Aurélie Colas, Karine Danno, Cynthia Tabar, Jenifer Ehreth, Gérard Duru
Health Economics Review20155:18
© Colas et al. 2015 – Received: 13 January 2015 – Accepted: 25 June 2015
Published: 8 July 2015
Health authorities are constantly searching for new ways to stabilise health expenditures. To explore this issue, we compared the costs generated by different types of medical practice in French general medicine: i.e. conventional (CM-GP), homeopathic (Ho-GP), or mixed (Mx-GP).
Data from a previous cross-sectional study, EPI3 La-Ser, were used. Three types of cost were analysed: (i) consultation cost (ii) prescription cost and (iii) total cost (consultation + prescription). Each was evaluated as: (i) the cost to Social Security (ii) the remaining cost (to the patient and/or supplementary health insurance); and (iii) health expenditure (combination of the two costs).
With regard to Social Security, treatment by Ho-GPs was less costly (42.00 € vs 65.25 € for CM-GPs, 35 % less). Medical prescriptions were two-times more expensive for CM-GPs patients (48.68 € vs 25.62 €). For the supplementary health insurance and/or patient out-of-pocket costs, treatment by CM-GPs was less expensive due to the lower consultation costs (6.19 € vs 11.20 € for Ho-GPs) whereas the prescription cost was comparable between the Ho-GPs and the CM-GPs patients (15.87 € vs 15.24 € respectively) . The health expenditure cost was 20 % less for patients consulting Ho-GPs compared to CM-GPs (68.93 € vs 86.63 €, respectively). The lower cost of medical prescriptions for Ho-GPs patients compared to CM-GPs patients (41.67 € vs 63.72 €) was offset by the higher consultation costs (27.08 € vs 22.68 € respectively). Ho-GPs prescribed fewer psychotropic drugs, antibiotics and non-steroidal anti-inflammatory drugs.
In conclusions management of patients by homeopathic GPs may be less expensive from a global perspective and may represent an important interest to public health.
Conventional medicine General practitioner Homeopathy Economic analysis Prescribing practice
The most effective ways to stabilise healthcare expenditure in France are widely debated by the authorities. Current healthcare represents approximately 10 % of all governmental spending (14.5 million €) . The way in which this care is dispensed in general practice should be examined. The types of care practised and treatments prescribed could be evaluated with regard to their efficacy, usefulness, value to public health and economic impacts on society. This could help identify the most respectful and ethical practices, support the best use of medicines, obtain positive clinical outcomes and reduce costs. With this information, the health authorities could then make optimal choices.
Over half (56 %) of the French population has used homeopathic medicines and 11 % use these medicines regularly . Homeopathic medicines are prescribed by general practitioners (GPs), but can also be recommended by and purchased directly from the pharmacy. In France, most GPs who prescribe homeopathic medicines undergo additional training on homeopathic medicine during their medical training or during their ongoing practice. The EPI3-La-Ser study  found that 24 % of patients in France consulted GPs who regularly or occasionally prescribed homeopathic medicines.
The evaluation of medical practices that prescribe homeopathic medicines is particularly important for public-health policy makers as it may have a considerable impact on healthcare costs. Although there have been many studies on the cost-efficacy of homeopathic or non-conventional treatments compared to other medical treatments [4, 5, 6, 7, 8], relatively few studies have analysed the actual costs of primary care to the Social Security Agency (l’Assurance Maladie), supplementary health insurance and the patient. In France, knowledge of the management of morbidity in hospitals has increased with the establishment of the PMSI (Programme de médicalisation des sytèmes d’information). This is not the same process that occurs in the ambulatory sector apart from some observational studies of general medicine and private company data from GP’s prescriptions taken from different surveys. However, the reimbursement of supplementary health insurance remains relatively poorly documented because there is a lack of publicly available data .
For example with respect to the potential of cost reduction, a study carried out in 2005 showed that complete replacement of the brand-name drug, Omeprazole (a proton pump inhibitor), by its generic counterpart for gastroesophageal reflux disease could reduce costs by 18.35 M€ (−4.3 % reimbursed expenditure) . Another study showed that educational programs led to a reduction in antibiotic prescriptions given to children with acute nasopharyngitis, thus significantly reducing (−20 %) Social Security costs while following guidelines for care . However, complementary healthcare’s contribution was not included in these studies.
As occurs in some other European countries and the US, homeopathic medicines are subject to management by the Social Security and the supplementary health insurances. To best understand French health insurance coverage, we compared the French data with those from the United States. French Social Security coverage is similar to that of the US Medicare system in terms of what is covered and what proportion of costs are covered. Any differences primarily lie in the type of populations covered. In France, individuals have their healthcare costs covered by a compulsory Social Security system. In this system, in 2008, the costs of medications were covered at 100 %, 65 %, 35 % or 0 % depending on drug-reimbursement rate in 2008. In addition to public insurance, people can also subscribe to supplementary insurance to obtain more complete coverage for their treatments. In France, there is a variety of private supplementary healthcare options, such as paying a standard fee-for-services or having a health care contingency account similar to those in the US. Today, 96 % of the French population are covered by supplementary health insurance, either individually, collectively through their employer, or through other free targeted public health insurance programmes (CMU-C) .
With 8,559 patients and 825 participating physicians, the EPI3 La-Ser study has been the largest study carried out to date in France to describe and compare, in a large representative sample of patients consulting their GPs, factors associated with different types of medical practice [13, 14, 15, 16, 17, 18]. We used data from this study to examine the economic perspectives. This current-economic analysis was carried out on the population from the cross-sectional sample of the EPI3 study. In France, the gate keeper coordinates all of the patients’ care. He/she orients it if necessary towards a specialist clinician or a hospital service. The GP provides the first access to healthcare and has an overall view of the health status of the patient. As patients presenting with chronic musculoskeletal disorders and who consult with a homeopathic physicians state that their GP is their regular GP in 54.1 % of cases . Thus to reduce bias, it was important in this study to only include patients who were visiting their regular GP in our analyses. This approach better reflects the patient’s healthcare management rather than that of any physician’s prescribing behaviour.
The aim of this study was to compare the costs generated by the different prescribing practices of the GPs (conventional, mixed or homeopathic) regarding all diseases that present in general practice. The different costs were compared from the point of view of Social Security, supplementary health insurance and the patients’ out-of-pocket expenditures. A description and a comparison of the drugs prescribed in the different medical practices was conducted.
Study design and participants
The EPI3 study was a French pharmaco-epidemiological study with a follow-up of 1-year that included a representative sample of GPs and their patients between March 2007 and July 2008 [3, 13, 14, 15, 16, 17, 18].
The GPs, chosen at random from the national registry of French GPs, were invited to participate in the study. Recruitment was stratified according to the prescription preferences of the GPs, who were classified into three groups: (i) physicians who prescribed conventional medicines only (CM-GPs); these GPs declared that they had never or rarely used homeopathic or complementary or alternative medicines; (ii) GPs who prescribed homeopathic,complementary or alternative medicines regularly in a mixed practice (Mx-GPs); and (iii) registered homeopathic GPs (Ho-GPs) who prescribed mainly homeopathic medicines. The participating physicians answered a telephone questionnaire in order to allocate them to one of these three groups. During a second stage of sampling, a one-day survey of all patients attending the medical practice of each participating GPs was conducted by a trained research assistant. They included all patients seen on the single day of the study unless the patient’s health state precluded them from completing a self-administered questionnaire. The study was approved by the Commission Nationale Informatique et Libertés (CNIL) and the Conseil National de l’Ordre des Médecins (CNOM). The participating GPs received remuneration for their time whereas the patients did not.
The population analysed in our study included patients of all ages from the EPI3 study who had consulted with their regular GP at inclusion. Thus, the population studied is different to that in the cross-sectional EPI3 study because only patients who consulted their regular GP were selected. The large number of participating GPs and patients included favoured a fair representation of clinical practice in primary French healthcare. A previous analysis of the EPI3 survey showed that the distribution of GP’s individual characteristics differed only slightly from those published in French national statistics .
In terms of the patients’ representativeness, the sample of the EPI3 survey was compared with other nationwide studies and demonstrated its efficiency through criteria reported in the previous study. For instance, patients registered by health insurance as eligible for the disease of long duration (DLD; Affection Longue Durée ALD in French) programme accounted for 28 % of patients in the EPI3 survey, which is a similar percentage to the 27 % reported in the national census of GPs’ patients .