In connection with the new law dated February 2, 2016 for the End of Life, a budget of 190 Million Euros has been allotted for the national development plan for Palliative Care for the period 2016-2018. Beyond the crucial problem of financing for palliative care, one might wonder if the charging system for the act is adapted to taking care of an individual at the end of life.
Since 2005, a new charging system has been applied in French hospitals: this is what is called T2A or « tariff per act ». The principle of T2A consists in paying the hospital in accordance with the number and the nature of acts performed on each patient, and not, as before, in accordance with the length of hospitalization. T2A’s principle objective is to encourage hospitals to shorten the length of hospitalization to improve their financial balance sheet.
Last November 5, the Health Minister, Mrs. Marisol Touraine, entrusted Dr. Olivier Véran, at the Medical Center in Grenoble, with an assignment to study this system of charging per act, recognizing that certain hospital activities, especially palliative care, do not correspond to this model of charging. Indeed, how can we talk about acts for a patient, for whom it has just been decided to stop curative treatment? What sense is there to try to shorten the stay for a patient at the end of life, whereas the objective of palliative care is to accompany him in the best way possible until his death?
With the T2A system, for a patient staying in Palliative Care between 4 and 12 days, the hospital receives a fixed amount from the French National Medical Insurance. Starting on the 13th day, the budget is only increasing very slowly. Therefore, from an accounting standpoint, the hospital would benefit from releasing the patient on the 14th day and admitting another patient. Thus, a patient who, a few years before, arrived in a Palliative Care Unit to end his days is sometimes sent back home, only to return to hospital a few days later, thus allowing the hospital to “turn the counter back to zero”. This appears to be incompatible with end of life care, and could even be considered contrary to ethical practices.
One can well see that this tariff per act can give rise to dangerous drifts when financial choices prevail over legitimate medical decisions. Accounting calculations should not be given the priority when accompanying individuals at the end of life; other qualitative criteria should be taken into account.
