国外药品费用控制的策略和措施

本文在描述了一些国家药品费用上涨的背景后，介绍了国外控制药品费用的策略和措施以及实施效果，这些策略和措施主要包括：直接价格控制、利润控制、参考价格体系、通科医生预算、鼓励使用普通替代药、药品报销范围、病人共付和非处方药等。从各国的经验来看，只有采取综合的政策手段，才能取得更好的效果。     

Pricing and reimbursement of pharmaceuticals in Italy

In Italy the price setting of medicines reimbursed by the National Health Service is regulated at the central level by AIFA, the national regulatory authority. Prices of non reimbursed medicines are indeed freely established, with some limitations, by pharmaceutical companies. To contain pharmaceutical expenditure and rationalise the whole sector the following measures have been introduced in the past years: a threshold to public pharmaceutical expenditure (PPE); a reference price system (RPS) for off-patent medicines; a pay-back mechanism as an alternative to price cut. In 2008 Italy launched a reform of the pharmaceutical expenditure governance system with the aim to introduce stability and promote development and competitiveness in the pharmaceutical sector.     

Funding processes for new vaccines: the need for greater understanding of the economic issues

Aim  Given the changing landscape for the economics of vaccines, this article discusses the nature of economic assessments, the criteria being applied by decision-makers, the available evidence on the cost-effectiveness of the newer vaccines and the methodological and policy issues involved. Subjects and methods  We examine the nature of economic assessments, recent evidence on the cost-effectiveness of vaccines as well as the methodological and political issues arising as a consequence of evaluating vaccination programmes from an economic point of view. Results  Economic evaluations of vaccination look at (1) different schedules and implementation of a vaccine in national programmes; (2) benefits for high-risk individuals as versus entire populations; (3) healthcare system costs and societal costs incurred as a result of vaccination programmes versus treating disease; (4) life years gained and quality-adjusted life years. Cost-effectiveness studies of vaccination range considerably in the ratios produced owing to the wide variation of vaccination programmes and differing target populations. Nevertheless, vaccination programmes with newer or less widely used vaccines such as as pneumococcal, meningococcal, hepatitis A and influenza vaccines have consistently demonstrated their cost-effectiveness. In practice, however, implementation of vaccination programmes generally precedes the demonstration of their cost-effectiveness Conclusion  In the face of growing pressure on health-care resources, vaccines–as other health interventions and products–will have increasingly to demonstrate their cost-effectiveness. This poses particular challenges given the specificity of vaccination both as an individual and collective health intervention.     

EU Country Specific Recommendations for health systems in the European Semester process: Trends,discourse and predictors

In the framework of “Europe 2020”, European Union Member States are subject to a new system of economic monitoring and governance known as the European Semester. This paper seeks to analyse the way in which national health systems are being influenced by EU institutions through the European Semester. A content analysis of the Country Specific Recommendations (CSRs) for the years 2011, 2012, 2013 and 2014 was carried out. This confirmed an increasing trend for health systems to feature in CSRs which tend to be framed in the discourse on sustainability of public finances rather than that of social inclusion with a predominant focus on the policy objective of sustainability. The likelihood of obtaining a health CSRs was tested against a series of financial health system performance indicators and general government finance indicators. The odds ratio of obtaining a health CSR increased slightly with the increase in level of general Government debt, with an OR 1.02 (CI: 1.01, 1.03; p = 0.007) and decreased with an increased public health expenditure/total health expenditure ratio, with an OR 0.89 (CI: 0.84, 0.96; p = 0.001). The European Semester process is a relatively new process that is influencing health systems in the European Union. The effect of this process on health systems merits further attention. Health stakeholders should seek to engage more closely with this process which if steered appropriately could also present opportunities for health system reform.     

Reimbursement policy of hospitals in the Federal Republic of Germany.

The factors that have contributed to an overhaul of German hospital policy in the last 12 months are both numerous and highly interrelated. Rising health expenditures and inflexible mechanisms for implementing hospital policy are major culprits, as are the considerably changed political and economic circumstances over the last 15 years. Although this overhaul does embody some changes in the direction of German health care policy, they can best be understood as a further manifestation of the continuity that has characterized policy in this area for the past 100 years; a continuity rooted in the widely shared belief that disease, whatever its nature, is beyond the control of individuals. The key to cost containment is considered to lie in the reduction of the average length of stay and in the better utilization of hospital facilities. Payment remains directly related neither to specific diagnoses of individual patients nor to occupancy rates in individual departments, which vary greatly across disciplines and specialities. In the era that is unfolding, one political phenomenon requires close watching in the future: policy coalitions at the Land-level will become even more important as prime movers than they have been in the past. Demands for Strukturreform are a regular feature of many governmental systems. Yet the capacity of political bodies--whether ministries or parliaments--is severely limited by the distribution of power and control over resources and by the political dynamics which they generate. In the FRG, major reforms will not take place until after the 1987 federal elections, and it is essential to remember that the realms of campaign rhetoric and of policy choice and implementation are governed by entirely different sets of rules and constraints.     

Effective healthcare cost-containment policies: A systematic review

Unsustainable growth in healthcare expenditure demands effective cost-containment policies. We review policy effectiveness using total payer expenditure as primary outcome measure. We included all OECD member states from 1970 onward. After a rigorous quality appraisal, we included 43 original studies and 18 systematic reviews that cover 341 studies. Policies most often evaluated were payment reforms (10 studies), managed care (8 studies) and cost sharing (6 studies). Despite the importance of this topic, for many widely-used policies very limited evidence is available on their effectiveness in containing healthcare costs. We found no evidence for 21 of 41 major groups of cost-containment policies. Furthermore, many evaluations displayed a high risk of bias. Therefore, policies should be more routinely and rigorously evaluated after implementation. The available high-quality evidence suggests that the cost curve may best be bent using a combination of cost sharing, managed care competition, reference pricing, generic substitution and tort reform.     

Health care reform in six Central European countries

This study gives an overview of the health care reform in six Central European countries after the transition from a central planning system to a regulated market economy. We focused on cost containment policies for drugs, especially the requirements for submitting health economic data in the pricing and/or reimbursement processes. The literature review was supplemented with a survey with decision makers at national health authorities in each country. The study covered Croatia, Czech Republic, Hungary, Poland, Slovakia, and Slovenia. All countries had in common that health economic information was used in reimbursement rather than in pricing processes. Differences between the six countries were mainly variations in the relative importance of health economic data and the presence of explicit requirements and guidelines. Published health economic guidelines exist in two countries and one of the six countries applies a mandatory submission system for a selected range of new drugs. In most of the Central European countries it is more typical that authorities issue a brief list of required data for reimbursement submissions that include health economic information among other data. There is a generally widespread expectation towards more systematic and formalized requirements for health economic and outcomes research data appearing within the next 3–5 years in the region.     

The organization and financing of end-stage renal disease treatment in Japan

End-stage renal disease (ESRD) affects 230,000 Japanese, with about 36,000 cases diagnosed each year. Recent increases in ESRD incidence are attributed mainly to increases in diabetes and a rapidly aging population. Renal transplantation is rare in Japan. In private dialysis clinics, the majority of treatment costs are paid as fixed fees per session and the rest are fee for service. Payments for hospital-based dialysis are either fee-for-service or diagnosis-related. Dialysis is widely available, but reimbursement rates have recently been reduced. Clinical outcomes of dialysis are better in Japan than in other countries, but this may change given recent ESRD cost containment policies.      

The economics of end-stage renal disease care in Canada: incentives and impact on delivery of care

Examining international differences in health outcomes for end-stage renal disease (ESRD) patients requires an understanding of ESRD funding structures. In Canada, funding for all aspects of dialysis and transplant care, with the exception of drugs (for which supplementary insurance can be purchased), is provided for all citizens. Although ESRD programs across Canada’s 10 provinces differ in funding structure, they share important economic characteristics, including being publicly funded and universal, and providing most facets of ESRD care for free. This paper explains how ESRD care fits into the Canadian health care system, describes the epidemiology of ESRD in Canada, and offers economic explanations for international discrepancies.      

The financing and organization of medical care for patients with end-stage renal disease in Sweden

The total health care expenditure as a percentage of the gross domestic product in Sweden is 9.2%, and health care is funded by global budgets almost entirely through general taxation. The prevalence rate of end-stage renal disease (ESRD) in Sweden is 756 per million. Fifty-two percent of ESRD patients have a functioning transplant. Almost all ESRD treatment facilities are public. Compared with other Dialysis Outcomes and Practice Patterns Study (DOPPS) countries, the salaries for both nephrologists and professional dialysis unit staff are low. Sweden’s high cost per ESRD patient, relative to other DOPPS countries, may be a result of expensive and frequent hospitalizations and aggressive anemia treatment strategies.      

公立医院医生防御性医疗行为及其影响因素研究——基于广东省某市公立医院医生问卷调查的实证研究

在卫生政策研究领域,中国医疗费用的急剧上升和由供方诱导的需求已是众人皆知。然而,现有文献大多倾向于将普遍存在的过度医疗行为归因于医院和医生的逐利动机,但其实是由根植在中国医疗体系中扭曲的激励机制所造成的。本研究于2013年12月对广东省某市公立医院504名执业医师进行了问卷调查,发现过度医疗行为并不完全由经济诱因支配;医生防范医患纠纷的防御性医疗动机也在很大程度上导致了＂大处方＂和＂过度检查＂的防御性行为。回归分析发现,低收入和对于付出和回报落差的不满确实在很大程度上刺激了过度医疗行为。与此同时,医生过往的医患纠纷经历亦显著地影响其防御性医疗行为。本研究揭示了当下紧张的医患关系对于医生行为的重要影响,并就此提出相应的政策建议。     

Healthcare system performance in continuity of care for patients with severe mental illness: A comparison of five European countries

Most healthcare systems struggle to provide continuity of care for people with chronic conditions, such as patients with severe mental illness. In this study, we reviewed how system features in two national health systems (NHS) – England and Veneto (Italy) – and three regulated-market systems (RMS) – Germany, Belgium, and Poland –, were likely to affect continuing care delivery and we empirically assessed system performance. 6418 patients recruited from psychiatric hospitals were followed up one year after admission. We collected data on their use of services and contact with professionals and assessed care continuity using indicators on the gap between hospital discharge and outpatient care, access to services, number of contacts with care professionals, satisfaction with care continuity, and helping alliance. Multivariate regressions were used to control for patients’ characteristics. Important differences were found between healthcare systems. NHS countries had more effective longitudinal and cross-sectional care continuity than RMS countries, though Germany had similar results to England. Relational continuity seemed less affected by organisational mechanisms. This study provides straightforward empirical indicators for assessing healthcare system performance in care continuity. Despite systems’ complexity, findings suggest that stronger regulation of care provision and financing at a local level should be considered for effective care continuity.     

The organization and financing of kidney dialysis and transplant care in the United States of America

In the United States, end-stage renal disease (ESRD) patients are primarily insured by the publicly funded Medicare program. Compared to other countries in the International Study of Health Care Organization and Financing (ISHCOF), the United States has the highest health care expenditures for the general population and among ESRD patients. However, because the Medicare program is more influential in the market for ESRD-related services than for other medical services, ESRD price controls have been relatively stringent. Nonetheless, ESRD costs have grown substantially through increases in prevalence and use of ancillary services. Treatment costs are also controlled by the relatively high rate of transplantation. Proposed reforms include bundling more services into a prospective payment system, developing case-mix adjustments, and financially rewarding providers for quality.      

“Out of Our Crisis”: The Lack of Long-Term Relationships in the Provision of Managed Care

During the thirty-year period between 1965 and 1995, national healthcare expenditures rose significantly to a point where it became an untenable situation for any payer class: patient, employer, or government. Although managed care was offered as a conceptual framework for providing an opportunity for improving the health of the population while limiting the growth in expenditures, significant concern remained regarding the perceived quality of care and the underlying incentive structures. The author examines current healthcare incentive structures and proposes a structural model associated with long-term contracting to allow managed care to attain its intended objectives of enhanced quality and cost containment.     

Legal thoughts on the implications of cost-reducing guidelines for the quality of health care

Health care expenditures in European countries are increasing. Many cost containment mechanisms have been developed, one of which is the introduction of clinical practice guidelines in binding legislation. In developing recent patients' rights laws, many legislators refer to practice guidelines when specifying the right to quality in health care. The courts often follow this example. Initially, practice guidelines were used to improve the quality of care. Recently, their potential to reduce costs is being discovered by policy makers and compliance with the cost-controlling guidelines is mandatory and subject to financial sanctions. This article will question the impact of the 'new generation' guidelines aimed at reducing health care costs and their impact on the quality of care, in particular. The authors will analyse whether a physician, in case of a conflict with a patient, who claims that his right to quality care has been violated, can defend himself in court by stating that he complied with 'financially' inspired guidelines, especially now that non-compliance with these guidelines is sanctioned.     

International study of health care organization and financing: development of renal replacement therapy in Germany

The German health system represents the case of a global budget with negotiated fees and competing medical insurance companies. Physicians in private practice and non-profit dialysis provider associations provide most dialysis therapy. End-stage renal disease (ESRD) modalities are well integrated into the overall health care system. Dialysis therapy, independent of the mode of treatment, is reimbursed at a weekly flat rate. Mandatory health insurance covers health expenses, including those related to ESRD, for more than 90% of the population. Both employees and employers contribute to the premium for this insurance. Private medical insurance covers the remainder of the population. Access to treatment, including dialysis therapy, is uniformly available.