Système de santé

Responsabiliser financièrement le patient n’a aucun sens

Ticket modérateur ou ticket d’exclusion ?
lundi 5 février 2007

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Elie Arié

Elie Arié est cardiologue, enseignant associé à la chaire d’économie et gestion des services de santé au Conservatoire national des arts et métiers. Il est proche de Jean-Pierre Chevènement et a été, au MRC, délégué national à la santé [1].

Dans un entretien récent [2], Nicolas Sarkozy, abordant le thème des dépenses de santé, répète à deux reprises : " Il faut essentiellement responsabiliser le patient. " par des franchises de remboursement (ticket modérateur - qui existe déjà et qui est un des plus élevés d’Europe).

Responsabiliser financièrement le patient n’a économiquement aucun sens dans la consommation médicale qui est, pour l’essentiel, une économie subie et non choisie ; on ne choisit pas d’être malade et, quand on l’est, on n’est pas compétent pour juger des dépenses qui vous sont prescrites. Si votre médecin vous prescrit un scanner, sur quelles bases pouvez-vous juger qu’il n’est pas indispensable ?
En revanche, l’importance de la franchise peut dissuader financièrement les plus faibles revenus de se soigner : le ticket modérateur est en réalité un ticket d’exclusion, puisqu’il ne joue que sur les possibilités financières de chacun, sans prendre en compte aucun critère d’utilité médicale.

Cette injustice sociale est doublée d’un non-sens économique complet : tous les spécialistes de santé publique savent qu’il faut faciliter financièrement le plus possible l’accès au médecin de premier recours - c’est-à-dire le médecin généraliste - car les diagnostics et les traitements précoces, susceptibles d’éviter qu’une maladie ne devienne grave - donc chère - constituent le premier facteur d’économies des dépenses de santé. C’est pourquoi, dans la plupart des pays développés, l’accès au médecin généraliste est dispensé de toute avance de frais et de franchise ; il est absurde de dissuader financièrement ce que les considérations de santé publique et d’économies de santé devrait inciter à encourager !

La seule responsabilisation financière possible serait celle des ordonnateurs des dépenses, c’est-à-dire des prescripteurs... celle que Nicolas Sarkozy écarte d’office : " La médecine libérale, qui ne représente que 15 % des dépenses, a fait beaucoup d’efforts ". Je ne vois pas lesquels, en dehors des combats facilement gagnés par les spécialistes pour obtenir des droits quasi constants aux dépassements d’honoraires, et dont le montant vient s’ajouter à la franchise financière pour majorer d’autant la part laissée à la charge des malades.

Il convient de rappeler ici :
- qu’entre 1990 et 2004, le revenu des médecins spécialistes a progressé trois fois plus vite que celui des salariés, selon le prochain rapport du Haut conseil pour l’avenir de l’assurance-maladie (HCAAM), attendu cette semaine, et qui illustre le fait que les efforts financiers ont toujours été demandés aux seuls salariés ;
- qu’en Allemagne, le montant des honoraires médicaux est fixé en fin d’année, en fonction des comptes de l’assurance maladie : en cas de déficit, il est abaissé, et les médecins doivent rembourser le trop-perçu, compte tenu des nouveaux tarifs à effet rétroactif (système dit des " lettres clés-flottantes ").

Mais, ces cinq dernières années, le gouvernement a été tétanisé par son obsession d’éviter de mécontenter de quelque façon que ce soit les médecins ; ce qu’on peut appeler son "syndrôme plan Juppé", auquel il attribue son échec aux législatives de 1997.
L’exemple de l’Allemagne montre pourtant qu’une réforme de l’assurance maladie, nécessairement douloureuse, ne peut réussir que si les sacrifices sont équitablement répartis entre les assurés, les professionnels de santé et l’industrie pharmaceutique : en choisissant, pour des considérations aussi électoralistes qu’idéologiques, de favoriser ces deux dernières catégories et de faire porter tout le poids financier des réformes aux seuls assurés, Nicolas Sarkozy opte pour une médecine de classe et prépare une situation socialement explosive.

[1] D’après la présentation de Michel Sorin pour MRC53 en préambule à cette contribution d’Elie Arié pour OpiMed, également publiée par l’Humanité, édition du 25 janvier 2007, sous le titre : "On ne choisit pas d’être malade".

[2] Interview publiée dans Le Monde daté du 23 janvier 2007.


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