Activity-Based Funding (T2A/DRG) between payment and regulation: Tariffs, sector, and implications for public health

La tarification à l’activité (T2A/GHM) entre paiement et régulation: tarifs, secteur et implications pour la santé publique

Carine Milcent ()
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Carine Milcent: PSE - Paris School of Economics - UP1 - Université Paris 1 Panthéon-Sorbonne - ENS-PSL - École normale supérieure - Paris - PSL - Université Paris Sciences et Lettres - EHESS - École des hautes études en sciences sociales - ENPC - École nationale des ponts et chaussées - CNRS - Centre National de la Recherche Scientifique - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement, PJSE - Paris Jourdan Sciences Economiques - UP1 - Université Paris 1 Panthéon-Sorbonne - ENS-PSL - École normale supérieure - Paris - PSL - Université Paris Sciences et Lettres - EHESS - École des hautes études en sciences sociales - ENPC - École nationale des ponts et chaussées - CNRS - Centre National de la Recherche Scientifique - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement

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Abstract: Hospital funding is a key structuring lever of health systems, shaping care organization, professional behavior, and equity of access. In France, Activity-Based Funding (T2A), introduced between 2004 and 2008, relies on lump-sum payments per hospital stay based on homogeneous patient groups. While originally designed to promote transparency, efficiency, and equity between public and private sectors, T2A has revealed significant limitations: growing complexity, strategic coding practices, and tensions between performance-based incentives and public service missions. Over time, T2A has evolved into a multi-purpose instrument—used not only for funding, but also to regulate care provision and generate epidemiological data. Yet these objectives may conflict: financial incentives for coding may distort data quality, encouraging upcoding at the expense of reliable public health analysis. Twenty years after its implementation, a marked gap has emerged between the complex classification system developed by regulators and the simplified version used in practice. Fewer than 500 DRGs (about 20%) account for 80% of hospital activity, pointing to unnecessary complexity in the current system. Meanwhile, the tariff ratio between private and public hospitals has stabilized around 48%, reflecting persistent structural differences. While this may stem from disparities in medical personnel costs, it may also signal deeper organizational or functional divides. This article offers a critical perspective on T2A—tracing its origins, evolution, and uses—while questioning its ability to address today's challenges of sustainability, equity, and care relevance.

Date: 2025-12-09
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Published in Santé Publique, 2025, vol. 37 (4), pp.123-129. ⟨10.3917/spub.254.0123⟩

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Persistent link: https://EconPapers.repec.org/RePEc:hal:journl:hal-05429140

DOI: 10.3917/spub.254.0123

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