Recherche pharmaceutique, prix du médicament et assurance-maladie

[fre] en fait les organismes d'assurance- maladie, n'était pas excessive. En France, le moyen privilégié pour cela a longtemps été le contrôle des prix. Si ce système a permis de maintenir les prix bas, il s'est avéré peu efficace en termes de maîtrise des dépenses et d'incitation à la recherche. Aujourd'hui, une tendance nette semble se dégager vers un système dans lequel les prix sont libres, mais où les niveaux de remboursement sont fixés en fonction des prix les plus bas au sein de chaque classe thérapeutique. Le système allemand (Festbetrag) en constitue l'exemple type- L'analyse de la politique optimale du médicament dans un modèle théorique simple d'assurance, avec aléa moral, et de concurrence entre firmes innovantes, conduit à trouver une justification forte à ce type d'organisation. En effet, une affectation très stricte des instruments aux différents objectifs de la politique du médicament apparaît, dès lors que l'on dispose dans la panoplie d'un instrument spécifique pour stimuler un comportement d'acheteur au moindre coût, par un mécanisme de type « remboursement sur la base du médicament le moins cher du marché ». Sous cette hypothèse, la question de la maîtrise des dépenses de santé n'interfère plus avec la politique industrielle: le premier problème appelle des instruments classiques de responsabilisation de la demande ou de la prescription médicale, par exemple par des mécanismes de coassurance; la liberté du prix du médicament [eng] The drug policy must reconcile industrial and health policies stakes. Research and technological change, that have hitherto largely contributed to improve the population general health level, are actually the main determinants of the health expenditure evolution. Moreover, the state policy, regarding prices and reimbursement, strongly determines pharmaceutical R&D investment and competitiveness. The complexity of these interactions has led to the implementation of a wide range of drug policies in industrialised countries. These notably set up various instruments in order to make sure that the profitability of pharmaceutical firms, whose customers are in fact health insurance organisms, was not too high. In France, price control was privileged. While such a system allowed to keep low prices, it was not very efficient concerning expenditures containment and research incentives. Today, a clear tendency seems to emerge towards a system in which prices are free, but reimbursement levels are fixed according to the lowest prices within every therapeutic class. The german system (Festbetrag) is a good example of this kind of system. The analysis of the optimal drug policy, in a simple theorical model of insurance with moral hazard and competition between innovative firms, provides a strong justification for this type of organization. As a matter of fact, a strict allocation of the instruments to the different drug policy objectives emerges, as soon as one has a specific instrument to stimulate a least cost consumer behavior, through a "reimbursement on the basis of the market least expensive drug" mechanism. Under this assumption, the issue of health expenditures containment does not interfere with industrial policy. The former problem calls for classical instruments aimed to control demand and medical prescription, by mutual insurance for example; freedom of price is furthermore desirable to stimulate innovation, for it allows firms to appropriate a sufficient proportion of the surplus. Patents, and possibly common law instruments, such as research tax credits, are therefore decisive here. Obviously, this reasoning can't be reversed: the creation of rents does not guarantee an appropriate level of research investment. In such an organization, the main difficulty lies in the economic evaluation of innovative drugs. Actually, the reimbursement rule by therapeutic class, defined above, only applies if there is no therapeutic benefit, innovative drugs having otherwise to get a bonus equal to the expected economic benefit.