Contenu du sommaire : Gérer l'hôpital : outils et modes d'emploi

François Engel, Jean-Claude Moisdon, Dominique Tonneau: "Official" constraint or real constraint? An analysis of the control of hospitals in France. Since the end of the seventies, different dispositions and reforms have been issued to try and limit the growth of hospital expenses, and change the management rules in place. Through a research dealing with a sample of 12 hospitals, and completed between 1986 and 1988, the authors studied the effects of these new budgeting constraints. A quantitative analysis was led on the 1980-1986 period of time, and it did not yield a significant bend in respect with the previous tendencies: growth of the hospital real expenses quite higher than the provided officiai rate, lack of tendencies as to the financial indicators, very heavy increase in the medical expenditures, etc. These results may be explained fiinctionally through a certain amount of derogations and various exceptions, as well as a local use of the allowed flexibility remaining in the definition of the budgeting procedure. More basically, such a state of facts may be linked to the présent actors' system. The authors show how physicians and hospital managers have gradually built up a consensus, in order to enter a strategy of technical development, centered on the hospital itself. As to the local trusteeship authorities, they are not in a position to oppose this strategy, because of two main factors: the power relations at stake, and the constraints deriving from the management tools in use.

Gérard de Pouvourville: Paying the hospital with DRGs: issues, principles and feasability. The Diagnosis Related Groups, a patient classification System designed in the USA, have brought a major change in the debates around hospital management. The theoretical and methodological grounds of this new tool are here analyzed, as well as the main characteristics of the context where they were first used as a rate-setting scheme. Consequently, it is then possible to discuss the issues, the principles and the feasability of using DRGs in a context wherein a dominant payor allocates resources through prospective budgeting. The discussion shows that such an endeavour requires a careful, slow experimental process, so as to make sure that redistribution of resources are a function of actual casemix differences, and not of unrecognized biases due to the construction of the payment scheme.

Michel Naidiich: Beyond DRGs, the Patient Classification Systems: objectives, methods, results. The emergence and the use of DRGs in the USA, as well as the controversies they have aroused, have stimulated the development of so-called alternative patient classification Systems, ail designed more or less to replace DRGs or at least to cope with its major weakness, the measure of severity of cases. This article examines the main alternatives on the market, i.e. Disease Staging, Patient Management Categories, Computerized Severity Index and Medisgroup, as well as the latest DRG version. Their relative objectives, methods and validity are analyzed. It is shown that their development is contingent to the north american context, and their utilization in a context driven by other incentives is finally discussed.