Aux contempteurs de la T2A

La T2A sous le feu des critiques. ((Titre de l’éditorial de M. Roland Cash, dans la revue Finances hospitalières, décembre 2009, n°31.))

Bostonbox3Il semble, au regard de ce qui se lit et s’entend depuis quelques mois dans la presse (y compris dans ces colonnes) et dans les colloques, que la Tarification à l’activité ne fait pas recette dans les opinions. Les critiques se font de plus en plus acerbes, précises, même si on peut noter que personne ne défend vraiment le retour à la situation antérieure du budget global pour les établissements publics.

Que reproche-t-on finalement à la T2A ? Les critiques sont de plusieurs ordres ; certaines sont aisées à récuser, d’autres vont plus directement au fond du sujet. Faisons un bref tour d’horizon de ces arguments :

« La T2A constitue un rationnement des budgets hospitaliers » : c’est faux, la T2A ne fait que répartir une enveloppe prédéterminée entre les établissements sur la base de critères d’activité. Le fait que cette enveloppe prédéterminée, l’ONDAM (Objectif national des dépenses d’assurance maladie), votée par le Parlement, soit jugée insuffisante par certains, n’engage qu’eux mais omet le principe de base de la gestion qui indique qu’il est compliqué de dépenser durablement plus que ce dont on dispose comme recettes. L’économiste est toujours décrié car il apporte une mauvaise nouvelle : la mauvaise nouvelle, c’est que les ressources sont limitées. Mais la T2A, en l’occurrence, n’y est pour rien.

« La T2A induit une baisse de qualité des soins » : c’est probablement faux, mais surtout invérifiable. Après des années d’effort, aucun pays ne dispose encore d’une « mesure » de la qualité des soins. Il est donc impossible de savoir si cette qualité s’améliore ou diminue. L’amélioration de la qualité des soins obéit de toute façon à d’autres procédures (certification, évaluation des pratiques professionnelles, tableaux de bord d’indicateurs de qualité). Il existe toutefois un lien entre T2A et qualité à travers le contrat de bon usage concernant les médicaments et dispositifs médicaux sur liste en sus. Ce contrat introduit des exigences de qualité qui, si elles ne sont pas respectées, peuvent conduire l’ARH à moduler le remboursement de l’établissement sur ces produits.

« La T2A conduit à sélectionner les patients ». L’argument sous-jacent est le suivant : si le prix d’un GHS est fixé trop bas par rapport au coût auquel l’établissement doit faire face, cet établissement peut être amené à éviter de prendre en charge les patients relevant de ces situations. Il va préférer accueillir des patients présentant peu de risques de surcoûts, des patients dont on peut prédire qu’ils rentrent dans la situation « standard ». Mais ce risque est-il réel ?[…]

Avec l’aimable autorisation du Directeur de la publication et de la rédaction, vous pouvez lire la suite de l’éditorial ici.

N’hésitez pas à faire part de vos réactions.

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