Cooperation between national and regional auditors on health care in France : hospital pharmaceutica

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Cooperation between national and regional
auditors on health care in France hospital
pharmaceutical expenses

• presentation by
• Christine de Mazières (Cour des comptes)
• Elisabeth Girard(Chambre régionale des comptes
  de Provence Alpes Côte dAzur)

EUROSAI -EURORAI Conference Copenhagen, June
5th 2003
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Points to be presented

• 1. Context
• 2. audit features and methods
• 3. main findings
• 4. conclusions

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1 - Context

• Since 1995, an annual Report on Social Security
  has been published by the French Court of
  Accounts.
• Theme of 2002 Report Hospital.
• Among other subjects related to Hospital,
  medicine costs were chosen (sharp rise).

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2 - MethodsTwo complementary competences

• The competence of Regional Chambers of Accounts
  (CRC) is to audit hospitals.

• The competence of the 6th Chamber of the Court of
  Accounts (CC) is to evaluate policies and
  expenses of Social Security.

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Hospital Group October 2000 - June 2002
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CRCs contributions

• 2000 Assessment guide, with 5 topics
• evolution of expenses
• organisation
• stock management
• tendering and purchases
• hospital research on new medicines

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CRCs contributions

• The CRC s audits pursued two goals
• juridictional control
• contribution to the Court s public report on
  Social Security

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The Court of Accounts task

• An auditor and a medical expert during 3 months
• synthesis of 25 CRC s reports
• national legal aspects
• benchmarking in Germany
• contradictory procedure draft / definitive report

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Result

• March 2002 26 draft reports representing 550
  pages
• September 2002 summary of 14 pages (among 200
  pages dedicated to Hospital) in the Court s
  Public Report on Social Security

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3 - Main findings

• the quick rise of medicine costs in French
  hospitals
• how hospitals face the financing problem
• insufficient regulation of pharmaceutics

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A/ the quick rise of medicine costs in French
hospitals

• 1 billion in 1990 ? 3 billions in 2001 (sales
  by industry)
• but
• lack of information (no precise national
  database)
• lack of economical analysis (e.g. it is not
  proven that a higher use of pharmaceutics reduce
  hospital costs)

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Hospital sales grow within total French
pharmaceutical market (from 11,9 to 16,3
1990-2001)

• Non-hospital market
• less dynamic sales grew by 85 in the same
  period
• less concentrated 10 major drugs 9,5 of sales
  
• less innovative average age of drugs 15,3
  years

• Hospital market
• more dynamic sales grew by 166 1990-2001
• more concentrated 10 major drugs 19,2 of
  sales
• more innovative average age of drugs 7,7 years

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What innovation to what price?

• The rise in medicine costs is more and more
  concentrated on a few  innovative  drugs (the
  first 20 products 54 of pharma expenses in
  Parisian hospitals in 2001)
• How innovative are new drugs?

commercial innovation
technological innovation
therapeutical innovation
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The example of anti-cancer medicines

• Innovation in cancer-related drugs 1075-1994

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B/ how hospitals face the financing problem

• 1) Medicine purchases by hospitals
• the generic drugs represent only 15 of expenses,
  although great volumes (often given for free)
• the patent protected drugs represent around 85
  of expenses
• Difficult competition between equivalent but
  patent protected drugs. Examplestaxans,
  erythropoietins

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a largely monopolistic market
Generics 15
Patent protected
substitution 10
without equivalent 75
competition possible
monopole
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• 2) drug prescriptions in hospital
• less control than outside of hospitals
• no nominative prescription despite of 1991
  reglementation
• very few therapeutical protocols

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C/ insufficient regulation of pharmaceutics

• Worldwide insufficient independant assessment of
  medicines before and after market agreement
• 2 French specificities
• the temporary use agreements (ATUs). A fast
  track for innovative drugs used against mortal
  diseases (e.g. AIDS)
• drugs with hospital limitated prescription
  almost no benefit/cost assessment

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The double pharmaceutical market in France
Agreement of drugs
Prescription restricted to hospital
No prescription restriction
Company choice
Ambulatory market ?assessment of therapeutical
innovation level ?prices fixed by State
Hospital market ?very  light  or no
assessment of benefit/cost ?free prices
Outpatients expenses 1 billion
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4 - Follow up

• Fall 2002 report publishing just before
  parliamentary discussion about social security
  financing law.
• Early 2003 ministerial mission on this subject,
  in order to implement the Court s recommendations

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Overall Conclusion

• Enhancing co-ordination on the pharmaceutical
  issue within EUROSAI-EURORAI
• 3 steps
• exchange information for benchmarking
• launch parallel assessments
• launch joint or crossed assessments