France

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Health systems in transition
France
similar health systems. For example, in Germany, the market share of generic
drugs among all covered drugs was 72.4% of volume and 34.7% of value
(IGAS, 2012a).
Pharmacists have been the key players in expanding the use of generic
drugs, largely because of financial incentives to encourage generic substitution,
including higher manufacturer rebates compared with brand name drugs. Since
the 2007 Social Security Finance Act, annual objectives for generic substitution
have been set and a new incentive for patients was instituted in departments
with low levels of generic substitution. Patients refusing generic substitution
must pay for the prescription and then claim reimbursement from SHI rather
than benefiting from third-party payment as is usually the case. Nonetheless, the
rate of generic substitution strongly decreased between 2008 and 2012, falling
from 82% to 72% of substitutable drugs, in part through public reluctance to
accept certain generic drugs because of concerns about their efficacy and safety
and partly from an increase in prescriptions marked as “non-substitutable”
by doctors. To counter this trend, the SHI expanded the patient incentive for
generics nationally to all SHI beneficiaries. In addition, a new P4P scheme
for pharmacists was established in 2014, and the indicators upon which the
remuneration is based include increasing the rate of generic substitution for a
list of drugs newly included in the repertoire, with an overall goal of 85%. The
government is also considering instituting penalties for doctors who abuse the
designation “non-substitutable” in prescribing drugs.
The 2014 Social Security Finance Act authorized the substitution of
off-patent biosimilar drugs (biosimilaires) at the pharmacy level, but only at
the initiation of treatment. As in other European countries, France hopes to
reduce drug expenditure through expanded use of biosimilar drugs.
Finally, the 2014 Social Security Finance Act also authorized a three-year
trial that allows pharmacists in selected regions to dispense certain antibiotics
in the exact prescribed number of units rather than by the box, with a fixed
number of tablets in order to reduce waste and the risk of microbial resistance.
The programme will be evaluated in terms of its effect on expenditure and also
on the proper use of antibiotics.
Controlling the level of extra-billing by doctors
Extra-billing is permitted for doctors practising in Sector 2, which includes 42%
of specialists and 11% of GPs. In an effort to discourage excessive extra-billing,
a “carrot and stick” approach was taken in a 2012 amendment to the collective
bargaining agreement between SHI and physician unions. Since 2013, Sector 2
doctors may be subject to sanctions for excessive extra-billing, defined as fees