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164 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
Health systems in transition France 165 in excess of 150% of official SHI tariffs. In addition, a voluntary three-year “Access to Health Care” contract (contrat d’accès aux soins) provides Sector 2 doctors with incentives to freeze their fees and average rate of excess billing at 2012 levels and to perform a share of their services at statutory tariff levels. The incentives include social and fiscal advantages and access for Sector 2 specialists to the €2 higher statutory tariffs of Sector 1 doctors. Patients consulting doctors who have signed the agreement also benefit from improved coverage of the services by SHI. However, from April 2015, patients of non-signatory doctors may be exposed to increased OOP costs under a decree that places a ceiling on the amount of extra-billing that may be covered by VHI contracts (125% of official SHI tariffs in 2015–2016 and 100% thereafter). The average rate of extra-billing by doctors practising in Sector 2 decreased from 56.9% in 2011 to 56.3% in 2013, marking the end of nearly uninterrupted increases in extra-billing since the 1980s. One explanation is fear of sanctions for excessive extra-billing. The financial crisis may also been a contributing factor, as doctors responded to the reduced purchasing power of their patients. Decreasing the impact on equity of shifting costs from SHI to private payers Certain cost-containment measures, particularly reductions in coverage rates, have resulted in a shift towards private expenditure (VHI and OOP payments), which has the potential to affect equity in financing and raises concerns about equity in access. Measures have, therefore, been put into place to increase the level of VHI coverage as well as equity in VHI contracts. For the less well-off, who were more significantly affected by decreases in SHI coverage, these measures include free public complementary VHI (CMU-C) and a voucher scheme (ACS) to facilitate purchase of private VHI contracts by individuals with low income who are not eligible for CMU-C (see section 3.3). In 2013, the revenue ceilings for access to CMU-C and ACS, which are adjusted annually for inflation, were increased by an additional 7% to afford broader access to these programmes. Nonetheless, many people who are eligible for these programmes fail to take advantage of them (CMU, 2013). Only a share of the working population benefit from group contracts paid by employers (see section 3.5.2), which generally offer better coverage at lower cost. In order to increase equity in coverage, all employers will be required to offer group contracts for VHI to their employees by January 2016, pursuant to the January 2013 National Interprofessional Agreement between representatives of employers and employees and enacted under the Employment Protection Law (Loi No. 2013–504 du 14 juin 2013 relative à la sécurisation de l’emploi).
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Contents Contents Preface
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Preface Preface The Health Systems
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Acknowledgements Acknowledgements T
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Abstract Abstract This analysis of
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1. Introduction 1. Introduction The
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