Tarification à l'activité et nouvelle gouvernance

In France, public hospitals have undertaken revolutionary reforms over the last 5 years. The goal of the different reforms is to create tools, which would enable public medical institutions to respond to several troublesome issues: rigid operating procedures and complex organizational arrangements of public hospitals, “de-responsibilization” of decision makers, competition with private institutions. The objective is to endow public hospitals with the resources necessary for improved patient care by improving their own internal organization via greater responsibility sharing among the entire range of decision makers working in the hospital system. The reform has focused on the standard fee schedule, T2A, a comprehensive system of itemized tariffs for individual medical procedures performed within the hospital. This reform revolutionizes the hospital budget by focusing on income before deciding on expenditure. Although the need for this financial reform is almost universally recognized, many are wary of its consequences, particularly when addressing the problematic of modernizing the French hospital system within a framework of cost effectiveness. One of the most controversial issues is how public hospital activity will be affected by a full 100% application of the standard fee schedule, which for many would be antinomic with values of public service and equal access to care. For healthcare professionals worried about a liberalized healthcare system, risks include closure of underperforming units, interruption of access to care and patient selection. The National Consultative Committee for Ethical Issues (CCNE) issued a severe statement on June 28th, 2007 denouncing a mechanism, which “privileges counting technical acts to the detriment of listening to patients or time-consuming precise physical exams, […] leading to considering many patients as “unprofitable”, particularly in general medicine, psychiatric, gerontology or pediatric units”. The CCNE emphasized that the T2A is only “a standardization tool (…) [which] cannot alone guide hospital funding”. The constant development of general interest missions, not included in the national sick fund allocations and designed to provide care for more vulnerable persons, have been insufficient to reassure hospital decision makers. To consider that the unique finality of the T2A is to oblige medical institutions to refocus on the most “profitable” diseases and the most solvent patients would deny the role and the force of the public health service. It is irrefutably the ethical responsibility of all to protect the future of the national health insurance system. This is why regulatory mechanisms should accompany the T2A in order to prevent deviant actions and guarantee access for all to quality care. The standard fee schedule should be first and foremost a means of rewarding the most dynamic and innovating institutions for their search for efficacy and of encouraging those institutions with particularly difficult situations to reorganize their internal structure and cooperate with the private sector. Without these regulatory or corrective mechanisms, the result would be to impose upon the health institutions alone political decisions, which would place them in intolerable conditions to guarantee access to quality care. In the final assessment, while there could undoubtedly be room for technical improvements of the T2A mechanisms, it must be recognized that the 2009 HPST law, which establishes a new governance for French hospitals, has not altered the fundamental principles of the standard fee schedule in France, but on the contrary, follows directly in line. The T2A is in fact one of the four pillars sustaining the overall reform initiated in 2007, together with plan making, local management, and quality control and certification. The success of this approach depends essentially upon the capacity of public hospital decision makers to implement all of these intimately-related elements simultaneously. In conclusion, the T2A, the standard fee schedule for French public hospitals, must be associated with a complete redevelopment of the organizational and management practices applied in these institutions. Local management, responsibility of decision makers and revision of internal operating procedures are important elements for the success of this reform, which to be properly implemented, must have a meaning: a search for efficiency, for knowledgeable expenditure. Raising the question of the meaning of the reform is in the nature of an ethical reflection.