Too long waiting times, geographical distance, inaccessible devices … the inadequacy of the equipment of the regional territory leads to a renunciation of care. The agreement changes, it remains to apply.
“Every request that reaches the agency is viewed positively” : Didier Jaffre, director of the regional health agency, spoke to an informed public who knows all too well the difficulties of accessing MRI during a press conference for Pink October, breast cancer screening awareness month on 29 September. magnetic and scanner in Occitania, subject to ARS authorization.
He insists: “I want to put an end to the quota logic”. Joseph Pujol, Director General of the Regional Cancer Screening Coordination Center, reacts immediately, delighted: “I’ve never heard such a speech.” Users, who for years have been juggling online appointment booking sites and direct numbers that are inaccessible or unresponsive.
The situation is disparate in the regions, but the territory is generally poorly equipped, and sometimes drastically. The inventory drawn up last June by ARS provides a very complete picture of the situation. Two examples: Ariège is devastated in terms of equipment, with 13.1 scanners and 6.5 MRIs per million inhabitants, just behind Lot. The regional average data are respectively 20.2 and 16.9.
Also in Ariège, one third of the population is more than 45 minutes from an MRI, in Gers it is one in two. “90% of the population of Occitania lives in rural areas”Insists Didier Jaffre. The problem : “If users are asked to travel tens of kilometers for an exam, they don’t go there, it’s a factor of forgoing treatment“. These are anyway “extraordinary means of prevention and diagnosis, especially of cancer”.
Things will really change, why, how?
New state border and “transition phase”
“Decrees published fifteen days ago” set a new course of action, says Didier Jaffre. Reform of the Imaging Authorization Act is underway. These texts will enter into force in June 2023, simultaneously with the implementation of the next regional health project, currently under preparation, which will integrate these data: no more dogmas “many scanners or magnetic resonance for many inhabitants, we will not put quotas”, says Didier Jaffre, “we are late”.
Meanwhile, for nine months, “We are in a transition phase”ARS explains: “The permissions for scanners and MRIs are still subject to quotas of the current regional health project, legally I cannot grant more than what is authorized. But the idea is to say” no “to anyone. So I say” yes “, with a deadline: I have already validated the new installations, under “exceptional needs”, so that they are effective in June 2023, the timing of the realization, the purchase of the machine, the works … it takes six months to a year for the installation, I don’t want to waste time “.
Where will the new equipment be?
“There will be a scanner in Limoux and maybe tomorrow an MRI”said Didier Jaffre, who underlines it“Another scanner was requested in Aude”they “I’ll say yes”.
Two further MRIs are also announced with certainty in the Lot, in Gourdon and Figeac.
Without providing an exhaustive list, the ARS specifies this “Hérault, Aude, Eastern Pyrenees and Gard” it will also be served. In total, 42 additional devices (24 scanners, 18 MRIs) will be authorized over the next nine months, “relying on local hospitals, territorial professional health communities”and also through “new ways of cooperation between actors”in “shared medical imaging platforms” For instance.
MRI and scanner, for whom and for what?
Medical imaging is both a means of “prevention and diagnosis” and “treatment,” ARS points out. Why prescribe a CT scan and not an MRI and vice versa? Both reviews provide complementary information. “The scanner is a radiological examination that uses X-rays and allows you to reconstruct images of the body in two or three dimensions,” specifies the health insurance. It is contraindicated in pregnant women.
Magnetic resonance imaging (MRI) “is an examination based on the use of electromagnetic fields” (not X-rays). It also provides “body images in two or three dimensions”. It is especially prescribed to visualize “soft tissues” (brain, spinal cord, muscles, viscera, tendons, etc.). To perform an MRI, the patient must not be in a magnetic field sensitive medical environment.
Public-private collaboration, medical demographics … the pitfalls
So, are the weeks of waiting for an exam over? “We have to arrive at reasonable deadlines, excluding emergencies that have already been handled. A month is too long. A week is fine.”, estimates the ARS. However, all obstacles have not yet been removed. To operate the devices, “We need radiologists and radiomanipulators”recalls Didier Jaffre. Medical demographics are halfway through, but according to the ARS, “there are enough radiologists and radiomanipulators to operate new devices, we are not in tension …” provided that those of the public and private sectors are added.
“The other point of view” of this opening, he adds, “is that public and private work together, and respond to the obligation of the guards”, “a change of mentality and perhaps of paradigm”: “I ask that the actors carry out the projects together and ensure the permanence of care, which does not mean that everyone the devices must work 24 hours a day “. He is not worried: “It is the quota policy that induces competition”.
On the other hand, the investment (from € 700,000 for a scanner, € 1 million for an MRI) should not be an obstacle. : “It is the assumption of the documents by the health insurance that ensures the financing, it is a virtuous circle. And most of the devices today are bought on lease, within seven years, the rental is with maintenance”.
An unknown factor remains: “There are some supply difficulties. We are careful that deadlines are fast”.
In the inventory drawn up last June, the report on the Regional Health Plan for the years 2018-2022 showed that as of May 31, 19 authorized devices had not yet been installed, 11 MRI scans (one in Gard, two in Haute Garonne, one in Gers, three in the Hérault, one in the Pyrénées-Orientales, two in the Tarn, one in the Tarn-et-Garonne) and 8 scanners (one in the Aude, four in the Gard, two in the Haute-Garonne, one in the Gers).
Jean-Michel Bruel, user representative: “Abnormal delays”
Vice-president of France Assos Santé Occitanie, representing users, Jean-Michel Bruel is also the former head of the radiology department of the Saint-Eloi hospital of the university hospital of Montpellier. He participated in talks with the regional health authority. He welcomes the new policy and expects a “materialization” because “the demand of the population is legitimate”. But there is so much to do … “There is no logical path to treatment. Apart from the scarcity of scanner and MRI resources, there is a coordination problem. There are too many patients leaving the doctor. with a prescription for a visit, and that they have difficulty, because if it is not the prescriber who does the process, the appointment is obtained with abnormal delays, “notes the user representative.
For Jean-Michel Bruel, we should also start implanting scanners “wherever there is surgery”. An example: “It is not normal for the Causse clinic in Béziers to be left without a scanner, the request has just been validated”.
“This development is good”, he concludes, recalling “why we have come to this”: “We could make the analogy with the numerus clausus, the political reasoning has long been that if we reduce the resource, it has also reduced demand” . According to him, “we should greatly improve the current situation” but “we will not solve all the problems, because there is a problem of medical demographics”.
Sophie Aufort, radiologist: “We must mesh the territory”
Sophie Aufort, radiologist at the Clinique du Parc, in Castelnau-le-Lez, represents radiologists at the Regional Union of Health Professionals (URPS).
Do you agree with the idea of freeing the installation of scanners and MRIs on the territory?
With my colleague Professor Jean-Michel Bartoli, from AP-HM, in Marseille, I participated in the debates in the ministry on the subject. We had not worked with the idea of ”letting go” on the installation of heavy material equipment (EML), but on the need to reform and integrate interventional radiology into the care process. Ultimately, this is progress. An authorization of less than three EMLs per geographic site will no longer be required. And it is great news that the regional health agency wants to work very quickly on the subject. This is unheard of after years of discussions where you had to choose between two sites that had as many needs as each other.
Is our region really poorly equipped?
We remain out of step with the national and European average, resulting in long waiting times. But a lot of effort went into the review of the latest regional health project, halfway through its completion. The devices have been authorized, but surprisingly they are not yet installed, often in public, for a matter of financing.
We should already have a scanner and an MRI in all hospitals and clinics.
Public / private collaboration, do you believe it?
There are things that work, and it’s very interesting in philosophy. I understand that this is the desire of the ARS. But there are many uncertainties and unknowns, it is a real concern, with implementation difficulties, which arise for example in isolated areas, far from health facilities, where private radiology studios have also closed. We had a project in the Eastern Pyrenees, to install a scanner near a nursing home, as part of a professional territorial health community (CPTS), so that the population has access to this equipment. The idea did not get a crazy reception … We also had the idea of offering a scanner in La Paillade, in Montpellier, near a multi-professional health center, because there are people in the neighborhood who have no intention of taking care of themselves. It is not a question of the geographical distance of the equipment in this case. This is the problem of a population far from treatment.
Are there no medical demographics issues?
There should be no angelism. Today is the hunt for radio manipulators.