Laure Millet (Institut Montaigne): “Candidates are not sufficiently interested in health”

“Overinvestment”, “persistent budget deficit”… It is with these words that the Institut Montaigne, a liberal think tank, opened its proposal document for the 2017 presidential elections. Since then, the health crisis has passed by, and this time, it is no longer about excessive spending, nor about an “unsustainable” increase in health spending. For its proposals for 2022, the Institute wants as a priority that the candidates care about improving the health of the French and giving hope to carers, focusing on innovation. Laure Millet, head of the health program at the Institut Montaigne and author of the note “Health 2022: a whole program”, published on Tuesday, details them for L’Express.

L’Express: Despite the health crisis, most candidates end up mentioning health problems very little. Have you not yet taken the measure of what is at stake around this strategic area?

Laure Millet: The Covid crisis has really been an opportunity to bring to light all the difficulties that our health system is going through. There has been an awareness of citizens and decision makers. But in the end, beyond health management, there is relatively little talk of structural reforms that make it possible to respond both to the loss of meaning faced by caregivers and to the difficulties of access to care for the population. And in fact, according to a recent survey, eight out of ten French people believe that the candidates neglect health issues too much.

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This sector is still seen only as a source of spending and not investment. This bias is explained by the budget construction logic, with the annual social security financing accounts. Each time, it is a question of evaluating the possible savings and not of imagining the benefits of a general improvement in the state of health of the French. For this reason, in our note, we propose a reform of Ondam, the national goal of Health Insurance spending. It is about getting out of this short-term logic, to facilitate the implementation of policies focused on the development of prevention.

Above all, shouldn’t the means be increased?

Salary increases, such as those released under the Ségur de la santé, are important, but it is clear that they are not everything. The lack of time generates a strong frustration, with the impression of attending at a discount. Improving the daily life of medical and paramedical teams obviously requires an increase in the number of caregivers, but also investing in digital tools that facilitate their work, simplifying procedures, facilitating the exchange of information between city doctors and hospitals. , or between two hospitals…

In his note, he first highlights the need to establish and publish indicators of quality of care. Why is this so important?

This practice has developed a lot abroad, and today we can see all the benefits. In the United Kingdom, the NHS has made two sites available to patients with activity data and results of treatments carried out in the different establishments in the country. We are often told that doctors can be reluctant, but in the Netherlands, for example, oncology surgeons have initiated this approach themselves, creating a first activity registry. Then they gradually developed into many specialties. Each time, practitioners were free to join or not, and hospitals to publish the results or not. Some began to play the game and this generated a strong collective emulation. Once these indicators have been widely collected, clinicians have been able to use them to assess and improve their practice.

It is clear that this could be very transformative for the health system, while helping to restore meaning to the work of caregivers. The projects were launched in 2018 and the High Authority for Health is seized, but in general, this is a file in which there has been little concrete progress in France in recent years. The candidates themselves say little about it, no doubt for fear of arousing the hostility of doctors.

For your part, you even propose linking part of the remuneration of interns to these indicators. Isn’t that the best way for this to fail?

Not at all, because we would be in a premium logic, voluntarily. Waiting for the emulation to work, as we saw in the Netherlands. The main point of attention is the risk of dislodgement of care, that is, establishments exclude heavier patients to show good results. It is imperative to build indicators that take this risk into account.

The other key issue for you is the role of digital in health. We talk about it a lot, but aside from teleconsultations, isn’t this still a bit theoretical for patients?

This will certainly change with the generalization of “My health space”. This tool should replace the shared medical record, which has had problems being implemented. This time it is a single space where policyholders can collect all their medical information, test results, etc. They’ll also find something to make it easy to book appointments, as well as wellness apps and practical tips. If doctors play along, it could be truly transformative.

In France, there is still a lot of work to be done to facilitate the understanding of the interest of digital tools to improve health monitoring. This is why we also suggest that health professionals receive more training in it during their studies.

Is there not, above all, a desire on your part to open up more access to French health data, an eminently sensitive issue?

We have had many exchanges with researchers but also with companies: they all tell us that access to databases is still relatively restrictive. It is normal that there are guarantees and that the CNIL validates the requests. But we must not neglect the other issue: managing to develop French solutions, based on national data, instead of being algorithms imposed from abroad, parameterized in populations whose characteristics and health status do not necessarily correspond to ours.

You also ask for the development of prevention. All health actors have been repeating this for years. How would it be possible to finally achieve this, in your opinion?

Establishing regular consultations on “aging well”. They would be long consultations, better paid, in which general practitioners could mobilize analysis grids to grade this preventive approach according to the needs of the person, their physical and cognitive state.

This could also imply the implementation of a “population responsibility” of care teams: the idea is to have all caregivers in a territorial dialogue and work together to develop specific clinical programs, adapted to local needs, from prevention to treatment. treatment. The objective would, of course, be to contribute to improving the health of the population. To overcome public-private opposition, regional health agencies could play the role of driver. The corollary would be to go further in transforming the forms of remuneration, so that the different professionals no longer compete, but rather are encouraged to cooperate within coherent and personalized healthcare itineraries.

Would you also like to involve psychiatric care in this reform?

Psychiatry has been Medicare’s top expense for several years, yet patients are diagnosed and treated late. Apart from serious pathologies, we know that people in distress are usually more likely to consult their family doctor first, than to psychiatric services or specialists. However, only 50% of general practitioners know the tools to assess and identify depression, while 60% of the first consultations in general medicine refer to a mental disorder. His residency does not include courses in psychiatry. Here too, we should give them new tools and involve them in the work of the hospital’s psychiatry services, through collaborative care. The idea would be that they would be essential in the treatment of mild or moderate psychiatric disorders, both to alleviate psychiatry and to improve access to patient care.

The express

Beyond the publication of your proposals, how do you intend to mobilize in the coming weeks to raise awareness among the candidates?

We have exchanges with their health advisors to present our recommendations. And we are also going to participate in “Place de la santé”, the “grand oral” of the candidates organized with other Think Tanks and the Mutualité Française at the beginning of March. With the production of notes, our goal is to actively contribute to the production of ideas within the framework of this campaign.



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