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Why and How To Renovate Our Health Care System?


Demographic changes, economic, health and social past twenty years are forcing us to rethink our social model, set up after World War II, to adapt to new challenges. In the current financial crisis and economic recession European sustainability of our social model is becoming an urgent issue that should be a political priority. The European economy leaves us less time to complete this renovation. Our health system is no exception to this need for transformation and adaptation to the modern world.

A health system out of breath

Our health system is out of breath and decay generates negative pressures on the key players, healthcare professionals and users. Inform and convince that reality is an essential step to generate a vast movement. This decline is reversible, provided that we provide appropriate responses. Our health care system generates social inequalities that result in an exclusion of the poor, seeking care for millions of citizens and indecent a difference in health status according to social category. The crisis will inevitably weaken and impoverish a part of the population and inequalities in health will be all the more glaring and dramatic at the end of this crisis. The health divide, already striking in our country will become in the coming years a huge social burden, economic and moral if we do not react.

Our health system has grown and flourished on a basis consistent with the world of yesterday, but not in tune with the world today and even less the future. This is true both in terms of health, with the explosion of chronic diseases, characteristics of our civilization as the twentieth century was dominated by acute diseases, as financially, in which economic prosperity of the war boom with full employment has massive funding through payroll taxes on wages. And also at the organizational level with a hospital-centrism excessive care and vertical organization of the system that are not adapted to new challenges.

Health suffers from the corporatist vision of its actors, its organization silos and lack of democratic functioning. If the level of health of a population depends on the quality of its health system, it still depends much more economic, social and behavioral. All major health reforms of recent decades have focused on the care system or some of its components, such as hospital or a disease like cancer. This led to a disruption of health activities with other programs carried out in particular the National Education, the Environment, Agriculture or urban policy. It is therefore a challenge to our approach of this policy is needed much more than reform of a particular domain.

We have been through the specialization of social security on major health risks and additional health risks on small, after the logic of payroll taxes by payroll taxes, and certainly after the logic of the right to health without associated duties. The current crisis is an accelerator of change predictable and inevitable that other countries like Germany have expected more. We pay heavily for the delay on the economic front, with a deficit abyss of our social security and competitiveness deteriorated sharply in the euro area.

On health, our health care system is less effective than many of our European neighbors. Life expectancy without disability is declining in our country. It increased from 64.6 years to 63.5 years from 2008 to 2010 among women (12th position in the EU 27) and 62.7 years to 61.9 years for men (14th position in the EU 27). Obesity has increased by almost 100% in 12 years we went from 3.5 million in 1997 to 6.5 million obese in 2009 (ObEpi study), 20 million French people are now overweight or obese is 47% the adult population. 33% of the French population over 15 million French smokers with an increase in recent years of smoking among adolescents and women. France is a laggard European countries in terms of premature mortality (105,000 deaths each year before age 65) and avoidable mortality (35,000 deaths preventable with better prevention).

Knowing that our health costs are the highest in the world – € 234 billion in 2010 or 12.1% of GDP (an average of 9.1% dasn OECD) – after the United States, our system is poorly placed on cost-effectiveness.

A social model undermined by deficits

Over the past 30 years, health insurance has never been in equilibrium even in years with strong economic growth. Over the past 10 years she has accumulated a deficit of 86 billion € in France while the German Health Insurance accumulating a surplus of 19 billion €. Despite ONDAM respected in 2010 and 2011, deficits in both years were respectively 11.6 and 8.6 billion €. For 2012, it should be € 6 billion (14 billion for Social Security). These deficits swell the French social security debt (CADES) representing more than 140 billion € in 2010 and forcing France to lift the debt capital markets which poses a financial problem by weakening the financial position and a moral problem in making fund our health care spending by future generations. Our social security, including the health insurance industry, is structurally underfunded than ten billion euros and its financing relies too much on the payroll, sensitive to economic conditions and represents a funding base too narrow.

The financing of our health spending is based on two bases, two levels of sharing: a first level, public health insurance compound that works to credit for many years, and a second level, private (mutual insurers, institutions pension), which can not operate on credit. The current financial crisis Intern ational, which implies an essential reduction of public debt, will intensify the financial transfers from public to private in the past ten years for the financing of small risks. These transfers have attracted considerable criticism because they almost always come with a premium increase of complementary and thus represent a financial barrier to care in some care. Considering that health spending will continue to grow by 1 to 2 percentage points faster than the national wealth in the coming years, it faces three possible scenarios:

Option 1: Maintaining Social Security from its current level (75.5% of total funding) which will lead to increased specialization of the small risk to private and Social Security for the big risk. This is the scenario and let the two-tier medicine for routine care today with a risk of spread to major services.

Option 2: A rise in the share of funding Social Security at 80% (1980 level), an increase of annual public expenditure health of more than 10 billion euros. This is the approach of the maximalist proponents of public funding, the only guarantee to them of solidarity and equity. This is the scenario of blindness to the debt crisis.

Option 3: A declining share of Social Security with an increase of that of complementary health, knowing that the transfer to individuals live can only be marginal if you want to stay in a fair system of access to care. This scenario requires a fundamental review of the regulation and operation of mutuals and their links with Social Security. This is the proactive scenario to perpetuate the values ??of our health system.

The first option is more likely if we analyze what is going on for twenty years and the absence of the subject of health in the political debate. In a normal economic environment, the other two options are defensible and neither one nor the other would lead to the establishment of a morally unsustainable and socially unjust.

Advocates of the second option will have the greatest difficulty in finding new sources of funding and the overall balance of public accounts that results. In the current economic and financial climate, this scenario is unrealistic.

Analyze the third option.

A realistic scenario is in a growth in public spending at inflation, which would de facto reduce the level of public support around 73.6% of total expenditure and a transfer of some 5 billion euros to pooling private by 2017. In this context, a role of mutuals in the treatment of diseases of long duration (ALD) seems inevitable. Public expenditure finances long-term illnesses to 100% and approximately 55% of routine care spending, which amounts to a specialization of Social Security on major risks and the private sector on small risks. This rate is a real problem of solidarity and distorts the role of complementary taking, with the remainder dependent, almost instead of health insurance for many small risks such as dental, hearing impairments and optics. For the complementary health keep their true function of additional payment, they must be given a role in serious conditions, long term while reducing their weight in favor of health insurance in the management of small risks.

These three options are undeniably social choices, political choices that will impact long-term welfare of our country and the organization of our health system. They are also choices that orient and structure fundamentally the nature of the reforms to be undertaken and which should be decided first. The renovation of health financing is a key subjects of political debate needed on health as it is affected by the current financial and economic crisis.

Redefine our social model long-term

For a dynamic large-scale reformer, it is necessary to give rune long-term vision of our social protection. Dramatic changes in the economic and social consequences associated with the financial crisis of the past three years, requires developed countries to reinvent their social protection policy. Over the past two decades, all major industrialized countries have used debt, public or private, to finance their social protection expenditure, they can not do over the next decade. We must construct a second generation of social protection from values ??that reconcile social justice and the financial constraint. If you want to reach a relevant agreement on the definition of a new social contract, we have to accept certain principles. The book addresses five pillars of the new social contract with the concept of human duties.

Fairness implies rights for citizens who are generally widely taught and claimed what is legitimate. It is not demagoguery to assert that contemporary societies attach too much importance to claim rights in regard to compliance and enforcement duties. For a right to have its full force, it must be associated with the duties, rights and duties go together and form two sides of one coin. Without duties involved, the rights become arbitrary. Health illustrates this phenomenon where the right to health has not been associated with quite a number of duties. Complementarity of rights and duties applies to the health sector. If each person is entitled to medical care, we can consider it a duty to avoid putting their health and that of others in danger. It must do all it can to optimize its health by appropriate behaviors. Otherwise, a person who does not take care of his health could become an unfair burden on society, his family and for others, because of his personal negligence. This is an essential principle of justice which the application through concrete measures must be fully discussed.

Establish a course of medicine

About empowering patients, we could ask all those who enter the system of care for diseases of long duration (ALD) to sign a pact that would include civic health health behaviors recommended and adapted to the pathology they suffer. The pact would have no binding force, but would be a moral commitment of the patient to make every effort to improve their behavior and lifestyle to optimize his chances of recovery and / or quality of life if his condition is incurable .

Optimising care of ALD requires a more integrated management of health care provision affected by these ALD to better track patients, improve their orientation in the system of care and reduce costs of care .

This integration of care can be controlled by the regional health agencies. It must improve the quality of life of patients and greater cost control, including the devolution of hospital care to ambulatory care and home care. This aspect of the financing of health expenditure and the management of ALD is highly structured in our health system and is a social issue. It should be publicly discussed with all stakeholders in health, and decided by the citizens. As in Germany, the care pathway would involve three parts: the general practitioner, medical specialist and a hospital, the GP is the gatekeeper of the device. This course must encourage the development of ambulatory care in the management of long-term illnesses.

Integrate prevention at all levels of the health system

So far, no political will to make prevention a major focus of our health policy is manifested, we are still at the stage of casting. Built at a time when infectious diseases and acute health dominated the landscape of our country, the French health system is structured around the management of these pathologies ignoring the health of the healthy.

This requires changing attitudes of everyone: users, health professionals, policy. This is possible if the official discourse and change if actions are consistent with lyrics and carried with transversality. Requires a preventive system to upgrade the training and compensation of professionals, the relationship between primary care and hospital medicine, investment choices, the collection and use of data, the establishment and operation of the Department of Health, etc..

A health system with a human face to promote a culture that is holistic new address as the patient to the healthy person, and to prevent diseases. The greatest added value to contribute to the health system of Western countries undoubtedly lies in the field of prevention (Custom). First, the challenge of our century health concerns what is commonly called “non-communicable diseases” (non-communicable diseases) such as cardiovascular disease, diabetes and cancer. They are mainly due to our lifestyles and our environment. It is up to the root causes of these diseases and to deduce an effective prevention policy. The genetics of individuals with little or no change from one generation to another, the increase of chronic diseases must involve essentially the environmental factors themselves, have changed. Some of these factors require decisions at the global level, this is the case of chemical pollution, atmospheric, electromagnetic … However, it is dependent on individual behaviors such as nutrition, exercise, or medical procedures: treatment of latent chronic infections, the cause of many neurodegenerative diseases, joint, or heart disease.

Why such a failure of preventative health care in France, which would save each year to more than 20,000 families – by extrapolating the results of road safety – the pain of losing a loved one? First, because the medical profession has not been associated with prevention policy. Make preventive medicine without doctors can only be a failure. We spend tens of millions of euros each year for major media campaigns to educate our citizens to their health. The result is that for a few days, we hear of the great dangers of certain behaviors without the least adapt our own behavior. The beautiful harmony of synchronous coordination of saying and doing is very hard to find health. Studies show that prevention policy should be disseminated through health professionals whose word is gold to our compatriots. Further studies, it is common sense to understand that our 210,000 physicians who see every day thousands of patients are best placed to help them change their health behaviors. Then, almost our entire health system is oriented on cure. Of the € 234 billion of health spending, France spent € 6 billion is only 2.5% of health expenditures in 2010 for prevention. Excluding management fees, France devotes 94% of its health expenditure on his patients. The credits allocated to research in preventive medicine are minimal in the mass budget of medical research. Yet it is seeking to better understand the causes and means of early diagnosis of chronic diseases that happen to contain the enormous social and financial cost of these pathologies. Out fraud and waste, health expenditures are expenditures high value on social and economic whose reduction is not a health policy program. It is therefore the distribution of this sum must be completely rethought, and therefore the paradigms that underlie our health policy should be changed.

Take the example of tobacco control, 29% of the French population smoke against 21% in Finland and 16% in Sweden. The increasing use of tobacco among adolescents will generate enormous damage in premature death for women if we do not stop this trend. 37% of adolescents 11 to 15 years state they can not do without tobacco and over 50% of youth aged 18 to 34 smoke. Tobacco kills 65,000 people each year, is the leading cause of premature mortality and costs more than € 15 billion annually to Social Security. Faced with such a scourge, the few hundred tabacologues, who do an outstanding job, can not do much at the magnitude of the task. It is not doubling the price of cigarettes, which amounts to tax heavily the disadvantaged and youth, we effectively fight against tobacco, nor by communication campaigns. It is through the mobilization of all health professionals and a program of health education, particularly in schools for addictions, we achieve tangible results.

Another danger that emerges is that of addiction to communications by electromagnetic waves of our citizens and especially young people, which can increase the number of chronic diseases. A number of experimental studies in animals suggest that prolonged exposure to these waves can have long-term adverse effects (cancer, neuropathies), by altering the permeability of the blood-brain barrier. In accordance with a rational application of the precautionary principle should therefore that governments undertake urgently a policy of risk reduction against this potential danger.

The renovation of our health system is all about vision, belief, political rather than additional funding. To save his welfare and health system, France can no longer afford to wait. The main short-term corrective measures were used, the limited financial flexibility remaining are insufficient to close the gaps. We are in a state of emergency. The overhaul of our health system therefore requires a new approach to financial, cultural and organizational will cross into society and will impact all activities of State and Government. Model of curative medicine of the twentieth century, we must move as soon as possible to the model of medicine P 4 of the XXI century – preventive, predictive, personalized and participatory. We have fallen far behind for the establishment of the first level of this building. It is not yet too late but the hourglass is empty.

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