2.24 The way that medical establishments are currently organised does not ensure compliance with the ONDAM. This can be explained by the fact that the responsibilities of those in the system are not clearly defined (OECD, 2000).
While this method of funding did ensure that the ONDAM was respected in 1998 and 1999, it failed to eliminate big disparities in the budgets of hospitals with identical activities and did little to encourage efforts to improve efficiency and modernize, thus generating rents, resource allocation inefficiencies and the risk of increased spending in the long term.
In addition, the recent sharp rise in hospital spending and part of the initial ONDAM overruns are due to the introduction of the legislation on the reduction in working hours (RTT) which was accompanied by a plan for the recruitment of hospital staff (53 000 jobs created between 2002 and 2005) and the application of the 1993 European Directive resulting in hospital doctors' on-call hours being incorporated in their weekly working hours.
* The system of funding tied to activity was introduced in March in the private sector, having been somewhat delayed; ONDAM overruns in this sector have been high.
* Institutional reform (details of which are given in Annex 2.A2): creation of a warning committee responsible for preventing any excesses, improved participation by all sickness insurance actors in managing the ONDAM.
Parliament will vote the balance on the main sickness insurance systems and the impact of the ONDAM vote will be strengthened by virtue of a detailed discussion of its component parts.
If the general practitioner is simply going to refer patients to specialists without reducing the number of visits, expenditure in terms of doctors' fees, which accounts for 20% of the ONDAM, is not going to be contained.
Lastly, the question of health professionals' remuneration is not tackled, even though it accounts for nearly 50% of the ONDAM.
Each year Parliament sets a national health spending target (ONDAM) based on revenue estimates and the national health goals defined by the National Health Conference.
Since the ONDAM has been repeatedly exceeded, the authorities have reorganised, in the 2004 reform of the social security law, the way that the ONDAM is to be constructed by broadening the range and the role of stakeholders in the system.
* The health insurance system will participate in developing the ONDAM through the Union national des caisses d'assurance maladie (UNCAM) (23) that will regroup the three major social insurers: the CNAM, CANAM and the MSA (24).