Activité libérale à l’hôpital : la redevance ne peut varier selon les catégories d’actes

Quelle est la nature de la redevance due par un praticien hospitalier au titre de l’activité libérale qu’il est autorisé à exercer au sein d’un établissement public de santé ? Est-elle liée à une occupation privative du domaine public ou est-ce la contrepartie du service que l’établissement rend à ce praticien en lui permettant de percevoir une rémunération à l’acte tout en bénéficiant des installations et du personnel du service public hospitalier ?

Rendue par la formation la plus prestigieuse du Conseil d’État (en Assemblée), la réponse, appelée à faire date, est on ne peut plus claire : le montant perçu par l’établissement public ne revêt pas le caractère d’une redevance domaniale mais celui d’une redevance pour service rendu ((CE, Ass., 16 juill. 2007, n° 293229 et 293254, Synd. nat. défense exercice libéral de la médecine à l’hôpital, Synd. nat. chirurgie reconstructrice et esthétique.)).

Pour être légalement établie, une redevance pour service rendu doit essentiellement trouver une contrepartie directe dans la prestation fournie par le service ou, le cas échéant, dans l’utilisation d’un ouvrage public et, par conséquent, doit correspondre à la valeur de la prestation ou du service. L’objet du paiement que l’Administration peut réclamer à ce titre est en principe de couvrir les charges du service public. Cependant, le montant de la redevance peut excéder le coût de la prestation fournie. Le respect de la règle d’équivalence entre le tarif d’une redevance et la valeur de la prestation ou du service peut en conséquence être assuré en retenant plusieurs paramètres simultanés tels que le prix de revient de ce dernier, mais aussi les caractéristiques du service, en tenant compte de la valeur économique de la prestation pour son bénéficiaire.

Dans tous les cas, le tarif doit être établi selon des critères objectifs et rationnels, dans le respect du principe d’égalité entre les usagers du service public et des règles de la concurrence.

S’agissant de la redevance prévue par l’article L. 6154-3 du Code de la santé publique, la valeur du service rendu par l’établissement hospitalier au praticien y exerçant une activité libérale n’est pas limitée au coût des installations techniques et des locaux mis à la disposition de celui-ci, ainsi que des dépenses de personnel exposées par l’établissement. Elle peut également être appréciée au regard des avantages de toute nature qu’en retirent les praticiens hospitaliers, eu égard notamment à la possibilité qui leur est ouverte d’exercer leur activité libérale dans le cadre et avec les moyens du service, en bénéficiant le cas échéant de la notoriété qui s’attache à l’établissement dans lequel ils exercent cette activité. La redevance due aux établissements hospitaliers par les praticiens en cause peut donc être fixée en pourcentage des honoraires.

Mais, au regard de l’objet de la redevance, l’avantage économique dont bénéficient les praticiens hospitaliers exerçant leur activité libérale dans le cadre et avec les moyens du service public ne présente pas de différence de situation appréciable selon que leurs actes sont ou non pris en charge par l’assurance maladie, cette prise en charge ne faisant pas obstacle à ce que le médecin perçoive du patient des honoraires supérieurs au montant résultant du tarif de l’assurance maladie. Dès lors, la différence établie par l’article D. 6154-10-1 du Code de la santé publique, qui retient comme assiette de la redevance le seul tarif pris en charge par l’assurance maladie dans tous les cas où l’acte en relève et le montant effectif des honoraires perçus dans les autres cas, méconnaît le principe d’égalité.

Le décret attaqué n°2006-274 du 7 mars 2006 est en conséquence illégal en tant que, ayant choisi d’asseoir la redevance sur le montant des honoraires effectivement perçus, il a limité ce choix à certains actes des praticiens hospitaliers bénéficiant d’honoraires librement déterminés.

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