The 2nd HPD report - Health Policy Monitor

eimbursement rate is 35 percent. Most drugs belong to this
category.
– The remainder, drugs with an insufficient SMR, is not
reimbursed; the patient or the patient’s supplemental insurance
pays the full cost.
The “Commission de Transparence,” a commission of physicians,
pharmacists, members of the health insurance association
and representatives from the pharmaceutical industry, issues
recommendations based on this classification. Between 1999 and
2001, the commission evaluated all of the 4,200 listed pharmaceuticals
with respect to each possible indication. Based on its
findings, the commission recommended reducing the reimbursement
for 840 drugs from 65 percent to 35 percent and excluding
another 835 drugs from the list of reimbursable drugs
altogether. Until 2003, however, only a few drugs were actually
delisted or moved to a lower reimbursement category.
In April 2003, the MoH implemented a new system, reducing
the reimbursement rates for 617 drugs. Pharmaceutical companies
raised an outcry, criticizing the criteria for reimbursement
and reevaluation of the drugs and accusing the “Commission de
Transparence” of inconsistency. Taking their case to court, on the
grounds of breach of procedural rules and insufficient justification
for reducing the rate, some of the affected companies won
rulings that reversed the decreased reimbursement for 12 drugs.
Some scientists criticize the SMR criteria as too narrow in
scope. They argue that the criteria should consider not just efficacy,
but also benefit-risk-ratios, social dimensions and equity
aspects. Furthermore they argue that the consequences of this
policy have not been evaluated.
In response to these criticisms, the MoH decided to implement
the delisting in three waves spread out over three years. In
the first wave, 84 drugs were delisted in summer 2003. The MoH
also reorganized the “Commission de Transparence” in September
2003, changing the composition of its membership.
51
Evaluations to
little effect
Drug companies
fight further
reimbursement cuts
Delisting criteria
lack equity
dimension
MoH speeds
up delisting in
response to critics