essential medicines > note n°6

Essential medicine and the freedom of prescription

Jean-Claude Salomon (January, 2015)

Two questions were put in repeatedly during the too rare debates on essential medicine (EM ):
1- Must they be fully paid off to all the patients by the compulsory health insurance?
2- Will they be opposable, has their prescription to follow an authoritarian order of the health insurance ?

To the first question, we are tempted to answer no, for a whole series of reasons, while in a first moose we would have affirmatively answered. The EM belong or should all belong to the category paid off in 65 % - or to 100%. (100% if their prescription is made within the framework of a long-term disease or of a recognized occupational disease or of an occupational accident). The rest will be charged to the additional health insurance, that is 35 % of the sale price in pharmacy and it will follow the fluctuations of the prices of generic drugs, which constitute the majority of the elements of the list of EM.

The decision concerning the price of generic drugs is of a big simplicity. The political option is the following one: a) maintain a high price of the generic medicines by drawing from the resources of the patients. At the risk of seeing the patients with low income not being treated if this expense exceeds their available resources. These high prices are imposed by the government to the citizens to force them to support shareholders of the pharmaceutical companies, and the salaries of their managers. b) The other political option would be to set the prices of EM at a level close to the marginal cost (factory price), that is usually very low.

To the second question: will they be opposable (compulsory) ? We do not hesitate to answer negatively. The only chance to see the EM gradually occupying a wide place in the prescriptions of the general practitioners at first, then of the specialists, is to find the arguments capable of being convincing without forcing. In their relationships with the compulsory health insurance, in France, the practitioners have, rightly or wrongly, the feeling to be subjected to pressures and to be exploited.

The sustainable practice to prescribe in priority EM for 95 % of the prescriptions should be the object of a major effort of promotion toward the prescribers at first, but also toward all the healthcare professionals and patients. This effort of promotion must only use arguments proving the therapeutic efficiency and the good knowledge of the unwanted side effects. The consensual positive opinion of the doctors, independent from pressures exercised by the commercial and industrial companies, is naturally a determining element. These drugs must be mostly valued by the excellence of the results on the health, much more than by the modesty of their sale price. Both are however main advantages.

Of course this excellence depends so widely of the opportunity of their prescription and of the professional quality of the doctor in the face of his (her) patient. But it is perfectly clear that a small number of medicines, in a list numerically limited, will be better mastered by the doctors than more recent, badly studied medicines, deceitfully described, decked out by unproved qualities, often intended to be removed, because of dangerous late discovered side effects. It is to succeed in supplanting these useless and/or dangerous medicines, that block pharmacies, confuse the mind of the doctors and above all contribute to reduce the confidence that it is necessary to select much less numerous products, but minutely chosen.