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La maîtrise des dépenses de santé, la réforme de l'assurance-maladie (1996-1999)

Author

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  • Pascale Breuil-Genier
  • Frédéric Rupprecht

Abstract

[fre] La croissance des dépenses de santé, qui est légitime si elle résulte de choix collectifs délibérés en faveur de la santé, ne l'est plus si elle traduit la dynamique propre d'un système de soins qui, bénéficiant de rentes informationnelles et d'une demande solvabilisée, poursuivrait une logique dictée par l'offre. Sur la base de ce constat, les réformes françaises de 1 996 ont introduit un débat au Parlement sur le montant souhaitable des dépenses d'assurance- maladie, à travers le vote d'un objectif annuel de dépenses. Elles ont également réaffirmé la nécessité de progresser dans la connaissance du fonctionnement du système de soins, ce qui constitue un préalable à des choix collectifs éclairés et à la mise en place d'instruments de régulation efficaces. En effet, le système de santé reste une « boîte noire » : si les ressources consacrées à ce secteur sont suivies avec une précision croissante, la connaissance des processus de production, et en particulier de leur effi- cience, reste très parcellaire, et la production finale du système, les gains en santé, est largement inobservée. Ce sont ces lacunes qui permettent aux producteurs de soins de bénéficier de rentes informationnelles qu'ils peuvent exploiter au détriment de leur tutelle. De telles réformes suffiront-elles pour qu'à terme on passe d'une logique de maîtrise des dépenses à une logique de gestion de la production de santé ? En particulier, les mécanismes d'enveloppe mis en place en 1996 pour rétablir les comptes sociaux seront-ils un jour rendus obsolètes par une régulation fondée sur une connaissance fine de la production de santé et des besoins ? Une telle évolution, qui constitue sans doute un objectif de long terme louable, est malheureusement compromise par la complexité du système de soins. En effet, si la plupart des chantiers de réformes ouverts progressent indubitablement, force est de reconnaître qu'ils n'ont pas toujours abouti dans les délais escomptés, et surtout que certains mécanismes de régulation montrent déjà leurs limites. [eng] The increase of health expenditures is not a problem per se. It is non questionable if it results from a public choice in favour of health. But it should be controlled to the extent it might reflect the free evolution of an economic sector which may take advantage of a subsidised demand and asymmetric information to pursue its own interests. This concern was taken into consideration by the French reforms initiated in 1996. First, the level of socialised health expenditures is now voted by the Parliament each year. Second, the reforms aimed to improve the knowledge about the health care system, and hence, its regulation. The health care system is a « black box » : if the imputs are measured more and more precisely, the information on the production process (and in particular on its efficiency) is still very poor, and the output (health outcomes) is to a large extent unobserved. The 1996 reforms aimed to develop both the information system and evaluation procedures of the efficiency of the health care system. In the long run, such reforms may allow to forsake a regulation based on the control of expenditures in favour of a management of the health production : some of the financial mechanisms introduced in 1 996 (efficient in the short run) may be replaced by a medica- lized regulation. After a presentation of the 1996 reforms, this paper deals with how the reforms initiated in 1996 have been implemented, what can be said so far about their achievements and limits, and what they could brin in the long term.

Suggested Citation

  • Pascale Breuil-Genier & Frédéric Rupprecht, 1999. "La maîtrise des dépenses de santé, la réforme de l'assurance-maladie (1996-1999)," Revue Française d'Économie, Programme National Persée, vol. 14(3), pages 129-166.
  • Handle: RePEc:prs:rfreco:rfeco_0769-0479_1999_num_14_3_1089 Note: DOI:10.3406/rfeco.1999.1089
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