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Doctors Are Becoming ‘Cash Registers’

Translated Wednesday 20 May 2009, by Claire Scammell

Mohand Goudjil , a cardiologist at Argenteuil Hospital in the Val d’Oise, is seeing the perverse effects of tarification à l’activité on a “daily basis”.

Doctor Mohand Goudjil has a small amount of time available in which to review his patient’s files. Among these patients is Mrs ‘D’, admitted earlier in the day for an angioplasty. The doctor registers her file with a flash of the ‘scanner’, a simple bar code reading. “In one click I see immediately on the screen how much she is going to bring in for the department,” comments the doctor. In this case, 5000 Euros. “We don’t know how much it is going to cost to treat the patient, we just know that if they stay for only 3 days in the hospital then they are going to bring in a lot of money”, reveals Mohand Goudjil. “Today, money is part of our day-to-day practice. The department has become a business, with turnover, expenses and revenue” deplores the doctor. In 2008 the hospital’s intensive care unit “brought in” 4 million Euros. And all of this is a result of ’tarification à l’activité’, [1] the famous ’T2A’, which, as Mohand Goudjil is witnessing, “is turning doctors into cash registers”.

While he recongises that this method of funding has made staff “aware of the importance of the expenses and revenue of each department” and has allowed the development of very costly procedures such as cardiac stimulation, because they are “profitable”, the cardiologist remarks above all that it “encourages doctors to provide more individual acts of treatment”. And there are besides, according to the doctor, “more perverse effects than there are benefits”. He sees it on a daily basis. “It is not unusual to carry out three surgical procedures when just one would have sufficed. We are therefore billing for three treatments instead of one," reveals the specialist. He also points to the “abuse” of the Codage system [2]: “If a patient suffers from a cardiac insufficiency and a coronary, we’ll record the latter because it brings in more money.”

“Everything is considered entirely from a financial point of view”, sums up this young doctor, a thirty nine year old. “We have been clearly asked to reduce the average length of patient stays. Whether a patient stays 6 days or 23 days, the hospital will be reimbursed the same amount by Social Security. We are therefore encouraged to keep patients in for 6 days, no longer”, relates Mohand Goudjil. Which, in his mind, “goes against quality of care and therapeutic education - we don’t even have the time to encourage a coronary victim to stop smoking. But then, everyone knows that uneducated patients come back to hospital more often.”

Contrary to statements from the government, the T2A has been the cause of a long line of dysfunctions. “Just as we have reduced the average length of a patient stay, we have reduced the number of beds from 40 to 30. Except that we still have 3000 patients. That’s where the perversity of the system lies”, assesses the doctor. And that’s without counting the nursing posts which have been cut. As a result, the department no longer has emergency beds at its disposal. “In the event of a real catastrophe we cancel patients,” explains the cardiologist. “It often happens that we have patients on stretchers in the corridors.” Less beds and shorter stays means patient selection. A scheduled treatment involves the “minimum” of cost and “brings in more” than an emergency patient. Patient selection also depends on the gravity of their condition: “We privilege patients with the most severe pathology, the others are treated by general medicine.”

As for the effects on medical personnel, Mohand Goudjil sees it everyday. “Relations are very tense. Not only does the T2A bring with it an enormous number of administrative tasks but in addition, we feel as though our patient care is compromised.” Although he might have “chosen to work in the public sector”, Doctor Mohand Goudjil is sorry to find himself “charging fees as if he were working in the private.”

[1"Tarification à l’activité", or T2A for short, activity based funding aimed at harmonising the way non-profit and non-profit hospitals are funded in France.

[2Part of the government’s ‘Hospital 2007’ programme, ‘la Codage’ (Coding) is the clinical evidence base on which activity-based funding is based.

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