much of this waste, as well as repeated monthly consultations with the sole purpose of renewing an order could be drafted for 3 months or for 6 months.
- Finally, the third form of waste, cost secondary to inefficient management and inadequate supervision.
Pretext to limit the first form of wastage due to irresponsibility, we chose to expand dramatically the other two forms!
What will be the immediate outcome of this market reform? Some activities will be discontinued. Some centers will be restructured and even some hospitals will close. All this, thinks it initially, will be limited by the status of public service that guarantees employment for the staff. Proponents of reform have understood, which aims to abolish the status of public service to turn to hospitals as public service remit. The name change apparently trivial, is of great consequence. There will be more owners but only contractual staff which will facilitate the “social restructuring”, that is to say the possibility of layoffs, because the cost of staff (70% of hospital cost) is the “principal adjustment variable.
Private hospitals to nonprofit groups are participating in the service model. Thus, we often speak of the Institut Montsouris in which patients are generally very satisfied, but we forget to say that this hospital does not emergencies and selects patients. So he decided a few years ago to remove the palliative care unit. Later, he decided not to support insulin-dependent diabetics I’ve seen happen in my consultation without even having been warned. When you request an appointment with a urologist is first on the phone a “medical control”. This lets you know that eventually your reason for consultation is not the business of this hospital and send you to a private clinic. That is what happened to one of my patients who eventually came in the urology department of Mercy – SALPETRIRE where he found a prostate cancer failed. This medicine market that sorts the patients, including by telephone, by the standards of modern management, can not be a medicine of the overall management of the patient.
The private hospital SAINT JOSEPH, used cutting-edge and field experimentation. It was removed from service and even their letterhead so that everyone understands that it was not a care team but it was only an agent can move within the hospital. Its restructuring plan provides for the elimination of 400 positions of 20 doctors and paramedical FTE. To do this, we will “outsource” a number of activities involving subcontracting. To finish the job security that appear to “modernist” as a privilege of a bygone era, it already offers to set up performance incentives for hospital doctors, including the premium amount should be “significant incentive to be.” It easily picture what are the criteria for these awards, particularly the observance of “management criteria” and “productivity gains”. One day a patient or patient’s family, will sue the doctor or surgeon who, to earn a performance bonus, will have taken risks. At the trial of a child who died of acute dehydration in hospital OUTFIT internally who had been criticized for not having called the head of the clinic, had this response: “I could not disturb her, she did the coding! . The mixture of genres between the care and profitability, can only lead to disaster comparable to infected blood.
How did this happen? The real defeat without fighting is the result of a reversal of the spirits. Unable to submit the medical profession to the principles of public regulation, managers and health economists on the left have opted for market regulation. Gilles JOHANET, former director of Social Security, now medical director of AXA has offered to entrepreneurs for excellence health insurance for 12 000 euro per year. Jean de Kervasdoué, former director of hospitals from 1981 to 1986, today defended the private medical activity within the public hospital reform and supports the “Hospital 2007″ arguing that the hospital must learn to “sell” ( sic) and that the regulatory costs should be the possibility of staff reductions. So they joined the camp of liberal economists, unable to think of medicine as anything but a commodity.
All these decision-makers believe that it makes medicine as an airplane pilot suddenly procedures and regulations. Obviously, when they or their relatives are sick, they forget these principles of management. Just read the book by Jean de Kervasdoué “view of the hospital bed” to see that for him was not the most spectacular operation of the acetabular fractures, but his shampoo missed by a student carer!
So at first glance more surprising, a number of department heads are committed headlong into reform. Most heads of division, who will now spend half time in management, will see more than just sick. Is that the major advances in medical technology have transformed the profession but also the cultural model of many physicians. Some are now living longer as engineers or “super technician”. Their model has become the businessman, they dream of stock options. The mandarins were holding them for scholars or philosophers. They ended their career by writing books about the meaning of life. However the majority of hospital doctors undergo this reform with resignation and often a feeling of humiliation.
Reform “Hospital 2007″ is already as the largest company of demotivation hospital doctors, already burdened by the shortage of medical personnel especially in general hospitals and regional shortage desired and programmed by all governments of both left and right for 30 years, without any inflection. The most surprising is that those who have implemented this policy, continue to speak with such assurance of necessary reforms of the health system. When hospital managers, their culture of “reserve duty” does not really know their position. Those who advocate this reform manageuriale speak. Again, the change of representation is significant. The hospital director today do live longer as a servant of the state but as a champion of management and the public – private cooperation. It is quite significant that Rose-Marie Van Lerberghe, past Director of the AP-HP is increased from Danone for Public Assistance for 4 years after starting in business profit nursing homes. Some gossips noted that his change of activity was logical since it had closed 900 beds for long stays at the Assistance Publique Hôpitaux de Paris!
. Advances in technology on the one hand, the commodification of the other, threaten the ethical basis of society in general and medicine in particular. It belongs to every generation to defend, rebuild and update the principles of humanity which should govern social organization and especially the health organization. Alternatives to reform the “Hospital 2007″ are possible. It is possible to think of organizations tailored to the needs of populations to changing conditions, advances in technology. Thus, in the same hospital, there must be a large department and a small service. It is clear that the proliferation of subspecialties, investments in technology, rapid changes in conditions warrant service groups, but these groups must be done according to medical projects relevant to people’s needs and not according to management criteria.
It is normal that at the hospital, there are two powers: a power management and a medical power. These powers must sign contracts, but to do so, they must be distinct and not merged, even if the doctor’s duty to report the expenditure arising from its requirements and accept a regular evaluation of its practices. Physicians should not be appointed by the hospital managers but by their peers based on medical projects. We must remove the T2A and initially at least, separate the logic of funding those private clinics of public hospitals. T2A should be replaced by a budget allocated and distributed by hospital services. This overall budget, taking into account all the operations, should be able to evolve according to the activity and more specifically the quantity and quality of medical service rendered. To do this, we must develop in hospitals and health regions, public health departments whose primary task of assessing the quality of care.
Will we as helpless spectators to the collapse of the public hospital? We can not exclude this possibility, as the strategy of “reform-cons” is ominous grinds, divisions, advances in small steps, temporary setbacks, denials or lies … Or will we see a surge in ethical physicians join the hospital matrons and nurses not to defend corporate interests, but the public hospital serving the public in a very old values but actually a very modern .
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