Activité libérale à l’hôpital : suite du feuilleton jurisprudentiel

Photo personnelle - argentLa question de la détermination de l’assiette des redevances dont les praticiens hospitaliers à temps plein doivent s’acquitter au titre de leur activité libérale a récemment donné lieu à une nouvelle décision du Conseil d’Etat ((CE, 29 mai 2009, Syndicat national de chirurgie plastique, reconstructrice et esthétique et autres, n°318071 et Syndicat national de défense de l’exercice libéral de la médecine à l’hôpital, n°322288.)), lequel avalise la solution retenue par les pouvoirs publics. Rappelons le contexte.

Le 7 mars 2006, un premier décret a établi les modalités de calcul des redevances dues par les PH exerçant une activité libérale à l’établissement dans lequel ils évoluent. Le dispositif a été contesté devant le juge et le Conseil d’Etat a mis fin à la règle selon laquelle son montant devait être plafonné par le coût de la prestation fournie par le service et a validé l’instauration d’une tarification en fonction des honoraires perçus ((CE, Ass., 16 juillet 2007, Syndicat national de défense de l’exercice libéral de la médecine à l’hôpital, Syndicat national de chirurgie plastique, reconstructrice et esthétique, AJDA 2007. 1807, chron. J. Boucher et B. Bourgeois-Machureau.)).

Nous nous en étions ouverts ici.

Dans la même décision, le Conseil d’Etat a rappelé que « le tarif doit être établi selon des critères objectifs et rationnels, dans le respect du principe d’égalité et des règles de concurrence », ce qui l’a conduit à censurer, au nom du principe d’égalité, la différence d’assiette de la redevance établie dans le décret, lequel opérait une distinction selon que les actes accomplis sont ou non remboursés par la sécurité sociale.

Les pouvoirs publics ont naturellement tiré les conséquences du sens de la décision en modifiant le mode de calcul de la redevance par deux décrets (n°2008-464 du 15 mai 2008 et n°2008-1060 du 14 octobre 2008) : peu importe que les actes soient ou non remboursés par la sécurité sociale, le calcul étant désormais fonction des honoraires effectivement perçus par les praticiens concernés.

Ces deux textes ont fait l’objet d’un recours contentieux devant le Conseil d’Etat qui s’est prononcé à ce sujet par décision du 29 mai 2009. Les nouvelles bases de calcul de la redevance établies dans les textes attaqués sont, estime-t-il, légales.

Exerçant un contrôle restreint sur la détermination du taux des redevances, le juge administratif considère que les taux retenus dans les décrets attaqués ne sont pas manifestement disproportionnés au regard de la valeur du service rendu aux praticiens par les établissements de santé.

S’il existe évidemment des différences de pourcentage entre les CHR faisant partie d’un CHU et les autres établissements publics de santé, cette différence, qui n’excède pas 20%, n’est pas manifestement disproportionnée, au regard notamment des coûts de structures (liées aux installations techniques, aux locaux ou encore aux personnels) qui existent entre ces catégories d’établissements.

Au plan pratique, l’administration hospitalière éprouvera sans doute quelque difficulté à percevoir l’intégralité de ce qui lui est dû, dans la mesure où la connaissance des montants des honoraires effectivement perçus s’avère délicate. Il faudrait que les PH délivrent consciencieusement les informations sur leur activité libérale chaque trimestre à la commission de l’activité libérale rattachée à la commission médicale d’établissement, laquelle doit en principe, selon les textes, établir un rapport annuel, qui sera ensuite présenté notamment devant le conseil d’administration de l’établissement (ou selon la taille de l’établissement : conseil de surveillance/directoire).

A lire les rapports d’observations définitives des Chambres régionales des comptes, il semble que ces obligations réglementaires ne soient pas scrupuleusement respectées, loin de là.

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