In whose best interest? Framing pharmacists’ and physicians’ (conflicts of) interest in the French market for generic drugs

Résumé 0

The introduction of generic drugs in France is quite recent. While they represented barely 3% of all drugs sold in pharmacies in 1999, they now account for one third, still far behind the United States’ 84%, the United Kingdom’s 83%, Germany’s 80%, and the 48% average of the 19 main countries of the OECD. Generic drugs offer a particularly heuristic case for questioning conflicts of interest, because they are theoretically supposed to align all interests surrounding drug prescription: they are legally defined as “substantially similar” to the original drugs and are therefore supposed to have exactly the same benefit/risk profile for patients as their original counterpart; they are less expensive than the original drugs and therefore save money for patients and (public and private) insurers; and they do not hinder innovation, since they do not reach the market until the patent on the original drug expires, many years after it is marketed, and thus allow insurers to finance innovative drugs that reach the market. The prescription or dispensation of these copies should therefore be self-evident for physicians and pharmacists. However, the development of generic drugs has given rise to a paradoxical framing of conflict of interest in the media and in political and professional fields. Although pharmacists have strongly invested in substitution since 1999, they have been questioned on numerous occasions because of the higher margin they make when selling these copies. On the other hand, although physicians have not prescribed generics generics or have even opposed them, they have been questioned very little for possible conflicts of interest. How can this paradoxical framing of conflicts of interest around the (non-)prescription of generics be explained?To answer this question, I focus on how the prescription choices of physicians and the substitution choices of pharmacists are “framed” (or not) as conflict of interest in the relationships they establish with pharmaceutical companies, France’s (public) national health insurance scheme, patients, and other healthcare professionals. I first analyze the framing of the prescription and substitution of generic drugs from the perspective of the financial interests of healthcare professionals, pharmaceutical companies, and the National Health Insurance scheme. I turn then to the controversies surrounding the qualification of the health benefits and risks related to the prescription and substitution of generic drugs. Finally, I highlight the central role of inter- and intra-professional hierarchy and competition in the framing of professional interests and the prescription or substitution of generic drugs.