2023-11-16 16:44:00
For several weeks, the social security financing bill (PLFSS) has been under discussion in parliament. It includes an amendment, carried by MP Stéphanie Rist, which aims to modify the terms of financing dialysis. We strongly support these provisions, for the following reasons.
✅ Dialysis is a heavy, recurring treatment, generally 4 to 5 hours, 3 times a week. It must be continued chronically, until transplant or death. It is one of the treatments that most degrades quality of life. Median survival on dialysis is lower than for most cancers.
The economic profitability (operating result) of private dialysis structures is around 15%, much higher than that of other care activities (between 4 and 5%) (Court of Auditors, 2020).
The “net profit” of the structures can reach around €6,000 to €8,000 per patient per year. 3.6 billion euros per year, for 56,000 patients, is a considerable windfall, and not only for the lucrative private sector.
These very high levels of profitability give rise to strategies aimed at “optimizing the package”, by increasing volumes and cutting costs:
1) Multiplication of the most profitable acts and “race to fill”: dialysis in center and in UDM, heavier and more expensive, at the expense of autonomous dialysis
2) Limitation of the quality of care and support: restrictions on human, medical resources, supportive care, lack of information and education of patients, non-compliance with recommendations, standardization of the quality of treatment and equipment/consumables at an insufficient level, dissuasion of autonomy, lack of personalization, disappearance of the offer of sessions at staggered times, the only ones to allow patients to remain employed, etc.
3) Lack of access to innovationand in particular to “unconventional” dialysis techniques (daily, long night, etc.) which we know nevertheless improve the quality of treatment and life of patients, promote continued employment, etc.
4) Deterioration of patient comfort, according to mechanisms similar to what is observed in EHPADs: elimination or limitation to a bare portion of the catering offer, patients are asked to bring their own sheets, dilapidated premises, etc.
✅ This quest for profitability also contributes to the artificial maintenance of the strong “attractiveness” of dialysis:
upstream, for increase incoming flows : low effectiveness of prevention strategies and slowing down the progression of kidney diseases, or even anticipation of the start of dialysis, or even carrying out unnecessary chronic dialysis downstream: limitation and slowing down of access to the transplant waiting listmaintenance on dialysis of very elderly/end-of-life patients at the expense of their referral to palliative care.
See as well :
???? In total, the loss of opportunity for the patients concerned, poorly informed, poorly oriented, poorly treated, is considerable and irreversible, in terms of quality of life, life expectancy, social and professional life, etc.
Furthermore, kidney transplant is the most efficient treatment, in all age groups (HAS 2015).
Compared to dialysis, it significantly improves quality of life and life expectancy, and is also much less expensive. Several international examples, notably that of Spain, show that there is significant potential for the development of kidney transplantation in France. Various medico-economic studies confirm that if France were to meet the best European standards in terms of kidney transplants, it would make significant savings while considerably improving the quality of care and pathways. Developing kidney transplantation is a perfectly realistic objective, which constitutes the most effective lever in terms of public health and health savings. Curiously, in France, this observation, although drawn on multiple occasions, has not to date given rise to measures that meet the challenges.
✅ The amendment under discussion to the PLFSS could constitute real progress, provided that it puts an end to the current excesses, some of which hit the media headlines, but the majority of which continue in opacity.
It will also be necessary to “go to the end” of the reform. It has already been the subject of public commitments on several occasions, including recently. The last ones date back to 2018, as part of “My health 2022”. Each time, the massive pressures exerted to maintain the status quo were successful and the work was abandoned.
The objective for Renaloo is not to reduce the costs of dialysis, but to ensure that its funding through national solidarity is used wisely.to optimize patient care and pathways, by encouraging best practices, rather than enriching shareholders, pension funds, or the real estate assets of associations or foundations.
This could be the case if elements are taken into account evaluating the quality and relevance of care (results indicators, patient experience, medical ratios, etc.), but also populationnelsto promote prevention (= delay as much as possible, or even avoid, dialysis) and encourage transplantation (= accelerate the exit from dialysis towards a more efficient mode of care).
To be continued.
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