France

Health systems in transition France 161
Cost containment measures fall into two broad categories: strict accounting
cost-containment policies (maitrise comptable des dépenses de santé), which
have been implemented since the late 1970s and focus on controlling provider
tariffs and the volume of care provided and on decreasing SHI expenditure,
and medically based cost-containment policies (maîtrise médicalisée des
dépenses de santé), which were developed later in the 1990s and aimed to
reduce the financial and equity losses linked to medical practice variations
while improving medical practice. The strict accounting cost-containment
policies were strongly opposed by physicians (see section 3.5 in Chevreul et
al., 2010). However, both types of policy continue to be used in France. The
following subsections highlight measures taken since 2010 (for additional
details and earlier cost-containment reforms, see section 7.1.3 in Chevreul et
al., 2010), as well as measures to mitigate the impact of shifting costs from SHI
to private expenditure.
Strict accounting cost-containment measures
Decreasing the benefit package
Decreasing the benefit package is one means of decreasing the financial burden
on SHI. Of all health care goods and services, drugs were the most affected
by this type of measure. Between 1990 and 2009, prescription drug sales in
France multiplied 2.5 times, with SHI covering approximately 75% of the total
(Cour des comptes, 2011b). The steady increase in pharmaceutical expenditure
has led to a series of measures aimed at limiting the usage of certain drugs
and/or reducing the cost for SHI. Cost-containment measures have included
increasing patient contributions (often covered by VHI), either by de-listing the
drugs completely or reducing the rate of SHI coverage, reducing drug prices
and encouraging generic substitution. Economic evaluation is the newest tool
in the cost-containment policies.
De-listing drugs has proven to be politically sensitive, as revealed by
the history of de-listing since the late 1990s. In certain cases, drugs with
insufficient SMR were subject to lower prices or reimbursement rates or even
left at a 65% rate rather than being de-listed. A provisional coverage rate of
15% was instituted for certain drugs as an interim step towards de-listing in
2008. In 2010, the coverage rate for drugs with weak relative SMR decreased
from 35% to 15%, and in 2011, the rate for drugs with moderate SMR was
reduced from 35% to 30%. An additional 26 drugs were de-listed in 2011,
including 17 that had been covered at 15%. The Minister in charge of Health
announced in January 2011 that all drugs with an insufficient SMR would be
de-listed or subject to a systematically motivated decision if coverage was to