Rapport de recherche - Le Défenseur des Droits

!
"!
!
!
!
!
!
#$%!&'()*+,$%!-./*0(1$%!$)!/$2)(*'$%3!$2)'$!
/*44.'$20*()*52!$)!/*%0'*-*2()*526!
72$!(2(18%$!/$!/*%05,'%!/$!-./$0*2%!$)!/$2)*%)$%!
!
!
!
9(&&5')!/$!'$0:$'0:$!
!
;('51*2$!#<=>9<=!
%5,%!1(!'$%&52%(?*1*).!/$!9.-*!@A@BAC9<!$)!>*$''$!DEFG9AHD6!
!
Recherche financée par le fonds de financement de la protection
complémentaire de la couverture universelle du risque maladie et le
Défenseur des droits
!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!
!
!

!
I!
Table&des&matières&
INTRODUCTION! 7!
1.!PREAMBULE! 7!
2.!DEFINITIONS!DE!LA!DISCRIMINATION!10!
LE!PROJET!DE!RECHERCHE!11!
1.!ETAT!DE!LA!RECHERCHE!11!
""6!D<=!J9AKA7L!=79!DA!#H=;9HFHBAJHEB!""!
"I6!DA!#H=;9HFHBAJHEB!#AB=!DMA;;<=!A7L!=EHB=!"I!
"N6!D<=!J9AKA7L!=79!D<!9<O7=!#<!=EHB=!"P!
2.!ENJEUX!ET!QUESTIONNEMENTS!DE!LA!RECHERCHE!16!
I"6!D<!;QEHL!#M7B<!A>>9E;Q<!=E;HERABJQ9E>EDE@HS7<!"T!
II6!D<=!EGU<;JHO=!"V!
IN6!F<JQE#<=!"W!
AX!;EB=JHJ7JHEB!#7!;E9>7=!<J!#<=;9H>JHEB!"W!
GX!DHFHJ<=!F<JQE#EDE@HS7<=!I"!
IY6!ABADC=<!II!
IP6!7B<!AJJ<BJHEB!>A9JH;7DH<9<!A7L!;AJ<@E9H=AJHEB=!<J!A7L!9<>9<=<BJAJHEB=!IY!
PREMIERE&PARTIE&:&L’INTERACTION&MEDECIN/PATIENT&ET&SON&CONTEXTE!27!
1.!CONTEXTE!GENERAL!ET!RELATION!MEDECIN/PATIENT!27!
""6!DA!9<DAJHEB!F<#<;HBZ>AJH<BJ!<B!;EBJ<LJ<!>D79H<D!IV!
"I6!#<=!;QAB@<F<BJ=!=E;H<JA7L!S7H!AOO<;J<BJ!DM<L<9;H;<!F<#H;AD6! I[!
"N6!<BKH9EBB<F<BJ!HB=JHJ7JHEBB<D!N"!
"Y6!7B!<L<9;H;<!FEHB=!HB#HKH#7ADH=<!\! NI!
"P6!DA!O<FHBH=AJHEB!#<!DA!>9EO<==HEB!F<#H;AD<!NI!
"T6!7B!;EBJ<LJ<!>EDHJHS7<!NN!
2.!LA!CONSTRUCTION!DE!CATEGORIES!DE!PATIENTS!34!
21.!LES!TRAVAUX!SUR!LA!CATEGORISATION!DES!PATIENTS!34!
I""6!D<=!<J9AB@<9=!NY!
I"I6!D<=!GEB=!<J!D<=!FA7KAH=!FADA#<=!NV!
I"N6!DMA@<!<J!DA!KH<HDD<==<!]!7B<!;AJ<@E9H<!GHEDE@HS7<!\! Y"!
I"Y6!D<=!FADA#H<=!=JH@FAJH=<<=!Y"!
22.!RESULTATS!:!LES!CATEGORIES!A!L’ŒUVRE!EN!MEDECINE!DE!VILLE!42!
II"6!D<=!GEB=!<J!D<=!FA7KAH=!FADA#<=!<B!AFG7DAJEH9<!YN!
III6!DA!;AJ<@E9H=AJHEB!=E;HAD<!#<=!>AJH<BJ=!YN!
IIN6!^!D<=!;F7!_!]!DA!;EB=J97;JHEB!=E;HAD<!#M7B<!;AJ<@E9H<!YP!
IIY6!D<=!<J9AB@<9=!<J!DMAF<!YV!
IIP6!A7J9<=!;AJ<@E9H<=!YW!
3.!CONNAISSANCES!ET!REPRESENTATIONS!DE!LA!PRECARITE!49!
31.!LES!REPRESENTATIONS!DE!LA!PRECARITE!49!
32.!LA!PRECARITE!D’ACCES!AUX!SOINS!53!
33.!UNE!HIERARCHIE!DANS!LA!PRECARITE!54!
34.!LE!LIEN!ENTRE!PRECARITE!ET!SANTE!56!
NY"6!DMHF>A;J!#<=!;EB#HJHEB=!#<!KH<!=79!DA!=ABJ<!PT!
NYI6!D<!9A>>E9J!A7L!=EHB=!<J!A!DA!=ABJ<!#<=!>AJH<BJ=!>9<;AH9<=!PV!
35.!LES!CONNAISSANCES!SUR!LA!CMU!ET!L’ACS!58!

!
N!
NP"6!DA!;F7!PW!
NPI6!DMA;=!P[!
36.!RAPPEL!DU!CONTEXTE!ET!PERCEPTION!DE!LA!LOI!PAR!LES!MEDECINS!ET!LES!DENTISTES!61!
37.!REPRESENTATIONS!ET!STEREOTYPES!DES!BENEFICIAIRES!DE!LA!CMU!63!
9<>9<=<BJAJHEB=!#<=!G<B<OH;HAH9<=!#<!DA!;F7!TN!
#<=!G<B<OH;HAH9<=!=E7=!=7=>H;HEB!#<!O9A7#<!TP!
7B!U7@<F<BJ!BE9FAJHO!=79!D<=!#<><B=<=!TV!
9<B#<`RKE7=!BEB!QEBE9<=!\! TW!
D<=!;F73!@9E=!;EB=EFFAJ<79=!#<!=EHB=!\! VI!
#<=!>AJH<BJ=!KHB#H;AJHO=!\! VP!
#<=!>AJH<BJ=!aJ9AB@<9=!VT!
38.!LES!REPRESENTATIONS!NON!DOMINANTES!77!
DEUXIEME&PARTIE&:&LES&PRATIQUES&MEDICALES!80!
1.!UNE!ETHNOGRAPHIE!DES!CONSULTATIONS!80!
11.!CARACTERISER!LES!PRATIQUES!81!
12.!MODALITES!D’ORGANISATION!82!
"I"6!DMA;;7<HD!#<=!>AJH<BJ=!<J!DA!>9H=<!#<!9<B#<`RKE7=!WI!
"II6!@<=JHEB!#<=!9<B#<`RKE7=!WN!
"IN6!KH=HJ<=!A!#EFH;HD<!WP!
"IY!6!DA!=ADD<!#MAJJ<BJ<!WT!
"IP6!DA!#79<<!#<!;EB=7DJAJHEB! WW!
"IT6!DA!D<;J79<!#<!DA!;A9J<!KHJAD<!W[!
13.!LA!CATEGORISATION!SOCIALE!OU!ETHNIQUE!DES!PATIENTS.!QUELLES!PRATIQUES!?! 90!
"N"6!;EFF<BJ!9<><9<9!DA!;AJ<@E9H<!=E;HAD<!\! ["!
"NI6!#EHJREB!E7!BEB!9<><9<9!DA!;AJ<@E9H<!=E;HAD<!\! [T!
AX!B<!>A=!9<><9<9![V!
GX!9<><9<9!>E79!S7EH!OAH9<!\! [W!
"NN6!9<><9<9!DA!;AJ<@E9H<!<JQBHS7<!"b"!
"NY6!S7<D!7=A@<!#<!DA!;7DJ79<!"bI!
AX!DA!;7DJ79<!#<J<9FHB<!7B!;<9JAHB!9A>>E9J!A7L!=EHB=!<J!A!DA!=ABJ<!"bI!
GX!DA!;7DJ79<!;9<7=ABJ!DA!#HOO<9<B;<!"bN!
2.!LOGIQUES!ECONOMIQUES!DANS!L’EXERCICE!MEDICAL!105!
21.!LES!LOGIQUES!DES!PRIX!107!
I""6!;QH979@H<B=!#<BJH=J<=!"bV!
I"I6!F<#<;HB=!=<;J<79!"!<J!=<;J<79!I! ""b!
22.!LE!TEMPS,!C’EST!DE!L’ARGENT!112!
23.!DES!LOGIQUES!CONCURRENTIELLES!113!
24.!UN!NIVEAU!DE!VIE!A!ATTEINDRE!114!
25.!MAITRISER!LA!FILE!ACTIVE!DE!PATIENTS!AU!TARIF!OPPOSABLE!COMME!VARIABLE!D’AJUSTEMENT!117!
26.!TENIR!LA!QUALITE!EN!RESTANT!RENTABLE!117!
27.!LA!PLACE!DE!L’ARGENT!DANS!LA!RELATION!118!
28.!LES!ACTES!GRATUITS!:!UNE!CHARITE!BIEN!ORDONNEE!119!
29.!LA!NOTION!D’ECHANGE!123!
RECOUVREMENTS!DES!TIERS!PAYANTS!126!
3.!PRESSIONS!DE!NORMALISATION!DES!CAISSES!DE!SECURITE!SOCIALE!ET!LOGIQUES!DE!
TARIFICATION!129!
N"6!DE@HS7<=!;EF>JAGD<=!K<9=7=!DE@HS7<=!#<!=EHB!"Nb!
NI6!DA!BE7K<DD<!BEF<B;DAJ79<!<B!#<BJAH9<!"NI!
NN6!7B<!#H=;9HFHBAJHEB!HB#H9<;J<!"NP!

!
Y!
4.!LA!CONSTRUCTION!DE!LA!PATIENTELE!136!
41.!LA!CONSTRUCTION!D’UNE!PATIENTELE!A!SON!IMAGE!136!
42.!LA!SELECTION!DES!PATIENTS!138!
YI"6!D<=!>AJH<BJ=!FH=!A!DA!>E9J<!"NW!
YII6!<OO<J=!@<E@9A>QHS7<=!"N[!
YIN6!=<D<;JHEB!>A9!D<=!JA9HO=!"Yb!
5.!STYLE!DE!PRATIQUES!:!UNIVERSELLES,!CATEGORISEES!OU!INDIVIDUALISEES!142!
;AJ<@E9H=AJHEB!E7!>9H=<!<B!;EF>J<!#M7B<!=HJ7AJHEB!HB#HKH#7<DD<!"YI!
TROISIEME&PARTIE&:&PRATIQUES&DE&DIFFERENCIATION&ET&LOGIQUES&EXPLICATIVES&DE&LA&
DISCRIMINATION!145!
1.!LES!SOINS,!ENTRE!DIFFERENCIATION!ET!DISCRIMINATION!145!
11.!LA!PRISE!DE!RENDEZ-VOUS!145!
"""6!<KH;JHEB3!=<D<;JHEB!#<!DA!;EB=7DJAJHEB!"YP!
""I6!FE#<=!#ME9@ABH=AJHEB!DE9=!#<!DA!>9H=<!#<!9<B#<`RKE7=!"Y[!
""N6!#<DAH=!#<!9<B#<`RKE7=!"Pb!
""Y6!;EB#HJHEB=!#<!DA!;EB=7DJAJHEB!"P"!
12.!DIFFERENCIATION!ET!DISCRIMINATION!DANS!LES!SOINS!152!
"I"6!DA!#HOO<9<B;HAJHEB!#<!DA!9<DAJHEB!#<!=EHB=!A7!>9H=F<!#<!DA!>9<;A9HJ<!<J!#<!DMHBJ<9;7DJ79<D
!"PN!
AX!9<>9<=<BJAJHEB=!#<!DA!>DA;<!#7!F<#<;HB!#AB=!DA!=E;H<J<!"PN!
GX!S7<DD<=!;EB=<S7<B;<=!#<!DA!>9ELHFHJ<!=E;HAD<!E7!;7DJ79<DD<!=79!DA!9<DAJHEB!\! "PY!
;X!DA!>DA;<!A;;E9#<<!A7!F<#<;HB!A7!>9H=F<!#<!DMA>>A9J<BAB;<!=E;HAD<!<JZE7!;7DJ79<DD<!"PW!
#X!DA!#HF<B=HEB!9<DAJHEBB<DD<!<J!=EB!HF>A;J!=79!DA!>9H=<!<B!;QA9@<!"T"!
"II6!DA!#HOO<9<B;HAJHEB!#AB=!DA!>9H=<!<B!;QA9@<!"TI!
AX!D@BE9<9!D<!=JAJ7J!=E;HAD!"TI!
GX!#HOO<9<B;H<9!D<=!=EHB=!#<DHK9<=!"TP!
;X!E9H<BJAJHEB!"VI!
#X!DMHBOE9FAJHEB3!DA!OE9F<!#<=!#H=;E79=!"VN!
<X!<#7;AJHEB!A!DA!=ABJ<!<J!>9<K<BJHEB!"VT!
OX!D<!9<DH@H<7L!"Wb!
2.!LES!PROCESSUS!DE!CATEGORISATION!182!
21.!CONSTRUCTION!DE!LA!CATEGORIE!CMU!183!
I""6!DA!;AJ<@E9H<!;EBJ9HG7<!A!DA!;EB=J97;JHEB!#<!DA!#HOO<9<B;<!"WN!
I"I6!7B<!KH=HEB!QEFE@<B<!A7!=<HB!#<!DA!;AJ<@E9H<!"WP!
I"N6!S7<D!=JH@FAJ<!\! "WP!
22.!PRATIQUES!ORGANISATIONNELLES!ET!CATEGORISATION!188!
23.!CATEGORISATION!ET!DISCRIMINATION!190!
24.!LES!LOGIQUES!DE!LA!DIFFERENCIATION!191!
3.!CONNAISSANCES!ET!REPRESENTATIONS!DU!REFUS!DE!SOINS!192!
31.!LA!PERCEPTION!DE!LA!REALITE!DU!REFUS!DE!SOINS!A!L’EGARD!DES!BENEFICIAIRES!DE!LA!CMU!192!
32.!LES!REPRESENTATIONS!DU!REFUS!DE!SOINS!194!
33.!LES!TYPOLOGIES!DU!REFUS!DE!SOINS!196!
4.!COMPRENDRE!LES!LOGIQUES!DU!REFUS!DE!SOINS!(CMU!ET!AME)!199!
41.!LES!DIFFERENTES!DIMENSIONS!DU!REFUS!200!
Y""6!DE@HS7<=!#<!BHK<A7!#<!KH<!<J!#<!9<BJAGHDHJ<!Ibb!

!
P!
Y"I6!9<>9<=<BJAJHEB!#7!9<O7=!#<!=EHB=!IbP!
Y"N6!JC>EDE@H<!#<!>9AJH;H<B=!IbT!
Y"Y6!D<!9A>>E9J!A!DM<JAJ3!D<!9A>>E9J!A!DA!DEH!Ib[!
Y"Y6!D<=!>9<==HEB=!BE9FADH=AJ9H;<=!I""!
Y"P6!7B<!9<DAJHEB!FEHB=!=AJH=OAH=ABJ<!\! I"I!
CONCLUSION!216!
1.!LES!FORCES!ET!LES!LIMITES!DE!L’ETUDE!:!REFLEXIONS!SUR!LA!METHODE!216!
11.!LA!PARTICIPATION!DES!MEDECINS!ET!DENTISTES!216!
12.!UNE!ETUDE!NOVATRICE!216!
D<=!DHFHJ<=!F<JQE#EDE@HS7<=!I"W!
2.!LES!APPORTS!DE!L’ETUDE!219!
21.!LES!REFUS!DE!SOINS!ET!LEURS!LOGIQUES!219!
I""6!D<=!DE@HS7<=!<;EBEFHS7<=!IIb!
I"I6!D<=!9<>9<=<BJAJHEB=!<J!D<=!>9<U7@<=!II"!
I"N6!D<!J9AKAHD!A#FHBH=J9AJHO!IIN!
I"Y6!DM<JQHS7<!<J!D<=!KAD<79=!]!;QA9HJ<!;EBJ9<!=EDH#A9HJ<!IIY!
I"P6!7B<!A>>9E;Q<!#7!9ED<!#7!F<#<;HB!<J!#<!=A!>E=HJHEB!A!DM<@A9#!#<!DA!=E;H<J<!IIP!
22.!EN!CREUX,!CE!QU’ILS!NE!DISENT!PAS,!CE!QU’ILS!NE!SAVENT!PAS!226!
23.!LES!SOINS,!ENTRE!DIFFERENCIATION!ET!DISCRIMINATION!226!
BIBLIOGRAPHIE!229!
ANNEXES!239!
ANNEXE!1!:!PRESENTATION!DES!DISPOSITIFS!D’ACCES!AUX!SOINS!239!
ANNEXE!2:!LISTE!ANONYMISEE!DES!PRATICIENS!RENCONTRES!243!
ANNEXE!3!:!DEVOIRS!GENERAUX!DES!MEDECINS!(CODE!DE!LA!SANTE!PUBLIQUE)! 245!
ANNEXE!4!:!COURRIER!TEMOIGNAGE!DES!CONTRAINTES!ADMINISTRATIVES!245!
ANNEXE!5!:!POURQUOI!PRENDRE!EN!COMPTE!LA!SITUATION!SOCIALE!DU!PATIENT!EN!CONSULTATION!?!
(EXTRAIT!D’UN!DOCUMENT!INPES!DESTINE!AUX!PROFESSIONNELS!DE!SANTE)! 246!
ANNEXE!5BIS!:!RÉPARTITION)DES)STATUTS!EN!FONCTION!DU!LIEU!D’ACTIVITÉ!246!
ANNEXE!6!:!EXEMPLE!D’UNE!GRILLE!DE!TARIFS!ET!REGLES!D’ACCES!A!LA!CONSULTATION!(ANONYMISEES)!
EN!FONCTION!DES!PRATICIENS!DANS!UNE!CLINIQUE!DE!LA!BANLIEUE!NORD!247!
!
!
!
! !