France

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Health systems in transition
France
be maintained. However, to date there has been no decree authorizing this
alternative coverage procedure, and the left-wing government elected in 2012
has not put this measure forward since then.
While this cost-containment strategy may be effective in reducing costs in the
short term, the long-term effect is less clear. The French Accounts Commission
has noted that de-listing drugs in a particular therapeutic class can have effects
on prescription of drugs in other covered classes that may reduce or eliminate
the cost savings. For example, when the class of expectorants was de-listed,
savings of €45 million were anticipated. However, prescriptions were shifted
to cough suppressants and bronchodilators, resulting in additional expenditure
of €40 million for these drugs (Cour des comptes, 2011b) and highlighting the
strong culture in French medical practice of offering prescriptions for every
symptom. This underscores the need to address medical practice through, for
example, changes in initial training and DPC (see section 4.2.3).
Price control
Strict control of tariffs was applied, notably to the price of drugs but also to other
type of service such hospital remuneration, medical devices and professional
tariffs. As a result of tight control of doctors’ tariffs, extra-billing, which is
not covered by SHI, was permitted starting in the 1980s for certain categories
of doctor (see Sector 2 doctors; section 3.7.2). However, extra-billing in some
specialties has significantly increased OOP payments, thereby impairing access
in some areas where extra-billing is the rule (e.g. gynaecologists in Paris). For
this reason, policies to reduce extra-billing were developed starting in 2013.
Drug price control
The CEPS (see section 2.7.2) is authorized to reduce previously negotiated
drug prices under four circumstances: at the time of renewal of the agreement,
particularly if there has been a significant increase in volume following
extensions of indications; when the drug’s patent expires and the first generics
enter the positive list (generally 85% of the price of the brand name drug); when
the evolution of drug expenditure threatens ONDAM targets (see section 3.3.3);
or when studies of the drug once it is on the market reveal differences in efficacy
or side-effects compared with the clinical trial data that were considered at
the time the pricing agreement was made. Drug price reductions, both in the
ambulatory and hospital sectors, constitute a significant source of savings in
the annual health budget, with a target of €960 million in 2014 (Sécurité sociale,
2013c).