Contrôles T2A 2011 : l’ATIH prescrit son ordonnance

L’Agence Technique de l’Information sur l’Hospitalisation a adressé le 19 mai 2011 aux Agences Régionales de Santé une notice technique n°CIM/MR-496-2-2011 ayant pour objet d’organiser la réalisation d’un bilan sur les sanctions attribuées aux établissements de santé dans le cadre des deux campagnes 2009 et 2010 d’une part, et de préparer la campagne 2011, d’autre part.

La notice présente également un nouvel outil consacré au suivi des sanctions et des contentieux, baptisé SUSANA ((SUivi des SAnctions Notifiées par les ARS.)) que l’ATIH met à disposition sur son site e-pmsi.

Brève par elle-même, la notice comprend trois annexes d’inégale importance. L’annexe 1 porte sur le nouveau recueil d’information sur les sanctions et les contentieux, l’annexe 2 traite des priorités nationales de contrôles de la tarification à l’activité de l’année 2011, et l’annexe 3 évoque l’enquête 2009 sur les sanctions en suite des contrôles T2A 2008.

S’agissant de l’annexe 1, l’outil SUSANA vise à recueillir des informations sur le montant des sanctions délivrées par les ARS d’une part, et à recenser l’ensemble des contentieux portant sur les contrôles T2A, d’autre part. L’ATIH entend obtenir une vision synthétique et globale sur le montant des pénalités infligées et sur les velléités de contestation contentieuse des établissements de santé.

Dans chaque ARS, un « correspondant contrôle » sera chargé de renseigner au fil de l’eau les informations requises, suivant un calendrier fixé par l’ATIH.

Les informations sollicitées par SUSANA sont nombreuses et précises, allant du montant de la première notification ARS (item 15) à la date de recouvrement notifié (item 29) en passant par la communication en pièce jointe de la décision juridictionnelle au format PDF (item 27).

L’ATIH souhaite de surcroît que toutes les informations soient saisies, à compter de la campagne 2007, « afin de disposer d’un historique et d’un suivi des pratiques de contrôle. »

Au-delà de la finalité purement statistique assignée de prime abord à cet outil, les lecteurs auront compris l’utilité politique et stratégique pour les tutelles de disposer d’un tel tableau de bord, les établissements publics de santé ayant commencé, sous l’égide de la Fédération hospitalière de France, à organiser leur riposte contentieuse contre des sanctions financières d’un montant qu’ils estiment disproportionnés.

L’item 17 relatif au montant définitif notifié par l’ARS éclairera par exemple l’ATIH et les tutelles sur les disparités régionales observées ça et là, la Direction de la Sécurité sociale ayant elle-même reconnu, dans son projet d’instruction aux Directeurs généraux d’ARS, une hétérogénéité dans les pratiques régionales, tant au regard de la fixation du montant des sanctions qu’au regard de la fréquence et de l’impartialité des contrôles.

Concernant l’item 27, l’étude de la motivation des décisions juridictionnelles favorables aux établissements requérants permettra aux ARS d’affiner leur stratégie de défense, qu’elle soit contentieuse ou extra-contentieuse, certaines agences n’hésitant pas d’ores et déjà à recourir à un protocole d’accord transactionnel afin de ne pas risquer un désaveu judiciaire, et une publicité négative.

A titre plus anecdotique, l’annexe 1 propose un calendrier de saisie des informations.

L’annexe 2 est tout aussi intéressante que la précédente en ce qu’elle fixe les priorités nationales de contrôles de la T2A de l’année 2011.

Après une proclamation des « principes fondamentaux du contrôle T2A », l’ATIH énonce sept priorités nationales de ciblage et de contrôle, relativement semblables à 2010, toujours dans l’optique de cibler les établissements les plus atypiques et ceux n’ayant jamais fait l’objet d’un contrôle externe, de contrôler un nombre de dossiers plus important et de limiter le nombre de champs contrôlés pouvant aboutir à des sanctions aux champs et prestations présentant les atypies les plus extrêmes.

De fait, les priorités ainsi retenues sont :

  • les établissements ayant utilisé le Logiciel d’aide à la mise à jour des données d’activité (LAMDA),
  • les prestations inter-établissements,
  • le contrôle des structures d’Hospitalisation à domicile (HAD),
  • les séjours contigus,
  • les séjours avec comorbidités,
  • le non-respect de la définition du Diagnostic principal (V11),
  • les prestations et champs déjà contrôlés au cours des campagnes antérieures, tels que les actes et consultations externes facturés en hospitalisation, les soins palliatifs en hospitalisation à temps complet, les suppléments et les ATU (dans les établissements ex-OQN).

L’annexe 2 se caractérise donc pas une intensification et une généralisation des contrôles.

Pour finir, l’annexe 3 se borne à faire état des résultats fort incomplets d’une enquête 2009 sur les sanctions prises consécutivement aux contrôles T2A 2008. L’ATIH s’interroge, à cette occasion, sur la bonne exécution des notifications d’indus par l’Assurance maladie et des notifications des sanctions financières définitives par les ARS.

Le présent exposé ne saurait faire l’économie de deux observations que cette notice technique inspire.

Au plan de la forme, ce texte invite à réfléchir sur le recours inflationniste à des textes dépourvus de valeur réglementaire mais dont les répercussions sur les finances hospitalières demeurent considérables. Il n’est pas certain que la lisibilité des textes en sorte grandie.

Sur le fond, ce texte confirme le rôle de plus en plus crucial joué par l’ATIH dans le cadre des contrôles de la tarification à l’activité, à l’heure où précisément cet établissement public improprement appelé « agence », dès lors qu’il ne remplit pas de fonction exécutive, travaille activement à l’élaboration d’un modèle de T2A dans le champ des soins de suite et de réadaptation.

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