2023-10-30 09:51:53
Analysis by Philippe Leduc, doctor and health journalist, initially published on the Les Echos-Le Parisien website.
The Court of Auditors denies wanting to bring the wolf into the fold. But its latest report, which analyzes the factors of competition and complementarity between public and private establishments, opens a path, a breach some would say, in hospital organization in France. The objective is laudable: to better respond to the concrete needs of patients. The subject is explosive.
We must “force practitioners and operators to cooperate more” via “revitalized content of the service public hospitalier (SPH)“. The Court, in its recent, somewhat unnoticed report “Public and private health establishments, between competition and complementarity” rightly wishes that the hospital offer is better organized in the territories, more in complementarity than in competition between the public and the private.
And proposes that “any health establishment authorized and financed by national solidarity (meaning both public and private) must participate in the effective establishment of an efficient public hospital service on the scale of the territory considered, depending on of its reception capacity, the specialties it practices and in response to the concrete needs of patients.
Revitalizing the public public hospital service
Concretely, to revitalize the “public hospital service” which “lacks consistency”, the Court proposes “a broader mobilization than that of public health establishments alone”. In short: make more use of the private sector. Under strict conditions.
In analogy and symmetry with private practice with excess fees in public hospitals, the Court would like “the existence of a liberal activity with excess fees to cease to prevent an establishment whatever its status (therefore public as private), to participate in the SPH, as long as restrictive conditions of financial and geographical access are respected. Thus “the activity of liberal practitioners in private for-profit establishments might fall within the framework of the SPH according to conditions formalized in the activity authorizations issued by the ARS”.
A consensus emerges, notes the Court on theimportance of involving all practitioners, including private clinics, to the public hospital service. The desired goal is important: to improve financial accessibility without out-of-pocket costs with or without additional insurance and to adapt regulation to territorial contrasts (concentration in metropolises and near coastlines).
A long stormy history
The SPH is a long and particularly stormy story. To know well. To avoid wandering and posturing. And achieve the set objective of better meeting the needs of patients. The SPH was created in 1970, then broken down into 14 missions in 2009 by the HPST (Bachelot) law and taking into account the excitement of the proponents of a coherent public service reviewed in 2016 by the Touraine law which defined a “bloc activities” carried out exclusively by public establishments and Espic.
We must therefore handle this type of reform with caution to avoid once once more these hesitations.
Strong contrasts
More generally, this report is very informative. He recalls that the hospital care is unequally accessible depending on specialties, territories and patients. The sharing of activity between the public and the private sector is implicit, schematically and on average: the most serious patients mainly in the first, the oldest in the second. Competition for short stays has intensified since 2014 in metropolitan areas.
The public sector increasingly and almost exclusively covers needs across the entire territory, the most severe pathologies and the most difficult social contexts. Surgery is mainly done in the private sector. With strong territorial specificities.
ARS at the heart
The reform of the regime of authorizations to practice issued by the ARS initiated 2 years ago might be an opportunity to better organize complementarity between the different hospital sectors. Relevance, quality and patient satisfaction should be better taken into account, particularly in regional health projects, ensuring the participation of all public and private establishments.
Likewise in the multi-year contracts of objectives and means from both public and private. More flexibility, finesse and precision should guide the ARS.
At high risk
The Court, through its First President, Pierre Moscovici, insisted, during the presentation of this report to the press on October 12, on the need to more systematically develop cooperation by overcoming the historical divisions between these two sectors. This is in no way a privatization of the public hospital service, he insists. Will the public authorities and the ARS in particular dare to embark on this path, certainly with a high risk of incomprehension and stiffening but which can be beneficial for patients and the hospital supply in each territory.
This 131-page thematic public report on hospital establishments is a mine of both figures and avenues to explore and will spark debate. It makes seven recommendations.
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