“The hospital crisis is a democratic crisis”

Tribune. The public hospital crisis is the result of many factors. Among them, it is useful to come back to the role of the reform of hospital financing in 2004, which is often called into question. Public hospitals have been funded since 2004 by a special system, T2A (activity-based pricing), which consists of remunerating the hospital according to the quantity and nature of the stays it makes.

In itself, T2A does not lead to a shortage of resources for establishments. Quite the contrary, since the T2A consists in fixing the price of hospital stays according to the cost of production.

A real difficulty

This production cost is estimated by the Technical Agency for Information on Hospitalization (ATIH), which evaluates, using the accounting data of a panel of hospitals, all the resources consumed to produce each stay according to the patient’s main diagnosis: time spent by caregivers, drugs, technical equipment, hospitality , real estate, etc.

Beyond the difficulty of the exercise, the T2A is criticized for penalizing establishments suffering from costs that are structurally higher than the average, in particular because of the health and social characteristics of the patients received. This is a real difficulty with this pricing method, but it cannot explain the current shortage.

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If the T2A has put health establishments in financial difficulty, it is because in France the price of stays is not equivalent to their production cost evaluated by the ATIH. Indeed, it was decided to adjust the rates for stays to meet the national health insurance expenditure targets (Ondam), voted annually by Parliament.

The Ondam represents the percentage of increase in health expenditure financed by Medicare that we collectively agree to aim for. The lower the Ondam, the more the rates for hospital stays decrease in relation to production costs. And the prices decrease even more when the volumes increase, to respect the Ondam.

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In the years following the establishment of T2A, Ondam was between 4% and 6%.

From 2008, the Ondam decreased each year to reach 1.75% in 2016.

Until 2016, spending on hospital care was driven up by volumes whose annual increase was greater than that of Ondam (around 2%). During this time, prices stagnated or even fell, which is particularly remarkable in a context where technological innovation was constant and structurally led to an increase in the cost of patient care.

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“The hospital crisis is a democratic crisis”