Daniel Guillerm, President of the National Federation of Nurses (FNI), the main union of liberal nurses, made public the letter he sent on March 2 to Thomas Fatôme, Director General of Health Insurance, about the freezing of the implementation of the third part of the nursing care report (BSI) which was initially to take place in April. The opportunity to come back, for La Veille acteurs de santé, on the issues of public health and the organization of care linked to the implementation of this conventional measure.
In a few words, what is the BSI?
Daniel Guillerm – The nursing care report, BSI, is a system integrated in amendment 8 to the Agreement signed in 2019 between the representatives of the private nurses and the Health Insurance. This device consists in flat rate approximately 35% of the envelope of the expenses of the liberal nurses devoted to the acts relating to the assumption of responsibility of the dependence.
Until then, we were on a fee-for-service basis for these treatments. The idea was to switch to a daily package with a classification of patients into 3 categories: light patients, intermediate patients and heavy patients. The valuation levels of packages differ logically according to the classification.
The device was to apply in three steps :
- The first, for patients aged 90 and over, took place in January 2020.
- The second, for patients aged 85 to 89, after a showdown with Health Insurance, came into effect in September 2022.
- And the third, for patients under 85, was to apply in April 2023. However, Health Insurance does not seem determined to fit into this calendar.
From 2019, were you therefore in favor of introducing a dose of flat rate in the method of financing your activity?
D.G. – We were more in phase with Jean-Marc Aubert who was thinking at the time about the reform of the financing of Social Security. We had, and we still have, the strong intuition that full fee-for-service or full-payment is not the solution. For us, the mix of funding is essential.
We therefore preferred to negotiate this transition to a fixed price for part of our activity rather than having to endure it like a hussar. We have been and still are proactive on the subject. Not to please the authorities, but because we are acutely aware that we have to move the lines in terms of financing methods. It is in everyone’s interest.
So how do you explain that Health Insurance is now putting its foot on the brake?
D.G. – Health insurance has underestimated the needs of the population. It notes, to date, an overrun of the envelope provided for the BSI for the first two stages of €11 million and therefore does not want to initiate the third stage.
However, we do not have the same analysis of this excess. Today, the CNAM wonders if there is not an overestimation of the levels of dependence and therefore of invoicing, the consequence of a windfall effect.
For us, it’s just the reality on the ground, a reality that the Health Insurance has underestimated from the start: a decorrelation of the resources allocated in relation to the needs. There are certainly some abuses and they must be punished. Health Insurance has the means to identify those who play with the rule. But it is easier to penalize an entire profession and the French rather than doing targeted risk management and dealing with the problem of those who go wrong.
What are the foreseeable consequences of this freezing of stage 3 of the application of the BSI?
D.G. – First of all, it penalizes our patients. They will be confronted with problems of access to care. The BSI allows private nurses to better take care of patients. Apart from a few cases, the BSI is financially more favorable than fee-for-service. This encourages us to invest more in this type of care.
This should not scare the guardians. Rather than seeing the planned overruns, they should be happy that dependent elderly people are well cared for at home by private nurses. This solution is by far the most efficient compared to other solutions – hospitalization, nursing homes, of course, but also home nursing services (SSIAD). It has been calculated that if the liberal nurses were to be replaced by the SSIADs, three times as many staff would be needed.
In addition, the message sent to liberal health professionals by Health Insurance is deleterious. It sabotages any inclination for change at a time when the President of the Republic himself is asking for a change in the methods of remuneration towards more diversity – fee-for-service/fixed-rate payment. Resistance is strong among city health professionals, many of whom are attached to fee-for-service. So if, in addition, we do everything to steer a profession that is efficient and proactive on the subject, the public authorities are shooting themselves in the foot and soaping the board of progressive professional unions.
By doing so, everything is done so that the pressure cooker explodes among health professionals and citizens alike. Piloting with Excel tables is a very short-sighted and dangerous piloting. From the point of view of the good health of our health system and even financially!
Interview by Lucien Sague