Understanding the Community Pharmacy Structure in France
Key takeaways:
France’s healthcare system has numerous insurance companies. These companies are heavily regulated by the federal government to control costs and provide essential benefits.
Drug pricing goes through a series of committees to determine both the maximum price received by the manufacturer as well as the patient’s out-of-pocket cost.
All community pharmacies in France are owned by a pharmacist, who cannot own more than one pharmacy.
Community pharmacies are those that dispense medications to patients who aren’t hospitalized or in nursing facilities. This series explores how community pharmacy practice differs around the world. In doing so, it gives us the opportunity to view our own system in a new light and possibly find opportunities for improvement.
We’ve covered the globe, exploring the practice of pharmacy in countries across continents, from Japan and Australia to Argentina and Finland. In this post, we’ll look at pharmacy practice in France, a country whose healthcare system was named the top in the world by the World Health Organization. Its healthcare system is often discussed in the U.S., especially in debates on healthcare reform.
How France’s healthcare system works
The Ministry of Social Affairs, Health, and Women’s Rights is the central federal agency responsible for creating and implementing the national health strategy, setting health policy, and financing the health system. It oversees Regional Health Agencies, which manage public health policy and regulate healthcare within their respective regions.
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Health insurance
Health insurance is required for everyone and provided through numerous Statutory Health Insurance (SHI) funds, all of which fall under the same parent organization, the National Union of Health Insurance Funds.
Unlike the U.S., however, the SHI funds do not compete with one another and are required to cover the same benefits. Benefits include hospital care, outpatient care, dental services, maternity care services, prescription drugs, and even transportation to and from healthcare facilities.
In addition to the required insurance, voluntary health insurance (VHI) is available, and over 95% of the population is also covered by VHI. It helps patients pay for copays and also provides coverage for services not included under SHI.
A major component of the French healthcare system is the Carte Vitale, which is a unique health card issued to everyone entitled to healthcare. It contains a chip, similar to a credit card, and is used anywhere a patient receives care. It electronically submits claims for reimbursement.
In most cases, the patient pays for treatment upfront and receives reimbursement within one week. The Carte Vitale is valid anywhere in France, so there are no provider networks or restrictions on which doctors or hospitals a patient can visit.
Outcomes
France’s annual healthcare spending in 2020 was $5,468 per person, or 12.2% of GDP. For comparison, in 2020, the U.S.’s healthcare spending was $12,530 per person, or 19.7% of GDP, according to the Centers for Medicare & Medicaid Services.
France’s under-5 mortality rate, a key indicator of health system performance, was 4.4 per 1,000 live births in 2020. This is somewhat lower than the U.S., which had a rate of 6.3 per 1,000 live births the same year.
The French also live longer than Americans on average. Life expectancy in France, another key indicator of health system performance, was 82 years in 2020, compared to 77 years the same year in the U.S.
Pharmacy regulation
The primary agency in France for drug regulation is the National Agency for the Safety of Medicines and Health Products (ANSM). It regulates clinical trials, approvals, marketing, and pharmacovigilance.
Drug pricing
The French federal government sets drug pricing after a medication receives marketing approval. The drug is first evaluated by the Transparency Committee (CT), which rates a drug based on the added value over existing drugs or therapies. This rating, termed an ASMR rating, is used to set a window of prices that the Healthcare Product Economic Committee (CEPS) must use when negotiating a maximum price with the manufacturer.
ASMR has five ratings:
ASMR I-III (major improvement-moderate improvement): Manufacturers might not need to negotiate the price and can receive a maximum price consistent with similar European countries.
ASMR IV (minor improvement): The price received by the manufacturer cannot exceed the price of the comparator drug in France.
ASMR V (no improvement): The drug can only be reimbursed if the price is lower than comparator drugs.
France also judges a new medication based on its actual benefit, or SMR. The SMR rating is used to determine the reimbursement rate for the drug. It has several levels:
Important: reimbursed at 65%
Moderate: reimbursed at 30%
Mild: reimbursed at 15%
Insufficient: not reimbursed at all
Taken together, these two ratings provide a unique approach to control both the total price paid by society for a drug as well as the patient’s out-of-pocket cost.
Daily pharmacy practice in France
All community pharmacies must be owned by a pharmacist in France, and each pharmacist can only own one pharmacy. They are allowed, however, to invest in up to two additional pharmacies. They are also allowed to establish an LLC or partnership, but in those cases the business is only allowed to own one community pharmacy.
France has a high number of community pharmacies relative to other countries, with 32 pharmacies per 100,000 people in 2019. The U.S. has 19 pharmacies per 100,000 people, and the average for Organisation for Economic Co-operation and Development OECD countries is 27 pharmacies per 100,000 people.
One striking difference from the U.S. is that over-the-counter medications in France can only be sold in pharmacies. Some say this is a reason for the high number of pharmacies there.
Like many other countries, including Finland, France regulates how many community pharmacies can be established, and where they can be established. Federal law requires a minimum population within the proposed area: 2,500 people for the first pharmacy license and 4,500 residents for each additional license.
As with other healthcare services, billing is done electronically using the patient’s Carte Vitale. If the patient forgets their card, they must send a paper care sheet to their insurance company to be reimbursed. Another option is for the pharmacy to send a form signed by the patient to the insurer, who will then reimburse the patient.
The bottom line
French healthcare is among the best in the world. France has high life expectancy, low total healthcare expenditures compared to the U.S., and relatively affordable out-of-pocket costs. A unique drug pricing model helps them control drug costs while also rewarding innovation, and the Carte Vitale helps simplify billing and reimbursement. Community pharmacies are independently owned and prevalent throughout the country.
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