Le Pen Claude
University of Paris-Dauphine, Paris, France.
Value Health. 2003 Jul-Aug;6 Suppl 1:S10-9. doi: 10.1046/j.1524-4733.6.s1.2.x.
The objectives of this study were to give a review of the complex system of budgetary constraints to which the French health-care system has been committed since 1996 and to evaluate the consequences on drug policy and on efficient use of pharmaceuticals.
Literature review, legal texts analysis, and interviews with policy makers and companies managers were performed.
The budgeting process applies to health insurance expenditures as a whole, but also to each of its components, especially hospital expenditures and pharmaceutical expenditures. Because the targets are set by reference to the gross domestic product growth while health-care expenditure is driven by demographic factors, technology, and expectations, there is inevitably a gap between the top-down budget and the bottom-up cost pressures. The pharmaceutical budget is achieved by a payback system that "taxes" companies when the growth target for aggregated pharmaceutical expenditure is exceeded. The government is now seeking to set more realistic overall global budgets and for pharmaceuticals in particular. It is also encouraging generics, delisting from reimbursement drugs of limited therapeutic value, making a special budget for new drug purchases available to hospitals, and replacing price control for innovative products with a more selective process of intervention in the expectation that companies will seek to price at a European level.
The budgetary system produces a perverse incentive for companies to heavily promote new products in the knowledge that the budget overruns will be spread across all companies, as well as lacking incentives for using pharmaceuticals efficiently. Although the new drug policy will increase the efficiency of pharmaceutical expenditure, it is not apparent that they change the poor incentives facing doctors, hospitals, and insurers to use pharmaceuticals cost-effectively to achieve the optimal gain in health care. They will not remove "silo budgeting" at the national level for pharmaceuticals, which inhibits the efficient substitution of drug therapy for hospital treatment.
本研究的目的是回顾自1996年以来法国医疗保健系统所遵循的复杂预算约束体系，并评估其对药品政策和药品有效利用的影响。
进行了文献综述、法律文本分析，并对政策制定者和公司经理进行了访谈。
预算编制过程适用于整个医疗保险支出，也适用于其各个组成部分，特别是医院支出和药品支出。由于目标是参照国内生产总值增长设定的，而医疗保健支出受人口因素、技术和期望驱动，自上而下的预算与自下而上的成本压力之间不可避免地存在差距。药品预算是通过一种回报系统实现的，当药品总支出增长目标被突破时，该系统会向公司“征税”。政府目前正在寻求制定更现实的总体全球预算，特别是药品预算。政府还鼓励使用仿制药，将治疗价值有限的药品从报销清单中除名，为医院提供新药采购专项预算，并用更具选择性的干预过程取代对创新产品的价格管制，期望公司能按欧洲水平定价。
预算体系对公司产生了一种反常的激励，促使它们大力推广新产品，因为它们知道预算超支将分摊到所有公司，同时也缺乏有效利用药品的激励措施。尽管新的药品政策将提高药品支出的效率，但并不明显的是，它们改变了医生、医院和保险公司在以成本效益方式使用药品以实现医疗保健最佳收益方面面临的不良激励。它们无法消除国家层面上药品的“竖井式预算编制”，这种编制方式抑制了药物治疗对医院治疗的有效替代。
