Public/privé : la divergence tarifaire

Site de Pat. Seiler - DH Magazine n°128Prévue par la loi du 13 août 2004 relative à l’assurance maladie, la convergence tarifaire entre hôpitaux publics et cliniques privées devait être pleinement opérationnelle en 2012, avec la montée en charge progressive de la tarification à l’activité. D’un simple courrier adressé uniquement à Claude EVIN, alors président de la Fédération hospitalière de France (FHF), la ministre de la Santé a annoncé le report de cette convergence à 2018, ce qui n’a pas manqué de provoquer le courroux de la Fédération de l’hospitalisation privée (FHP), qui a entamé une campagne de communication offensive (pour ne pas dire agressive) sur le thème des économies réalisables pour la Sécurité sociale, si cette convergence devait aboutir à la date initialement prévue.

Le 14 octobre dernier, soixante Professeurs de médecine signaient une tribune dans Le Monde intitulée Halte aux contrevérités de la Fédération de l’hospitalisation privée, dont je rappelle ci-après les termes :

« Nous nous interrogeons sur la campagne que la Fédération de l’hospitalisation privée (FHP) vient de relancer contre l’hôpital public en appelant les patients à se faire soigner dans les cliniques privées « pour sauver la Sécu ». Nous aimerions, Madame la ministre de la santé, connaître votre position sur cette publicité à la fois coûteuse et mensongère.

Coûteuse, cette campagne est en dernière instance payée par les deniers de la collectivité, dans la mesure où c’est la Sécurité sociale qui finance les cliniques privées commerciales. Les citoyens ont le droit de connaître le montant de cette campagne (plusieurs centaines de milliers d’euros, dit-on), et de savoir si cette publicité concurrentielle respecte les règles du code de santé publique.

Cette campagne publicitaire est aussi mensongère. Affirmer, comme le fait la FHP, que le coût d’une intervention en clinique privée est inférieur à celui de la même opération en hôpital public relève de la falsification. Si le coût pour la Sécurité sociale est parfois inférieur, c’est parce qu’une bonne part du séjour en clinique privée est prise en charge par la mutualité, les assurances ou le patient. Ces derniers coûts, non comptabilisés par la FHP, concernent les dépassements d’honoraires, le surcoût pour chambre seule, etc. Dans les calculs des coûts pour la société française, c’est évidemment l’ensemble qu’il faut comptabiliser et qui pèse sur la part de produit intérieur brut consacrée à la santé.

Affirmer que l’activité de ces cliniques est identique à celle d’un hôpital public, c’est méconnaître totalement les charges très particulières et très lourdes de ce dernier : prise en charge de plus de 80 % des urgences, traitement de tous les cas difficiles, y compris ceux provenant des cliniques privées après complications, infections en particulier qui relèvent maintenant, comme vous l’avez exigé, de centres identifiés publics ou participant au service public. Il en va de même pour la grippe dont vous définissez avec les hôpitaux publics (et non avec les cliniques privées) les modalités de prise en charge des formes graves.

Comparer les coûts sur cinquante actes, c’est méconnaître tous les actes ou situations qui ne sont pris en charge que par l’hôpital public : les précaires sans couverture sociale et les patients n’ayant pas de mutuelle, les cas les plus complexes – greffes d’organes, de moelle, neurochirurgie, accidents vasculaires cérébraux, réanimation néonatale, maladies infantiles graves ou maladies orphelines, etc. La liste en est fort longue et bien supérieure à cinquante. Enfin, et ce n’est pas la dernière des missions de l’hôpital public lorsqu’il est universitaire : l’enseignement des personnels médicaux et paramédicaux qui, une fois formés, permettront aux cliniques privées de travailler. Nous ne parlons pas non plus de la recherche, qui permet les progrès médicaux, et qui est une mission d’excel-lence des centres hospitaliers universitaires.

Certes, nous sommes conscients de la nécessité d’adapter les hôpitaux publics aux progrès de la médecine et à l’évolution des besoins de la population. Nous pensons qu’une évaluation comparative des hôpitaux permettrait d’améliorer la qualité des soins et leur efficience, en réduisant l’hétérogénéité des pratiques et l’inégalité de moyens soulignées par le rapport de la Cour des comptes. Encore faut-il comparer des hôpitaux comparables par la taille et par les missions.

Comme vous le savez, le mode de financement par la tarification à l’activité dite T2A ne permet pas d’atteindre ces objectifs, en raison de ses nombreux biais. Fixant un pseudo-prix de marché variant d’une année à l’autre, la T2A n’est qu’un outil grossier de répartition ne prenant en compte ni la qualité des soins ni même leur justification. Quant à la convergence tarifaire intrasectorielle, mélangeant l’ensemble des hôpitaux publics quelles que soient leur taille et leurs missions, et intersectorielle public/privé prévue pour 2018, elle n’a pas de pertinence.

Nous sommes favorables à toute mesure visant à garantir l’égal accès de tous les citoyens à des soins de qualité, selon le respect du principe « du juste soin au juste coût » et sommes tout à fait conscients des efforts nécessaires afin de pérenniser une médecine de qualité pour un coût optimisé, mais nous ne pouvons accepter que la réduction en cours des effectifs hospitaliers médicaux et non médicaux serve de variable d’ajustement à une politique de rationnement qui ne dit pas son nom.

Votre silence, Madame la ministre, sur la campagne menée par la FHP contre l’hôpital public inquiète notre communauté hospitalière. Les professionnels hospitaliers se demandent si vous la condamnez ou si au contraire vous l’approuvez. Exprime-t-elle haut et fort l’orientation voilée de votre politique ? Souhaitez-vous le renforcement du privé commercial et l’affaiblissement du service public hospitalier, dont le nom même ne figure plus dans la loi hôpital, patients, santé et territoires (HPST) ? Nous aimerions, Madame la ministre, vous rencontrer pour connaître vos réponses à ces questions ».

Réponse de la FHP à travers ce clip vidéo d’environ 5 minutes, accompagné du texte suivant :

« Un même métier, une même vision, un même tarif. Dans le cadre de la campagne pour le tarif unique, la FHP et ses trois syndicats, FHP-MCO, FHP-Psychiatrie, FHP-SSR mettent à la disposition des professionnels de santé et de l’ensemble de leurs parties prenantes : patients, associations, tutelles, décideurs,  un clip vidéo. En quelques minutes, les enjeux de la convergence tarifaire entre les secteurs public et privé ! »

Se voulant constructive, la FHP a échafaudé un argumentaire sous forme de livret présentant « quatre propositions pour un scénario de convergence réaliste et progressif ».

La FHF avait déjà réagi à travers un communiqué du 30 juin dernier, considérant qu’en clinique privée, le métier pratiqué n’est pas le même qu’en hôpital public купить деревянную мебель. Elle réitère sa position à travers un communiqué du 16 octobre dernier.

A vous de juger !

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