医保患者药品费用影响因素实证研究
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摘要
药品费用的快速增长是世界各国面临的难题,这一问题在我国也同样存在。对药品费用进行有效控制可以降低医疗总费用;可以优化卫生资源的配置,将有限的卫生资源用于提供更多更好的医疗卫生服务;可以提高医疗服务的公平性和可及性,让人人享有基本的医疗服务和优质药品;可以降低个人、政府、企业支付医疗费用,减轻患者的疾病负担。同时,国内外理论研究和实践经验表明,药品价格只是影响药品费用的一个方面,仅通过单纯降低药品价格来控制费用是远远不够的。
首先,本研究结合药品市场的固有结构及特点,运用微观经济学理论分析了国内药品费用现状,并探讨了近些年药品费用控制措施及实施效果。结果发现,目前药品费用调控效果多以价格变化作为主要评价指标,伴随着药品价格降低的趋势,药品市场相继暴露出廉价药品短缺、同一药品价差过大、费用仍然持续上升等问题。因此进行药品费用的相关分析,找到影响我国药品费用的关键性因素并挖掘其根源,探索控制药品费用的突破口是十分必要的。
其次,本研究采用天津市城镇职工医疗保险数据,通过三因素和六因素指数分析法对药品费用影响因素进行了实证分析。药品总费用三因素分析显示,2003-2007年间药品费用增长了9%,其主导因素为混合效应增长了48%,数量效应增长了10%,而药品价格下降了33%;分别观察注射剂与口服制剂费用中影响因素的变化程度,结果显示两种试剂的价格均显著降低,而混合效应贡献率显著上升,其中口服制剂的混合效应五年间增长达到了71%,是注射剂的一倍,但变化趋势不同的是,在注射剂用量增长22%的同时口服制剂用量下滑;另外,与以往定性研究所推断不一致的是,六因素实证分析结果表明通用名替代同样推动了药品费用的小幅增长。这些现象的产生可能是由于“医药补医”的存在使得价高的药品即可获得较高的绝对利润;并且一些价高的国产药品回扣也较高,导致医生更倾向处方高价药品,在这两种力量的共同推动和作用下,更加突出了药品过度使用和医疗保险中的道德风险等问题,进而导致用药量也呈现出上升趋势。最后,在实证研究的基础上,本文提出了建立以供方为主,供需兼顾的药品费用控制体系的必要性,并着重强调了药品费用控制关键在于建立和完善以预付制为主的医药费用管理良性激励及约束机制,在实现对医疗供方进行良性长效激励的同时,达到了合理降低药品费用支出以控制药品费用的目的。
The expanding of drug expenditure which is widely discussed in the world has become one of the great challenges. Controlling the expense of drug effectively can help to decrease the total medical expenditure, to utilize the distribution of limited health resource to provide more qualified healthcare service to the public, to enhance the equity and accessibility of medical service and drug usage, as well to alleviate the burden of government, enterprise and individual patients. Additionally, the theoretic research and empirical study show that the drug price is only one of the factors which results in the growth of drug expenditure. It is not enough to dominate the surging drug expenditure only by cutting the price.
Firstly, the implementation and effect of drug cost containment was analyzed based on the combination of the inherence characteristics of pharmaceutical market. The results show that price change is currently the main evaluating indicator of adjective effect on drug cost. However, lots of problems are exposing in succession with the decreasing price trend, including the shortage of cheap drugs, the big difference among the same active ingredients, and the continuing rising expenditure. Therefore, it is necessary to analyze the drug cost to figure out its key affective factors and the inherent cause behind it, then further to explore the breakthrough to control it.
Secondly, empirical study was used to evaluate the factors affecting the drug cost by three-factor and six-factor index analysis. The result of the three-factor index analysis shows that the drug cost grows 9% in which the mixed effect and the volume effect increase by 48% and 10% respectively, while the drug price decreases by 33%. As to formulation, both prices of injection and oral drugs drop obviously while the mixed effect still go up (oral 71%, injection 35%), but these two formulations show the opposite trends in volume change. Furthermore, the result of the six-factor index analysis shows that the utilization of the generic drug promotes a minor growth of drug cost different from the previous qualitative results. There are two main reasons that arouse these effects: on one hand, the existence of the compensation system of subsidizing hospitals by charging more medicine fees leads to the higher absolute profits of the expensive drugs; on the other hand, the higher commission leads to the doctors to prescribe the expensive drugs. And the problems of drug abuse and moral hazard of the medical insurance become more prominent, which further induces the increasing trend of the drug dose.
Finally, based on the outcomes of empirical methods, we suggest that it is necessary to build up the system of drug costs containment denominated by providers. Furthermore, this research emphasizes particularly on establishment of prepayment impress system which is proved to be one of the most effective approach drug contaminant. As administrative authority, the government should pay great attention to the establishment of healthy and long term economic incentive plans.
首先,本研究结合药品市场的固有结构及特点,运用微观经济学理论分析了国内药品费用现状,并探讨了近些年药品费用控制措施及实施效果。结果发现,目前药品费用调控效果多以价格变化作为主要评价指标,伴随着药品价格降低的趋势,药品市场相继暴露出廉价药品短缺、同一药品价差过大、费用仍然持续上升等问题。因此进行药品费用的相关分析,找到影响我国药品费用的关键性因素并挖掘其根源,探索控制药品费用的突破口是十分必要的。
其次,本研究采用天津市城镇职工医疗保险数据,通过三因素和六因素指数分析法对药品费用影响因素进行了实证分析。药品总费用三因素分析显示,2003-2007年间药品费用增长了9%,其主导因素为混合效应增长了48%,数量效应增长了10%,而药品价格下降了33%;分别观察注射剂与口服制剂费用中影响因素的变化程度,结果显示两种试剂的价格均显著降低,而混合效应贡献率显著上升,其中口服制剂的混合效应五年间增长达到了71%,是注射剂的一倍,但变化趋势不同的是,在注射剂用量增长22%的同时口服制剂用量下滑;另外,与以往定性研究所推断不一致的是,六因素实证分析结果表明通用名替代同样推动了药品费用的小幅增长。这些现象的产生可能是由于“医药补医”的存在使得价高的药品即可获得较高的绝对利润;并且一些价高的国产药品回扣也较高,导致医生更倾向处方高价药品,在这两种力量的共同推动和作用下,更加突出了药品过度使用和医疗保险中的道德风险等问题,进而导致用药量也呈现出上升趋势。最后,在实证研究的基础上,本文提出了建立以供方为主,供需兼顾的药品费用控制体系的必要性,并着重强调了药品费用控制关键在于建立和完善以预付制为主的医药费用管理良性激励及约束机制,在实现对医疗供方进行良性长效激励的同时,达到了合理降低药品费用支出以控制药品费用的目的。
The expanding of drug expenditure which is widely discussed in the world has become one of the great challenges. Controlling the expense of drug effectively can help to decrease the total medical expenditure, to utilize the distribution of limited health resource to provide more qualified healthcare service to the public, to enhance the equity and accessibility of medical service and drug usage, as well to alleviate the burden of government, enterprise and individual patients. Additionally, the theoretic research and empirical study show that the drug price is only one of the factors which results in the growth of drug expenditure. It is not enough to dominate the surging drug expenditure only by cutting the price.
Firstly, the implementation and effect of drug cost containment was analyzed based on the combination of the inherence characteristics of pharmaceutical market. The results show that price change is currently the main evaluating indicator of adjective effect on drug cost. However, lots of problems are exposing in succession with the decreasing price trend, including the shortage of cheap drugs, the big difference among the same active ingredients, and the continuing rising expenditure. Therefore, it is necessary to analyze the drug cost to figure out its key affective factors and the inherent cause behind it, then further to explore the breakthrough to control it.
Secondly, empirical study was used to evaluate the factors affecting the drug cost by three-factor and six-factor index analysis. The result of the three-factor index analysis shows that the drug cost grows 9% in which the mixed effect and the volume effect increase by 48% and 10% respectively, while the drug price decreases by 33%. As to formulation, both prices of injection and oral drugs drop obviously while the mixed effect still go up (oral 71%, injection 35%), but these two formulations show the opposite trends in volume change. Furthermore, the result of the six-factor index analysis shows that the utilization of the generic drug promotes a minor growth of drug cost different from the previous qualitative results. There are two main reasons that arouse these effects: on one hand, the existence of the compensation system of subsidizing hospitals by charging more medicine fees leads to the higher absolute profits of the expensive drugs; on the other hand, the higher commission leads to the doctors to prescribe the expensive drugs. And the problems of drug abuse and moral hazard of the medical insurance become more prominent, which further induces the increasing trend of the drug dose.
Finally, based on the outcomes of empirical methods, we suggest that it is necessary to build up the system of drug costs containment denominated by providers. Furthermore, this research emphasizes particularly on establishment of prepayment impress system which is proved to be one of the most effective approach drug contaminant. As administrative authority, the government should pay great attention to the establishment of healthy and long term economic incentive plans.
引文
[1]饶克勤,尹力,刘远立,中国居民健康转型、卫生服务需求变化及其对经济、社会发展的影响,中国卫生经济,2009,9:5~11
[2] Okunade A.A., Suraratdecha C., The pervasiveness of pharmaceutical expenditure inertia in the OECD countries, Social Science & Medicine, 2006, 63 (1): 225~238
[3]推行基本药物是为了人人享有卫生保健,中国医药报,2005.10.13(A3版)
[4] 2009年中国卫生统计年鉴,卫生部网站:www.moh.gov.cn/publicfiles/business/ htmlfiles/zwgkzt/ptjnj/200908/42635.htm
[5]夏林兵,李永斌,王芳等,全国重点联系城市社区卫生服务机构药品“零差率”政策实施现状及效用分析,中国卫生政策研究,2010,3 (2):11~13
[6]每年招标采购药品逾1100亿元,健康报,2007.03.29(A4版)
[7] Xiao Y., Is the overall drug price higher in China? Hospital Management Forum, 2008, 4 (25): 24~25
[8]王淑军,“救命药”断档白血病患儿苦盼,人民日报,2006.03.28(经济版)
[9]陈里予,万幸白血病男孩骨髓配对成功不幸:移植前清骨髓药物"环磷酰胺"断货,新闻晨报,2005.11.05(B2版)
[10]汪挺,药企再度联名呼吁廉价药涨价,中国商报,2008.01.08(A4版)
[11]廉价短缺药品问题调研情况报告,中国价格协会和北京大学医药管理国际研究中心,2008:36~38
[12]吴晶,天津市城镇职工基本医疗保险药品支付现状研究课题报告,天津市医疗保险研究会内部资料,2009:15~16
[13]吴晶,药品价格决定机制的理论与实证研究:[博士学位论文],沈阳;沈阳药科大学,2007
[14] Vernon J.A., Drug research and price controls, Regulation (winter), 2002-2003, 25, 4: 22~25
[15] Ess S.M., Schneeweiss S., Szucus T.D., European healthcare policies for controlling drug expenditure, Pharmacoeconomics, 2003, 21 (2): 89~103
[16] Kanavos P., Overview of pharmaceutical pricing and reimbursement regulation in Europe, LSE Health and Social Care, 2001
[17] Golec J.H., Vernon J.A., European pharmaceutical price regulation, firm profitability, and R&D spending, NBERWorking Paper NO.12676, 2006
[18] Dubois R.W., Chawala A.J., Neslusan C.A., et al, Explaining drug spending trends: does perception match reality? Health Affairs, 2000, 19 (2): 231~239
[19] Bernet E.R., Pharmaceuticals in U.S. health care: determinants of quantity and prices, Journal of Economics Perspectives, 2002, 16 (4): 45~66
[20] Chernew M.E., Smith D.G., Kirking D.M., et al, Decomposing pharmaceutical cost growth in different types of health plans, The American Journal of Managed Care, 2001, 7 (7): 667~673
[21] Hsieh C.R., Sloan F.A., Adoption of pharmaceutical innovation and the growth of drug expenditure in Taiwan: is it cost effective? Value in Health, 2008, 11 (2): 334~344
[22] Dubois R.W., Chawla A.J., Neslusan C.A., et al, Explaining drug spending trends: does perception match reality? Health Affairs, 2000, 19 (2): 231~239
[23] Merlis M., Explaining the growth in prescription drug spending: a review of recent studies, Department of Health and Human Services Conference on Pharmaceutical Pricing Practices, Utilization and Costs August 8–9, 2000 Washington, DC
[24] Morgan S.G., Productivity measurement in a pharmaceutical sub-sector: the real cost of treating hypertension, Vancouver, British Columbia: UBC Centre for Health Services and Policy Research, 2001
[25]唐艳,药品价格政策与效果评价研究:[硕士学位论文],南京;中国药科大学,2008
[26]韩晟,药品费用增长的相关因素研究:[硕士学位论文],北京;北京大学,2008
[27]厉李,我国药品费用的影响因素与控制机制研究:[博士学位论文],沈阳;沈阳药科大学, 2009
[28]梁雪峰,药价虚高治理困境及其出路,价格理论与实践,2006,2:38~40
[29]陈文玲,药品价格居高不下究竟原因何在——对药品价格问题的调查研究与思考(上),价格理论与实践,2005A,1:15~17
[30]陈文玲,解决我国药品价格问题的政策建议——对药品价格问题的调查研究与思考(中),价格理论与实践,2005B,2:28~30
[31]张桂文,刘百实,信息不对称竞争非均衡与药价规制失灵,价格理论与实践,2004,10:41~42
[32]龚向光,胡善联,澳大利亚经验对我国药品价格管制的启示,中国卫生经济,2002,21 (11):47~51
[33]张仁伟,西班牙的药品价格管理,中国卫生资源,2003,5:141~142
[34]高萍,我国药品价格规制失灵的经济学分析,商业时代,2009,10:53~54
[35]张炜,吴晶,天津市城镇职工基本医疗保险药品支付现状研究,天津市劳动与社会保障局课题,2008:59~62
[35] Addis A., Magrini N., New approaches to analyzing prescription data and to transfer pharmacoepidemiological and evidence-based reports to prescribers, Pharmacoepidemiology and Drug Safety, 2002, 11 (8): 721~726
[36] Morgan S.G., Drug spending in Canada: recent trends and causes, Medical Care, 2004, 42 (7): 635~642
[37] Morgan S.G., Agnew J., Barer M.L., Seniors' prescription drug cost inflation and cost containment: evidence from British Columbia, Health Policy, 2004: 68 (3): 299~307
[38]郑伟一,林枫,刘艳萍等,从医疗费用情况看完善支付机制的重要性,中国卫生经济,2004,23 (2):24~29
[2] Okunade A.A., Suraratdecha C., The pervasiveness of pharmaceutical expenditure inertia in the OECD countries, Social Science & Medicine, 2006, 63 (1): 225~238
[3]推行基本药物是为了人人享有卫生保健,中国医药报,2005.10.13(A3版)
[4] 2009年中国卫生统计年鉴,卫生部网站:www.moh.gov.cn/publicfiles/business/ htmlfiles/zwgkzt/ptjnj/200908/42635.htm
[5]夏林兵,李永斌,王芳等,全国重点联系城市社区卫生服务机构药品“零差率”政策实施现状及效用分析,中国卫生政策研究,2010,3 (2):11~13
[6]每年招标采购药品逾1100亿元,健康报,2007.03.29(A4版)
[7] Xiao Y., Is the overall drug price higher in China? Hospital Management Forum, 2008, 4 (25): 24~25
[8]王淑军,“救命药”断档白血病患儿苦盼,人民日报,2006.03.28(经济版)
[9]陈里予,万幸白血病男孩骨髓配对成功不幸:移植前清骨髓药物"环磷酰胺"断货,新闻晨报,2005.11.05(B2版)
[10]汪挺,药企再度联名呼吁廉价药涨价,中国商报,2008.01.08(A4版)
[11]廉价短缺药品问题调研情况报告,中国价格协会和北京大学医药管理国际研究中心,2008:36~38
[12]吴晶,天津市城镇职工基本医疗保险药品支付现状研究课题报告,天津市医疗保险研究会内部资料,2009:15~16
[13]吴晶,药品价格决定机制的理论与实证研究:[博士学位论文],沈阳;沈阳药科大学,2007
[14] Vernon J.A., Drug research and price controls, Regulation (winter), 2002-2003, 25, 4: 22~25
[15] Ess S.M., Schneeweiss S., Szucus T.D., European healthcare policies for controlling drug expenditure, Pharmacoeconomics, 2003, 21 (2): 89~103
[16] Kanavos P., Overview of pharmaceutical pricing and reimbursement regulation in Europe, LSE Health and Social Care, 2001
[17] Golec J.H., Vernon J.A., European pharmaceutical price regulation, firm profitability, and R&D spending, NBERWorking Paper NO.12676, 2006
[18] Dubois R.W., Chawala A.J., Neslusan C.A., et al, Explaining drug spending trends: does perception match reality? Health Affairs, 2000, 19 (2): 231~239
[19] Bernet E.R., Pharmaceuticals in U.S. health care: determinants of quantity and prices, Journal of Economics Perspectives, 2002, 16 (4): 45~66
[20] Chernew M.E., Smith D.G., Kirking D.M., et al, Decomposing pharmaceutical cost growth in different types of health plans, The American Journal of Managed Care, 2001, 7 (7): 667~673
[21] Hsieh C.R., Sloan F.A., Adoption of pharmaceutical innovation and the growth of drug expenditure in Taiwan: is it cost effective? Value in Health, 2008, 11 (2): 334~344
[22] Dubois R.W., Chawla A.J., Neslusan C.A., et al, Explaining drug spending trends: does perception match reality? Health Affairs, 2000, 19 (2): 231~239
[23] Merlis M., Explaining the growth in prescription drug spending: a review of recent studies, Department of Health and Human Services Conference on Pharmaceutical Pricing Practices, Utilization and Costs August 8–9, 2000 Washington, DC
[24] Morgan S.G., Productivity measurement in a pharmaceutical sub-sector: the real cost of treating hypertension, Vancouver, British Columbia: UBC Centre for Health Services and Policy Research, 2001
[25]唐艳,药品价格政策与效果评价研究:[硕士学位论文],南京;中国药科大学,2008
[26]韩晟,药品费用增长的相关因素研究:[硕士学位论文],北京;北京大学,2008
[27]厉李,我国药品费用的影响因素与控制机制研究:[博士学位论文],沈阳;沈阳药科大学, 2009
[28]梁雪峰,药价虚高治理困境及其出路,价格理论与实践,2006,2:38~40
[29]陈文玲,药品价格居高不下究竟原因何在——对药品价格问题的调查研究与思考(上),价格理论与实践,2005A,1:15~17
[30]陈文玲,解决我国药品价格问题的政策建议——对药品价格问题的调查研究与思考(中),价格理论与实践,2005B,2:28~30
[31]张桂文,刘百实,信息不对称竞争非均衡与药价规制失灵,价格理论与实践,2004,10:41~42
[32]龚向光,胡善联,澳大利亚经验对我国药品价格管制的启示,中国卫生经济,2002,21 (11):47~51
[33]张仁伟,西班牙的药品价格管理,中国卫生资源,2003,5:141~142
[34]高萍,我国药品价格规制失灵的经济学分析,商业时代,2009,10:53~54
[35]张炜,吴晶,天津市城镇职工基本医疗保险药品支付现状研究,天津市劳动与社会保障局课题,2008:59~62
[35] Addis A., Magrini N., New approaches to analyzing prescription data and to transfer pharmacoepidemiological and evidence-based reports to prescribers, Pharmacoepidemiology and Drug Safety, 2002, 11 (8): 721~726
[36] Morgan S.G., Drug spending in Canada: recent trends and causes, Medical Care, 2004, 42 (7): 635~642
[37] Morgan S.G., Agnew J., Barer M.L., Seniors' prescription drug cost inflation and cost containment: evidence from British Columbia, Health Policy, 2004: 68 (3): 299~307
[38]郑伟一,林枫,刘艳萍等,从医疗费用情况看完善支付机制的重要性,中国卫生经济,2004,23 (2):24~29