OBJECTIVES: Certain drugs requiring particular handling or monitoring are dispensed by French hospital pharmacies to outpatients. To leverage hospitals' purchasing power and contain drug costs, a financial incentive, called Reimbursable Rebate Difference (RRD), was introduced in 2015. National health insurance reimburses hospitals on the basis of their purchase price (PP) plus this RRD (quantities multiplied by 50% of the difference between negotiated prices and nationally set maximum reimbursable prices).

The aim of this study was to analyze hospitals' bargaining power in negotiating drug PP and producing RRD.

METHODS: RRD was calculated from the logistical and market data of the 38 Public Hospitals of Paris (AP-HP, €1.3 billion annual drug spending) from 2019 to 2023. Two indicators were analyzed: RRD amount and price differences between PP and national reimbursement prices (NRP), across therapeutic classes, time since generic introduction, competition levels.

RESULTS: During this period, 106 drugs (INN) generated an average of €10 million per year in RRD (min: 8,7 M€ max : 11 M€), representing around 3.7% of outpatient drug expenditures.

Five therapeutic classes accounted for 84% of cumulative RRD over 5 years: antihemorrhagics (35%), immunosuppressants (17%), antivirals (16%), antihypertensives (9%), and antimycotics (7%). Only 12 INN generated 83% of the RRD, mainly Factor VIII products in an oligopoly market (34% of RRD, PPs were 33% lower than NRPs) and generics (45% of RRD, PPs were 47% lower than NRPs).

For the top 3 RRD-generating specialties, the RRD began upon generic introduction. At that point, NRPs fell by 40%, with AP-HP PPs 82 times lower than NRPs. Over time, NRPs decreased towards hospital PPs. A similar pattern occurred with Factor VIII products followed by NRP alignment.

CONCLUSIONS: The rapid adaptation of hospitals to leverage competition from generics and oligopolies has enabled them to negotiate substantial savings that benefit both the hospitals and the NHI.