Etablissements de santé, qui est qui ?

Alors que le projet de loi « Hôpital, Patients, Santé et Territoires » (HPST pour les intimes) se propose de créer une nouvelle entité juridique supplémentaire – la communauté hospitalière de territoire -, il apparaît utile de revenir sur un jeu de piste, volontaire ou involontaire, que le législateur a réservé notamment aux juristes : la qualification juridique des établissements de santé.

Hormis les informations à caractère général délivrées par l’article L. 6141-1 du code de la santé publique, la loi n’apporte pas de définition précise de l' »établissement de santé » dans la mesure où, en particulier, ces établissements dispensent des soins « avec ou sans hébergement ». Que penser dès lors des structures non hospitalières qui organisent toutefois des activités comparables ? On pense notamment aux centres d’hémodialyse, aux centres de radiothérapie, aux centres d’imagerie médicale, aux cabinets de groupes et autres centres de santé.

Cette interrogation est d’autant plus cruciale qu’à une qualification juridique donnée correspond un régime juridique, c’est-à-dire l’application – dans le cas d’un établissement de santé – d’un certain nombre de règles spécifiques tenant notamment à la soumission à la planification hospitalière et à ses régimes d’autorisations sanitaires, à la production des donnés du PMSI (Programme Médicalisé du Système d’Information), à la certification, à la mise en place d’une commission de conciliation, etc.

Le juge administratif semble ne retenir qu’une définition essentiellement fonctionnelle, c’est-à-dire par référence à la nature de son activité ((TA Pau, 8 février 1996 : il s’agissait en l’espèce d’un cabinet médical pratiquant des endoscopies digestives ; cf. également pour un cabinet pratiquant la chirurgie ambulatoire, TA Nice, 20 juillet 1999, RDSS, p. 770, obs. M. Cormier.)).

Toujours est-il qu’en France, on distingue, parmi les établissements de santé :

  • les établissements publics de santé (1),
  • les établissements de santé privés participant au service public hospitalier (communément appelés PSPH, ou privé non lucratif, ou encore privé associatif) (2),
  • et enfin les établissements de santé privés lucratifs (appelés parfois par ses détracteurs : cliniques commerciales, pour insister sur le caractère lucratif desdits établissements, ou encore par ses zélateurs : hôpitaux privés, pour faire valoir la volonté d’être associés aux missions de service public) (3).

(1) Concernant la première catégorie, le code de la santé publique distingue les centres hospitaliers et les hôpitaux locaux.

Les centres hospitaliers se déclinent parallèlement aux collectivités territoriales auxquelles ils sont rattachés. Ils sont communaux, intercommunaux, départementaux, interdépartementaux et nationaux. Pour mériter le qualificatif de régional, le centre hospitalier doit figurer sur une liste établie par décret. A l’instar de l’échelon territorial, la nature de l’activité participe également de la qualification de l’établissement. Il suffit d’évoquer les centres hospitaliers universitaires qui jouent un rôle fondamental dans l’enseignement, la formation et la recherche, mais également les centres hospitaliers spécialisés (qu’on appelle aussi établissements publics de santé mentale) dont l’activité est centrée sur la psychiatrie.

Autrefois dénommés « hôpitaux ruraux », les hôpitaux locaux, comme leur nom l’indique, ont vocation à être des structures de proximité, souvent implantées dans les zones rurales et dont l’activité est essentiellement tournée vers la gériatrie. Ils ne peuvent dispenser des soins de courte durée qu’en médecine et sous réserve de s’être liés par convention à un ou plusieurs établissements de santé (publics ou PSPH uniquement).

Économiquement, les établissements publics de santé tiennent une place centrale. Pour mémoire, on rappellera que l’objectif national des dépenses d’assurance maladie a été fixé au titre de l’année 2008 à 152, 1 milliards d’euros. Médiatiquement, ils bénéficient globalement d’une bonne image auprès des Français. C’est la Fédération Hospitalière de France qui les représente.

(2) La deuxième catégorie vise les établissements à but non lucratif, telles que les associations, les congrégations, les fondations ou les établissements mutualistes. Souvent d’origine confessionnelle (juive, catholique ou protestante), ces établissements se focalisent généralement sur une discipline et sont particulièrement bien représentés dans le domaine des soins de suite et de rééducation, de la psychiatrie et de la prise en charge des patients alcooliques et toxicomanes.

Le mode de fonctionnement des PSPH est comparable à celui des établissements publics, encore qu’ils ne soient pas soumis au code des marchés publics, que leur personnel relève non de la fonction publique hospitalière mais des conventions collectives et que leur comptabilité est privée.

Si économiquement ces établissements représentent 15% des lits d’hospitalisation, ils souffrent sur le plan médiatique d’un déficit de visibilité et de communication. Mis à part les professionnels, qui se doute que les hôpitaux Foch et Saint-Joseph relèvent du PSPH ? La Fédération des Etablissements Hospitaliers et d’Aide à la Personne est naturellement la première à s’en plaindre.

(3) La troisième et dernière catégorie concerne les cliniques privées à but lucratif. Près de 40% de ces cliniques sont détenues par des grands groupes tels que la Générale de Santé, Capio Santé, Hexagone, etc. Sur le plan juridique, ces cliniques correspondent souvent à un montage de sociétés commerciales (SA, SAS, SARL, etc.) et de sociétés civiles (sociétés civiles immobilières principalement). Il ne faut pas non plus oublier que des médecins libéraux y exercent.

Ces derniers peuvent, par spécialités, se regrouper et créer leur propre société d’exercice (SCP, SELARL, etc.), indépendamment de la structure dans laquelle ils exercent. Sur le plan économique, elles jouent naturellement un rôle central, représentées par la Fédération de l’Hospitalisation Privée. Une audition des trois syndicats devant le Sénat permettra aux lecteurs de se rendre compte des différences et des points communs des différents types d’établissement, s’agissant notamment de la convergence tarifaire.

Le décor ainsi planté dans ses grandes lignes, est-il facile de se repérer dans les textes et les codes pour identifier ces différents types d’établissements ? Répondre par l’affirmative serait hélas mentir. Tout se passe comme si le législateur, dans son autisme ou sa schizophrénie, avait décidé d’utiliser des périphrases ou des litotes pour nommer les choses. Pour employer une expression imagée, au lieu de nommer un chat un chat, il utilisera tantôt « quadrupède félidé domestique », « mammifère carnivore qui miaule » ou encore « mangeur occasionnel de souris et de croquettes ».

Prenons un exemple concret, celui des établissements privés à but lucratif. Le code de la santé publique et le code de la sécurité sociale, s’ignorant superbement, n’utilisent pas le même langage. En effet, pour désigner une même réalité :

  • le code de la santé publique utilisera l’expression « établissement de santé privé ne participant pas au service public hospitalier » (art. L. 6161-2),
  • le code de la sécurité sociale emploiera le terme « établissements de santé privés autres que ceux mentionnés aux b et c ayant conclu un contrat pluriannuel d’objectif et de moyens avec l’agence régionale d’hospitalisation » ou encore « établissements de santé privés autres que ceux mentionnés au b, c et d » (art. L. 162-22-6),
  • la Caisse Nationale d’Assurance Maladie des Travailleurs Salariés – tout comme le ministère de la Santé dans son bulletin officiel – continue, dans ses circulaires, de recourir à la formule poétique suivante : « établissements ex-OQN ». Dans le cadre de la « réforme Juppé » de 1996, c’était effectivement le nom donné à l’enveloppe globale attribuée aux établissements de santé privés « contractualisés » (ex-établissements « conventionnés ») : Objectif Quantifié National (OQN).

En somme, trois qualifications, une seule réalité. Comprenne qui pourra.

On pourrait croire que cet exemple est anecdotique. En réalité, il n’en est rien. Les occasions foisonnent pour dénoncer les incohérences découvertes par les juristes dans leur pratique quotidienne. La sécurité juridique n’est donc pas pour demain.

Omar YAHIA

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