The trickle-down effect of public assistance, Orpea style

Glossary of terms:

  • ARS (Agences Regionales de Santé): France’s regional health agencies tasked with health insurance and public health policies for the population. In charge of delivering public money and of controlling the care homes. 
  • Departement: Administrative region in France, run by an elected body. There are 96 in metropolitan France and five ‘overseas’ territories. They distribute funds to the care homes. 
  • Nursing assistant/care assistant (aide-soignante): personnel who provide care. Trained to administer treatment, changes diapers and work with nurses. Paid by for the state’s care budget
  • Auxiliary employee/assistants (auxiliaire de vie): personal care assistant who does not administer treatment, but does chores in the room or the care home, paid for by the “accommodation” budget (directly from the coffers of the care facility)

Fear. This is what Martin*, former director of an Orpea care home who gave more than a decade of his life to the company, still feels about his former employer. Fear for his fragile health, fear that the company will sue him if it learns that he is talking to journalists.

In his apartment, on a glass table in the living room, are some precious documents saved from his stint at the world’s number one private nursing home. Many of them have already been shredded, he says, to allow him to erase the difficult memories and to “mourn” this period of his life. 

Like many former employees, Martin followed the recent “Orpea scandal” in France with interest. It broke out after the publication in late January of a book, Les Fossoyeurs, by journalist Victor Castanet. Today, Martin wants to tell his story — of how he fed into this system that was set up at Orpea. 

This included cutting back on the employment of staff who were tasked with looking after the care home residents. For the French state, staff is the biggest expense: 90% of the sums allocated by the health insurance (ARS) and the country’s departments (administrative territories) are earmarked for the payment of the salaries of the nurses, care assistants, psychologists, pharmacy employees and aides who work in the country’s elder care sector. 

Following Martin’s example, several former directors of Orpea facilities came forward to Investigate Europe and Mediapart to share their experiences. They talked about about how, under orders from superiors, they might have diverted public money from their own establishments to the benefit of the Orpea group. They did so even if it meant possibly endangering the health of their residents at times. Clément*, former director of a care home, summarised it like this: “They cut back on everything, track down every little saving, and it makes money in the end.”

Technique 1: Geographic detour

First and foremost, it is important to understand how aid is allocated to elder care establishments. Every five years, the Regional Health Agencies (referred to as ARS), the departments and the care facilities agree on a given number of workers. Each establishment is then allocated funds according to its needs, depending on the number of residents in its care and their level of dependency.  For care alone, in 2020, Orpea received €350 million from health insurance funds, according to figures from the Caisse nationale de solidarité pour l’autonomie (CNSA) that were sent to Mediapart and IE. 

At the end of this negotiation, the partners sign an agreement in which the number of full-time equivalents (FTEs) allocated to the establishment is recorded: X FTEs of care assistants, X FTEs of nurses, X FTEs of psychologists. But, if we are to believe these former directors, Orpea — a group that manages 226 residential elder care facilities in France — wouldn’t always play by these rules. 

Still sitting in his living room, Martin nervously touches the collar of his shirt. “I’ve had a very complicated few years, with a lot of pressure, and not enough staff,” he begins, as if to justify what he’s about to show us. He opens the folder of documents in front of him and pulls out invoices from a temporary employment agency for nursing assistants and nurse positions, all addressed to Orpea. The problem is that these employees had never worked there. According to these documents and emails in our possession, they were sent on assignment to other care homes to other parts of the country — in other regions. 

“It is an injustice,” Martin admits. “I had difficulties with my staff, families, residents. And part of the state money negotiated for by my care home with the ARS was used to pay employees in other care homes.”

According to these invoices,  the repurposing of public funds — ranging from one to more than ten thousand euros — took place on several occasions. Sitting in front of us, Martin says that he regrets this “dishonest” process in which he participated.

However, if we are to believe the internal email exchanges to which IE and Mediapart had access, the director was only following the orders of his employer. These misleading invoices had been required by the regional management of the Orpea group, and then validated by him. 

Sleight of hand during Covid

According to our investigation, this “geographical detour” of public money might not have been confined to Martin’s establishment. Francine M., former director of two Orpea care homes, tells us she left the company after refusing to pay for staff sent to other establishments. 

“I was opening a residence in the Ardennes , and we were not yet full,” she says. “The regional management called me to ask me to order temporary care assistants and nurses and to send them to a care home in Aisne. I had to pay them without them working for me. I said no, that I didn’t want to lie. That was the last straw.”

This sleight of hand even works in times of crisis. In the spring of 2020, the first wave of Covid-19 raged in elder care facilities. In France, 44% of Covid deaths were of care home residents. Like the majority of facility managers, Clément* was on the warpath. A former caregiver, he was even obliged to put on his smock again to support the staff in his facility. However, nothing prevented his management from asking him “to send staff to an establishment three hours away”. “At the end of the month I discovered, to my great surprise, that it was my establishment that had paid for this staff,” says Clement. 

A practice that makes regulation impossible

To summarise, the ARS and the departments concerned were paying for the salaries of staff who worked in geographical areas that were not within their remit. “It is not legal,” said the Ministry of Solidarity and Health to IE and Mediapart. “The ARS funding to which a care home is entitled depends on the evaluation of its care needs, which is based on the profiles of its residents. They cannot therefore be transferred to another care home, which is moreover in another region.” 

This geographical detour makes it very complicated to control the proper use of public funds. “This can cause major problems, particularly in the ability to really control how care and dependency allocations are used,” says Gaël Hilleret, an expert at the Caisse nationale de solidarité pour l’autonomie (CNSA), a public institution that funds assistance for the autonomy of the elderly and disabled.

In care homes, inspections are carried out at the regional and departmental level.Thus, the public accountant cannot guarantee that the money paid by a director in a care home in the north for a job of nurse in the south, was indeed used to pay for that precise job. 

“With this practice of paying temps elsewhere, they make the charges appear where it suits them,” says a former ARS executive who speaks on condition of anonymity. “For private commercial care homes, the public authorities do not see what is happening to 60% of their budgets.”

When questioned by IE and Mediapart, Orpea group replied that the “group does not organise a system aimed at paying the salaries of nursing assistants in one residence by using the funds allocated to another” and stated that it had “no knowledge of such practices”.

Technique 2: Shifting positions 

To understand how Orpea abuses the system, we need to unpack the complex way in which the allocation of public funds works. 

The French state distributes its aid in two tranches: one is devoted to “care” — mainly for the payment of the salaries of the nursing staff (including nurses, care assistants). The other chunk is devoted to “dependence” — for the payment of the salaries of the assisting staff (such as psychologists and AMP (medical and psychological aides). 

Then there is a third category of expenses that is dedicated to accommodation (management, entertainment, catering, etc.). This last one is paid for by the residents and their families. While it is forbidden for private care homes to make profits on the first two, it is on this third one that the giants of the silver economy make their margins. 

The rules of the game are simple for those who want to make huge profits: put the maximum amount of personnel expenses in the first two categories, which are paid for by the state, and limit accommodation expenses. 

According to AFP, Orpea announced some of its financial results on March 11. This included a 9.2% increase in revenues (to €4.285 billion euros) and a jump in its gross operating income (before rent) to €1.068 billion euros, a margin of 24.9%.

Francine M., the former director in the north, says that one process to achieve this is through  the “shifting of posts”. The idea is to ask the care assistants, whose salaries are paid by the social security system, to take over the household tasks assigned to the auxiliary assistants, whose salaries come out of Orpea’s coffers (accommodation” budget). “[Care assistants are asked] for example, to make the beds, a task normally assigned to auxiliary staff,” says Emilie*, a former management assistant in the Bouches du Rhône region.

This practice is not limited to the north and to the Bouches du Rhône. In an internal email to which we have access, the regional management explains that Loïc Battesti, current vice-president of the group (at the time in a lower-ranking position) clearly asked a care home director to reduce the number of life assistants and to have the care assistants carry out accommodation-related tasks.

When contacted for an interview, Loïc Battesti referred us to the Orpea communication and press department in order to “centralise” the requests. He nevertheless specified that our questions concerned his “former functions” and were related to “elements that probably date back more than 10 years”.

From trickery to dangerous medical practice

This is a practice that might aim to make a profit on public money, according to the former executive of the ARS. “If you say to the ARS and the department, I have so many expenses in care but in reality some of the staff are doing tasks that are part of the accommodation work (for example, a care assistant who is doing life auxiliary tasks), you make the health insurance pay for your auxiliary costs and therefore you increase your profit. And since, in this case, this profit is made on the accommodation budget, which the state cannot inspect, you can freely use it.”

Then there is also the case of auxiliary staff being asked to work as caregivers (a role for which they are not adequately trained), which could be detrimental to the resident receiving care. An Orpea-CGT elected representative (trade unionist) in the Bouches du Rhône region recently reported a practice that she deemed to be worrying. She reported it to the management of a facility in Vitrolles, to Orpea’s head office, to the ARS and to the department. “Last weekend, in an Orpea care home, auxiliary assistants took on the job of nursing assistants,” she said, according to testimonies collected on site during a visit in early February. “This means that employees without any diploma or training took charge of the care of the residents of this home.” This, she pointed out, is all the more disturbing because the auxiliary assistants, whose mandate is to carry out household tasks, “do not have the access codes to the software on which the transmission of pathologies, for example, is made”. So how can they know what the resident is suffering from and what contraindications apply?

In this particular facility, the temps don’t even have access to the diet of each resident, said the GCT representative. Should they eat blended, chopped or normally? “We had a concern one weekend in February,” the unionist testified. “A resident who was only supposed to be fed by syringe was fed by mouth.” According to two internal documents and the testimony of a caregiver present in the care home that weekend, at least two reports were made about this incident. One was an “improvement sheet” (an internal protocol document for incidents reported to Orpea management) detailing how a “temporary staff acting as a caregiver” had fed the wrong type of food to a resident. The reports also showed that the resident’s on-call physician had been called as a result of this “mistake”.

When asked about this incident, Orpea replied that, “In the context of a replacement, there is an access code to the care file for temporary workers, which is relayed by the nursing team on duty. In addition, like any employee, the temporary worker must have the care plan for each resident assigned to him/her on his/her cart, with details for the entire day, in order to secure the proposed care. In this way, Orpea provides the necessary means for each person to carry out their duties.”

Transferring the burden to the staff

In her report, the CGT official concluded that “these unqualified people took care of the residents without the supervision of caregivers… It is the housekeeper who took charge of the organisation of care and it does not seem to me that it is her role.” This staff member is responsible for ordering sheets, towels and general hotel supplies, and does not have any medical qualification.

In this regard, Orpea indicates that there must be “a simple confusion…concerning the role mentioned of a housekeeper within one of our establishments: every weekend, within each Orpea care home, a member of the establishment’s management team is present to accompany the teams and receive or respond to visiting families. Within the framework of this on-call duty, the employee on duty ensures the smooth running of the establishment.”

In response to our questions, ARS Provence-Alpes-Côte d’Azur stated that “the reports made have obviously been taken into account and have fed the ongoing investigations”. The ARS and the Bouches-du-Rhône Departmental Council had replied to the CGT unionist by email. The department told us that they were “informed of dysfunctions within this care home by reports from doctors and users since December 2020” and that they are “standing by the services of the State (ARS PACA) to implement the necessary corrective measures”. The management of the concerned care home did not respond to us.

Other sources familiar with the matter are worried about the consequences of these practices on residents. Jeanne*, a caregiver still working at Orpea, tells us that in her establishment, personal auxiliary staff are hired to act as caregivers. “There are only two qualified caregivers out of seven who have to be present to take care of the 80 residents,” she claims. 

“The housekeeper told a fellow caregiver that if she did diaper changes (caregivers’ job) and she got hurt, she wouldn’t be covered by insurance. The risk is real: in France, the frequency index of work-related accidents in care homes is twice as high as the national average.

In the Bouches du Rhône establishment mentioned above, the auxiliary employees “acting as” care assistants are paid from the accommodation budget. But what happens to the salary — public money — of the care assistants who were supposed to be there on this February weekend and who were not replaced? “I don’t know where this money from the care budget is going,” laments the union member. As for Clement, the former caregiver turned Orpea director, he is convinced that “the public money directly allowed for profits to be made at the expense of our elderly”.

“We were stealing money from the state”

For Francine M., in the north of France, there is no doubt as to who paid the bill. “The auxiliary caregivers were paid by the health insurance funds,” she asserts. In her case, the regional management did not beat about the bush.

“When I had to replace a nurse, they told me to put auxiliary assistants on the nursing assistant posts.” What was the trick to justifying this shift to the supervisory authorities? Francine said the orders were “to write that I was hiring a caregiver ‘while waiting for a caregiver to be hired’. Except that there was never any recruitment. We were definitely in the interim!”

Even if it is abnormal, is this practice of shifting positions illegal? These shifts are only authorised in cases of “emergency or significant absenteeism”, answers the Ministry of Health. But this justification is easy to find in the elder care sector, whose average rate of absenteeism is 10%. This is where the regulatory authorities are supposed to intervene, in order to verify the correct allocation of posts.  The problem is that even if they had the necessary staff to inspect all the care homes, they do not have access to a large part of the accounts. “Private commercial care homes are subject to complete financial reporting on care and dependency budgets, but on accommodation, this is optional. So their supervisors do not necessarily have the information,” says CNSA expert Gaël Hilleret.

This is the genius of the trickle-down process that happens as a result of this shifting: public accountants and even the Court of Auditors have no right to control the content of the “accommodation” budget. They can only look at the other two tranches where the public money was allocated, as if they are totally independent of each other. 

When questioned on this point, Orpea specifies that, “depending on their experience, some auxiliary workers may be required to work as “caregivers” in tandem with a qualified professional…This may be necessary in view of the recruitment difficulties linked to the shortage. In accordance with the regulations, these auxiliaries are paid from the care and dependency allowances as soon as they enter a nurse assistant diploma program. The Orpea group adds that it may be “required to reinforce its teams to deal with a particular context”. During the Covid crisis, for example, “to ensure the maintenance of the establishment, the service of meals in the rooms or in the living units or for the reorganisation of the sectors. Night staff were also able to be reinforced in many facilities.”

However, on March 8, in response to the scandal caused by Les Fossoyeurs, the French government promised that the court and the regional audit chambers could, in the future, “control the accommodation section” of commercial private care homes. This reform would require a law. On the same day, Véronique Hammerer, a member of the LREM parliament and co-rapporteur of a “flash mission” on care homes, said the following while delivering her conclusions: “Today, private groups do not have the same obligations [as public establishments] before the supervisory authorities, particularly with regard to the presentation of their accounts, an exception that they have obtained on the grounds of business secrecy. We can see that this is no longer acceptable.”

Technique 3: Non-replacement of absentees

The “non-replacement” technique is simpler to explain: in some facilities, the orders may have been to not replace absent staff, even though these salaries are paid in part by ARS and the departments. 

Understaffing is a major problem in nursing homes. In the private for-profit sector, the ratio of personnel to residents is already the lowest (less than six people per 10 residents). “When there were too many absentees, the residents who had no family were dressed in pyjamas and put into bed at 1.30 pm because the care assistants were overloaded,” says Francine M., the former director.

The same directive seems to have been issued in another French region. This time it is Emilie*, an assistant manager till 2019 in a care home in the south, who testifies that even though they were understaffed, “the head office encouraged us to reduce replacements in the payroll forecast”. 

Victor Castanet, in his book Les Fossoyeurs, also mentions similar orders in Orpea care homes in Bords-de-Seine, Ile-de-France and in Brittany. 

The Orpea group told Mediapart and IE the opposite: “The group does not give instructions not to replace positions. Our desire is to ensure the proper care and safety of residents in all our care homes with the appropriate resources…On the other hand, it is certain that when a caregiver is unexpectedly absent from work on the same day, it can sometimes be complicated (or even unsuccessful) to replace the absent staff immediately, given the shortage of health professionals, even though the facility directors are doing their utmost to find replacement solutions, both to guarantee the care of residents and to maintain the number of staff that will allow our employees to work under the best possible conditions.”

However, an internal email to which we have access suggests that the non-replacement of staff is an institutionalised practice. In this document, the same Loïc Battesti, Orpea’s current executive vice president (who was at a lower-ranking job in the management), clearly orders several care home directors who had sent their budget forecasts for validation, to not replace the missing staff. We are not able to quote this document, due to the confidentiality agreement signed by our source, but the orders of non-replacement were related to nursing and care assistant positions, financed by ARS. Contacted to clarify this point, Loïc Battesti again directed us to Orpea’s communications team.

Not replacing positions already funded by the ARS and the departments could generate a direct surplus. However, as the former ARS manager explained, the law is very clear. “If there is a surplus on the two categories of public assistance, you must report it and reinvest it, but not make a profit. Afterward, you can say that you have financed a training course run by your own training institute and no one will be able to check.” 

Did Orpea declare its surplus to the state before reinvesting elsewhere? Did it actually reinvest it? Perhaps. When contacted on this point, Orpea did not provide us with any clarification on this matter. Whatever happens, the assertion remains the same: Orpea, by not replacing the staff who left, could have endangered the health of its residents and worsened the working conditions of its already overworked employees. 

Why did its directors agree — some of them for years — to collaborate in the implementation of these procedures? By alternately waving the carrot and the stick, Orpea has managed to ensure the loyalty of these directors. 

Technique 4: The “top” and the “flop”

The “carrot” in question is a system of bonuses detailed in a document that displays the rules of the game. This document that we have obtained is given to managers when they sign their contracts. In it, Orpea promises several thousand euros in rewards and “signs of recognition”, such as trips worth €4,000, if they meet their objectives. One objective that figures prominently is the management of the “wage bill”, which includes gross salaries, temporary work and subcontracting.

“The less money you spend, the more you get a nice bonus,” says Francine M., who has spent 10 years navigating the Orpea system. Martin is more graphic. “The less a manager consumes [in terms of spending], the bigger the carrot.” 

Clément’s interpretation is more polite. “If a manager wants his bonus, he has to find between nine and 20% savings per year. So, if you reduce the payroll, you get more bonuses because you can potentially free up some margin. The payroll is by far the largest expense item for a care home. The bonus is  good motivation to not replace missing staff and to shift the caregivers’ positions.”

If the lure of profit is not enough to get the directors of the establishment to join in, the stick can bring them to heel. “In the Executive Committee (the monthly meeting at the headquarters) they would do a ranking of the 10 best and worst facilities: ‘the top and the flops,’” shares Clement. “This was a way of rewarding and punishing the good and bad performers in terms of cost control.”

Clément has never been reprimanded for his personnel management, but on the other hand, his care home was once in the ‘flops for food expenses’ category. For wanting to improve the ordinary meals of his residents, Clément says he was subject to a public “humiliation” in the presence of his counterparts and then, for several months, to a “close follow-up” on his chef’s expenses. “Orpea really [instills] the culture of fear,” says Clément. 

“I ended up in the shrink’s office,” confides Clement. He says he could no longer reconcile budget pressures with his ideal of caring for the elderly. Clément eventually left, as did Martin and Francine, who left after 10 years of loyal service. They found a job, rebuilt their lives, but for all of them, the Orpea wound is still open.  

*Some sources have been anonymised to protect their identity

Click here to read the response provided by Orpea to our questions. A version of this article was published in French by our media partner, Mediapart

Edited by Sindhuri Nandhakamur