The market for psychiatric clinics - France

1.2 Very unequal reception capacities in Europe

The observation of the number of psychiatric hospital beds in European countries shows a higher number of beds for two countries: France and Germany . However, these data must be qualified. On the one hand, because patient care is highly dependent on the type of social security system in force in a country, but also because the size of the population partly explains these variations.  

Number of psychiatric beds in hospitals in selected European countries Europe, ****, in thousands of units Source: ****

In order to remove the bias due to population size, it is possible to establish a ratio expressing the number of inhabitants per bed in psychiatric hospitals.

Number of inhabitants per * psychiatric hospital bed per country Europe, ****, in number of units Source OECD We can see that in Belgium, Germany and Norway, the supply of psychiatric beds is highly developed . For example, the Belgian market has about * bed per *** inhabitants. In these countries, it is likely that competition is more intense or that the system of state care for psychiatric patients is more developed.

We note that countries like Spain and the United Kingdom have few beds for psychiatric patients . Moreover, the particular situation of Italy can be highlighted; since the ...

1.3 The French market: decrease in available supply and market estimate

There are no precise data on the turnover of the private psychiatric clinic sector in France. However, it can be approximated using the volume of activity (***) and the average cost . It is thus possible to estimate its evolution over the period ****-****

First, the chart below highlights the number of psychiatric care beds in hospitals per ***,*** inhabitants in France from **** to **** In ****, there were approximately **.** psychiatric care beds per ***,*** inhabitants in French hospitals . We can observe a steady decrease in the number of beds allocated to psychiatric care with a slow but steady decline (***).

Number of psychiatric care beds in French hospitals France, ****-****, per ***,*** inhabitants Source: ****

Full-time hospitalization

Full-time hospitalization is the almost all the activity of private for-profit clinics (***).

According to lerimp The average cost of a full-time hospitalization for adults is ***€ per day against ***€ for the same type of hospitalization for children. This gives us an approximate market value for full-time hospitalization of approximately *.** billion.

Part-time hospitalization

Day hospitalization constitutes almost the entire part-time hospitalization market With respective costs of ***€ and ***€ , n this gives us an approximate market value for part-time hospitalization of approximately *.** billion.  

It is then possible to estimate the market as follows:

Market estimate for ...

1.4 Psychiatric impact of Covid-19

Many cases of psychotic disorders are appearing in **** so that the situation in France is alarming at the end of the health crisis

We hear a lot about the cases of depression caused by the crisis and the isolation of individuals, but in reality all sectors of psychiatry are affected. Whether it is mood disorders, depression or bipolar disorders, patients with these psychiatric conditions have seen a large increase in ****. [***]

According to the observations of the University of Lille after a survey of **,*** students, students were particularly affected by psychiatric disorders in ****. According to the study, **.*% of them were crossed by suicidal ideas, **% experienced severe depression and **.*% a high level of anxiety. [***]

The vast majority of people suffering from mental disorders are treated on an outpatient basis. Establishments dedicated to psychiatric services have had to adapt to the health context to ensure continuity of care.

According to the CoviPrev survey, conducted on **** people aged ** and over by Santé Publique France since March ****, a significant increase in anxiety states has been observed. In fact, **% of those questioned in the survey during wave ** (***) presented an anxious or depressive state. [***]

2.1 The profile of patients hospitalized in psychiatry

Source: ****

Observation of the characteristics of patients followed in psychiatric institutions reveals several structural differences:

In children and adolescents The proportion of men is higher **% of the total number of patients treated in hospital and **% of those treated as outpatients in this category The share of partial hospitalization is higher than the number of full days, representing **% and **% depending on the type of care

In adults The proportion of men and women is more equal, **% of adult patients are women as far as inpatient care is concerned. Less than one in five hospitalizations is a partial day for adults. The **% of inpatient care therefore lasts at least one full day The average length of hospitalization is half as long for adults as for children. It is **.* days for adults compared to **.* days for child and adolescent psychiatry

More generally (***) in ****, ***,*** patients were hospitalized in psychiatry, and about *.* million were followed in outpatient care

The type of pathology treated (***) for the elderly is sometimes at the border of the retirement home and the EHPAD . Orpea, one of the European leaders in dependency care, is present in this segment through its subsidiary Clinea .

2.2 The type of treatment depends on the individual being treated

Source: ****

There are significant differences in the type of disease depending on the gender of the individual

For hospitalization, among men, the three most frequent pathologies are

schizophrenia and delusional disorders (***) mood disorders (***) mental and behavioural disorders related to the use of psychoactive substances (***)

For women, there are:

mood disorders (***) schizophrenia and delusional disorders (***) neurotic or stress-related disorders (***)

3.1 Three types of players coexist in a market where full-time hospitalization clearly dominates

Distribution of the number of beds or places by type of actor France, ****, in % Source: ****

The following figures are for general psychiatry:

With nearly two-thirds of the market In terms of capacity, public establishments remain in the majority (***)

Private for-profit institutions represent only **% of capacity while private non-profit institutions (***) have an even smaller market share of **%.

Source: ****

In terms of types of treatment, full-time hospitalization clearly dominates the type of treatment offered, concentrating nearly **% of the total accommodation capacity in France in **** . Therapeutic foster care is the main alternative to full-time hospitalization  

Distribution of the number of days by type of actor France, ****, in % Source: ****

The observation of the activity shows little difference compared to the reception capacities, we can however note a higher capacity utilization rate in private not-for-profit facilities.

Source: ****

Observation of the ratio of the number of days per bed or place shows a more intensive use of available places in private for-profit facilities. In ****, an available bed or place was used on average *** days per year in this type of establishment compared to *** for private not-for-profit institutions and *** for public institutions.

Another notable difference between the various structures is the absence of services such as therapeutic foster ...

3.2 A concentration of the private psychiatric clinic market

A dynamic of concentration of hospital players

A concentration movement can be observed in the private psychiatric clinic market The acquisition by Inicea of Korian's psychiatric activity in **** as well as the purchase the acquisition of the ** Médipsy psychiatric clinics from Générale de Santé by Ramsay Santé in the same year considerably increased the concentration of the sector. Ramsay Santé is advancing on its website represent **% of the private hospital market

In ****, the Lyon-based C*S Group will acquire two clinics in the Doubs region: Saint-Vincent (***), bringing the number of C*S establishments in the Bourgogne Franche-Comté region to nine In the same year, the BERGMAN CLINICS group acquires six clinics.

In ****, the he LA CHERY medical and health group is reorganizing its capital to to acquire a psychiatric clinic.

This concentration offers advantages for the players in the sector, in particular thanks to economies of scale (***) or the potential creation of central purchasing agencies.

The arrival of new players

Investment funds are also interested in this market, such as of Antin Infrastructure Partners who took over the clinics Inicea in **** .

In ****, the s clinics PASTEUR and BERGOUIGNAN merge to offer complementary specialties to patients.

Recurring revenues, growing ...

3.3 Unequal distribution of density and hospital places

Number of Psychiatrists by Region

France, ****, in number of units

Source: ****

Source: ****

Observation of the density of psychiatrists, but also of psychiatric hospital beds in metropolitan France reveals strong regional disparities.

It is partly to fight against this territorial divide that the Ministry of Health has announced a increase in the annual allocation for public psychiatric institutions in **** [***].

The observation of existing supply allows private players to position themselves in the departments where supply is weakest. In ****, the Sinoué group of clinics thus opened an establishment in Vernon in the Eure department following the recommendation of the Haute-Normandie Regional Health Agency (***), which was seeking to make up for the region's backlog in this area

According to agency data The Eure had only * psychiatrists per ***,*** inhabitants, compared to an average of ** for the whole of France.

The map of the different private psychiatric clinics in France is available on the website of FHP-Psychiatry which gathers *** private and psychiatric hospitals [***].

4.1 Costs in 2017 and structural trends

The unit of measurement used to assess the cost of care provided is the costs for work units (***) which is calculated from national data for public and private not-for-profit institutions.

These data show the unit costs of care activities and support functions in the following categories:

Cost per day of clinical services HAH, MCO, PSY, SSR ; Cost of medical-technical platforms ; Cost of laundry/restaurant activities ; Cost of medical logistics ;

Average unit labour cost by form of activity In euros Source: ****

The observation of these costs allows us to observe several trends in the costs charged in psychiatry:

The care of children represents an additional cost compared to adults Full-time hospitalization costs more than day hospital care, which is itself more expensive than outpatient care.

4.2 Price examples and downward pressure

Examples of prices charged

The prices charged by private psychiatric clinics are not always visible. As a comparison, we can show the prices charged in the Maison-Blanche Health Establishment, which takes care of the mental health of the population of the north and east of Paris.

Source: ****

However, we can note strong price variations depending on the location and the type of therapy implemented:

Source: ****

Downward pressure on prices

The psychiatric clinic sector in France has suffered from a continuous decline in the rates charged. It was only in **** that the rates for procedures and stays paid by the Health Insurance to health establishments increased for the first time, after * years of continuous decline [***]. Psychiatry has been heavily drained in recent years (***) provoking protests from the Federation of Private Hospitals whose president Lamine Gharbi had stated in **** : " Over the past ten years, rates have fallen by *% while inflation has risen by **% and our costs have increased by **%. "

In ****, public psychiatry in particular will benefit from an annual funding allocation (***) of *.*%, which the Ministry of Health evaluates at "*** million in additional perennial credits" aimed at "engaging the necessary transformations in this field" and "reducing existing territorial inequalities." However, as far as private ...

4.3 Diversity of supply: the type of care structure depends on the patient's pathology and age

The type of care depends on The type of establishment

Of age

Patient autonomy

It can be assessed through * variables that make up the scale ADL (***) :

Dressing or grooming ; Movement and locomotion ; Power supply ; Continence; Behavior; Communication.

Each variable is then classified according to four rating levels:

Independence ; Supervision or arrangement ; Partial assistance ; Total assistance.

Source: ****

4.4 An evolving service offering

In order to develop the market, new care units are being created: gerontopsychiatry (***), eating disorders, care of adolescents and young adults, perinatal disorders, overwork syndromes.. The progression of ambulatory care While private for-profit establishments were totally absent from this type of service in **** (***) which is a private mental health establishment offering an alternative to full hospitalisation. In France, the volume of outpatient procedures recorded a rapid increase of **% between **** and **** [***]. The establishment of networks The creation of networks with doctors, associations and EPAHDs makes it possible to pool resources and find new sources of growth. A charter formalising the reciprocal obligations of EHPADs and psychiatric establishments was set up in october **** on the occasion of the *th day of the French Hospital Federation (***) devoted to the challenges of psychiatry.

5.1 T2A has had a major impact on activity

One of the events that had the greatest impact on the activity of psychiatric clinics concerned activity-based pricing (***) for private clinics

Its application to psychiatric institutions had been postponed to **** . Its implementation has crystallized many critics [***] not all activities are valued in the same way

While some (***) are well paid, prevention or long term care as in psychiatry or for chronic illnesses or monitoring the elderly is much less so .

More generally, the private psychiatric clinic sector is highly regulated and subject to regulatory instability. The implementation of the payroll tax credit (***) since January *, **** as well as the CICE have partially offset the rate cuts of the past ten years.

In ****, the law concerning psychiatric care was amended for the first time since the **** law (***)

This reform allows for the systematic intervention of a liberty and detention judge in the case of detention without consent of a patient for more than ** days. It also facilitates access to care that is different from full hospitalisation: over partial days, at home, etc. The reform provides a framework for the care and examinations carried out during the first ** hours of hospitalization

5.2 The role of the SRAs

The Regional Health Agencies are public institutions under the supervision of the Ministry of Health and Social Affairs

According to Ecohealth their role is to " to ensure unified management of health care in the regions, to better meet the needs of the population and to increase the efficiency of the system ".

The ARS can also play a role in the establishment of new psychiatric care centres These can issue calls for projects to develop the supply of psychiatric care . The three establishments created by the Sinoué Group were created following calls for projects by the ARS [***].

6.1 Segmentation

• Ramsay Générale de Santé
• Inicea
• Sinoué Groupe
• Les Cliniques de Saujon
• Clinique la Brière
• Maison De Santé De Nogent-Sur-Marne
• Clinique Saint-Vincent De Paul
• Clinique Ker Yonnec
• Orpéa Emeis
• Clinéa (Orpea Groupe)
• Vivalto Santé
• GHU Paris