[Control of hospital expenditures].

Hospital expenditures in France (300 billion francs in 1995) comprise half of the expenditures of the Health Care Assurance system. The government directive dated 24 April 1996 created a national accreditation and evaluation agency. The effectiveness of the agency will largely depend on the ability of the experts to create a pragmatic system. The 5-year maximum delay for an accreditation request can be explained by the fact that the system is new, but will nevertheless delay hospital closure decisions and thus prolong the function of hospitals with reduced activity and thus less medical experience, leading to extra cost for the society. The directive also created regional hospitalization agencies which are to develop a regional health care policy, analyze and coordinate hospital activity and determine hospital resources. It is hoped that these agencies will be more effective than the former health care and social organization committees. The necessary decisions for hospital closures will be difficult due to the opposition of both the populations and elected officials. Finances for public facilities will continue on the basis of a global budget, an attempted macro-economic cost-containment policy which has had only limited effect. For private facilities, use of medicalization data systems could have unfavorable effects if the data is too approximative and could cause undue increase in cost over benefit if the data is too exhaustive. The directive does not appear to modify the authorization system for major equipment expenditures. There is no mention of the increasing size of hospital administration staffs. Finally, the directive does not address the fundamental question of medical behavior: a modification of medical training which would place more emphasis on clinical training and reasoning.