药品定价体制探讨

目前，尽管列入国家基本医疗保险药品目录的药品的价格已经一降再降，但人民群众看病贵的情况仍然没有太大的改观，其中重要的原因就是我国缺乏明确的药品定价政策以及合适的定价方法。对此，笔者就国外各种药品定价体系及其特点进行分析归类，旨在寻找适合我国国情的药品定价体系     

影响药品招标采购政策实施效果及满意程度的多因素分析

采用定性、定量相结合的方法筛选出影响药品招标采购政策实施效果及满意程度的主要因素为：政府职能的有效发挥、网络招标、中介组织实施能力、药品定价合理程度、药品企业规范性以及药品采购相关政策本身的完善程度等。提出规范药品流通领域的关键在于政府职能的有效发挥和药品的合理定价。     

法国药品定价及其补偿机制对我国的启示

对法国的药品定价方法和药品费用偿付政策进行介绍,阐述了与之相关的公共药品支出控制措施,提出了对我国药品定价与补偿政策调整及药品费用控制等方面的一些启示。     

药品集中带量采购政策对药品利用与支出的影响分析

目的:分析药品集中带量采购政策对于药品利用与支出的影响。方法:利用2018—2019年的药品采购数据,采用双重差分模型比较了集采品种和同类替代非集采品种的价格、采购量、采购金额、质优药品的使用比例在药品集中带量采购政策实施后的变化。结果:药品集中带量采购试点政策实施后,与未实施试点政策的省份相比,实施试点政策或部分实施试点政策的省份集中采购试点品种的标化价格下降72.2%,标化采购量增加16.9%,采购费用下降55.3%,质优药品的使用比例增加15个百分点(均为P<0.01)。尚未发现集采品种的采购向同类替代非集采品种转移的证据。结论:药品带量集采政策有利于药品支出的控制和用药质量水平的提升,有必要扩大药品带量集采的覆盖面,尽快将中成药和生物类似药纳入集采之中。     

部分发达国家药品价格管制政策比较及启示

目的：分析比较主要发达国家的国家药品价格政策或措施，为我国药品定价政策改革提供建议。方法：文献综述和比较法。内容：法国、德国、英国等国家药品价格政策的实施、优缺点等。结果：国家药品价格政策实施具有综合性；政策的因地制宜；影响药品费用的多因素性；政策实施效果的有限性；直接控制的国家比间接控制的国家药品价格水平低。建议：药品价格改革必须与医疗保险等改革配套；采取多种费用控制措施；药品价格改革不应损害本国医药产业的健康发展；充分考虑政策对卫生服务供方的影响，尤其是对医生既得利益的影响。     

基于利益相关方分析的药品集中采购政策实施影响效应研究 ——以河南省为例

药品集中采购政策的实施有助于社会医药资源的合理配置、规范医疗机构和医生的诊疗行为、降低药品价格、减轻患者的就医负担,并能够降低医保资金支出的过快上涨带来的医保基金压力.基于河南省药品集中采购政策的实施现状,从利益相关方的角度分析药品集中采购流程中的四个阶段,总结药品集中采购政策实施对政府机构及相关部门、医疗机构和医生、...     

国际药品价格管制方式及效果研究的系统综述

目的：分析国际药品价格管制方式及效果。方法：采用系统综述的方法归纳不同国家药品价格管制方式、对象、过程及效果。结果：共纳入来自36个国家的130篇文献,其中包括定价管制政策文献97篇,评价定价管制影响文献33篇,且多为评价参考定价效果研究。大多国家主要对报销药品价格进行控制;国家价格比较和参考定价是两种最主要的政府定价方式;药品加成采用递减加成体系;现有证据表明参考定价对于降低药品价格、节省药品开支和对其他卫生服务的影响效果较好。建议：以药物经济学评价为基础,通过参考定价对药品报销价进行有效管制,通过协商谈判、递减加成和完善医保支付方式来控制药品费用不合理增长。     

部分发达国家药品价格管制政策比较及启示

目的分析比较主要发达国家的国家药品价格政策或措施,为我国药品定价政策改革提供建议.方法文献综述和比较法.内容法国、德国、英国等国家药品价格政策的实施、优缺点等.结果国家药品价格政策实施具有综合性;政策的因地制宜;影响药品费用的多因素性;政策实施效果的有限性;直接控制的国家比间接控制的国家药品价格水平低.建议药品价格改革必须与医疗保险等改革配套;采取多种费用控制措施;药品价格改革不应损害本国医药产业的健康发展;充分考虑政策对卫生服务供方的影响,尤其是对医生既得利益的影响.     

怎样发挥药品集中招标采购的作用

为了规范医院药品采购行为，降低药品虚高定价，全国各地相继出台了药品集中招标采购政策，在一定程度上减轻了患者的负担，取得了初步成效。但同时也应该承认，社会期望值很高的药品集中招标采购工作，在治理药品购销不正之风和降低药价方面并没有达到预期的效果。笔者认为，要充分发挥药品集中招标采购的作用，就必须完善相应的配套政策，本文就此提出一些粗浅的看法。     

WHO药品定价方法在我国中成药医保定价中的应用与启示

WHO于2020年发布的WHO国家药品定价政策指南中提到的10种定价方法是国际常用的定价方法。但由于中成药成本构成比例的特殊性,单纯参照化药及生物药品制品对中成药进行定价存在适用性偏差。当前,我国药品定价主要方法为内部参考定价、招标谈判定价、促进使用有质量保证的仿制药和生物类似药、汇总采购等方法。文章在系统分析各种定价方法的基础上,明确其对于中成药医保定价的适用性及其原因,其中价值定价和提高价格透明度的方法有助于提高中成药医保定价的合理性。     

Perspectives of physicians practicing in low and middle income countries towards generic medicines: A narrative review

Objectives

This review was conducted to document published literature related to physicians’ knowledge, attitudes, and perceptions of generic medicines in low- and middle-income countries (LMICs) and to compare the findings with high-income countries.

Methods

A systematic search of articles published in peer-reviewed journals from January 2001 to February 2013 was performed. The search comprised nine electronic databases. The search strategy involved using Boolean operators for combinations of the following terms: generic medicines, generic medications, generic drugs, generic, generic substitution, generic prescribing, international non-proprietary, prescribers, doctors, general practitioners, physicians, and specialists.

Results

Sixteen articles were included in this review. The majority (n = 11) were from high income countries and five from LMICs. The main difference between high income countries and LMICs is that physicians from high income countries generally have positive views whereas those from LMICs tend to have mixed views regarding generic medicines. Few similarities were identified among different country income groups namely low level of physicians’ knowledge of the basis of bioequivalence testing, cost of generic medicines as an encouraging factor for generic medicine prescribing, physicians’ concerns towards safety and quality of generic medicines and effect of pharmaceutical sales representative on generic medicine prescribing.

Conclusion

The present literature review revealed that physicians from LMICs tend to have mixed views regarding generic medicines. This may be due to differences in the health care system and pharmaceutical funding system, medicine policies, the level of educational interventions, and drug information sources in countries of different income levels.     

Transnational tobacco companies and the mechanism of externalization: A realist synthesis

Externalization theory assumes that risks and costs are systematically displaced from high-income countries (HICs) to low- and middle-income countries (LMICs). We review how and why transnational tobacco companies (TTCs) influence the local circumstances of LMICs that trigger externalization mechanisms, leading to tobacco-attributable risk outcomes. Our realist synthesis of scientific evidence and gray literature identifies externalization mechanisms with risk outcomes at the level of health policy, smoking trends, and tobacco production. The results reveal the mediating role of local and global third parties and intermediaries. Externalization mechanisms produce systematic tobacco-attributable inequalities between places located in HICs and those located in LMICs.     

The level of income appears to have no consistent bearing on pharmaceutical prices across countries

A generally accepted view is that it is more efficient and ethical if global pharmaceutical prices vary according to countries' relative income. To understand manufacturers' pricing strategies, we compared average pharmaceutical prices in fourteen middle-income countries to those in three high-income countries and a low-income region in western Africa from 1999 through 2008. We found that some middle-income countries pay more for pharmaceuticals than high-income countries--for example, prices in several middle-income countries exceeded those in the United Kingdom for some years of the study period. Other middle-income countries paid less than low-income countries--for example, average prices in India were consistently below prices in western Africa. These variations suggest that we need new policies on pharmaceutical pricing to improve access to pharmaceuticals around the world.     

The role of economic evaluation in the pricing and reimbursement of medicines

In most countries, governments or health insurers have taken initiatives to influence the price and utilization of medicines. One stated objective of these schemes is to encourage efficiency, or cost-effectiveness. In principle, economic evaluation should to be relevant to decisions about the pricing and reimbursement of health technologies, since it offers a way of estimating the additional value to society of a new intervention (e.g. medicine) relative to current therapy. However, the application of economic evaluation in drug pricing and reimbursement schemes is variable. Therefore, this paper reviews the actual and potential role of economic evaluation in different drug pricing and reimbursement schemes, such as 'free pricing' systems (United Kingdom, United States), two-stage administered systems (France), reference pricing systems (Germany, Netherlands, Sweden) and economic evaluation systems (Australia, Canada). It is concluded that, other than in the case of Australia and Canada, the potential role of economic evaluation could be greatly developed, especially in the case of new medicines, for which there is no close substitute. Comments are also given on the practical problems of using this approach. However, it is noted that economic evaluation alone cannot set a price for a medicine, since a decision has to be made about the proportion of added value going to society and the proportion going to the pharmaceutical company as a reward for innovation.     

Trust in health care: theoretical perspectives and research needs

PURPOSE: This paper presents some key theoretical issues about trust, and seeks to demonstrate their relevance to understanding of, and research on, health systems. Although drawing particularly on empirical evidence from low- and middle-income countries (LMICs), the paper aims to stimulate thinking across country settings. DESIGN/METHODOLOGY/APPROACH: Drawing both on conceptual literature and relevant empirical research from LMICs, the paper presents an argument about the role of trust within key health system relationships and identifies future research needs. FINDINGS: Theoretical perspectives on four questions are first discussed: what is trust and can it be constructed? Why does it matter to health systems? On what is it based? What are the dangers of trust? The relevance of these theoretical perspectives is then considered in relation to: understanding the nature of health systems; issues of equity and justice in health care; and policy and managerial priorities. The identified research needs are investigation of: the role of trusting workplace relationships as a source of non-financial incentives; the influence of trust over the operation of different forms of citizen-health system engagement; approaches to training trustworthy public managers; and the institutional developments required to sustain trustworthy behaviour within health systems. PRACTICAL IMPLICATIONS: The policy and management actions needed to strengthen health systems within LMICs, and elsewhere, include: recruitment of health workers that have the attitudes and capacity for moral understanding and motivation; training curriculae that develop such motivation; and developing the institutions (e.g., communication and decision-making practices, payment mechanisms) that can sustain trusting relationships across a health system. It is also important to recognise that distrust in some relationships may act to guard against the abuse of power. ORIGINALITY/VALUE: Although the notion of trust has become of increasing importance in health policy debates in high-income countries, it has received less attention in the context of LMICs. The papers adds to the very limited literature on trust in LMIC health systems and also opens new lines of thinking for those working in high income countries--particularly around the role of health systems in generating wider social value.     

Differential Pricing for Pharmaceuticals: Reconciling Access, R&D and Patents

This paper reviews the economic case for patents and the potential for differential pricing to increase affordability of on-patent drugs in developing countries while preserving incentives for innovation. Differential pricing, based on Ramsey pricing principles, is the second best efficient way of paying for the global joint costs of pharmaceutical R&D. Assuming demand elasticities are related to income, it would also be consistent with standard norms of equity.To achieve appropriate and sustainable price differences will require either that higher-income countries forego trying to import low drug prices from low-income countries, through parallel trade and external referencing, or that such practices become less feasible. The most promising approach that would prevent both parallel trade and external referencing is for payers/purchasers on behalf of developing countries to negotiate contracts with companies that include confidential rebates. With confidential rebates, final transactions prices to purchasers can differ across markets while manufacturers sell to distributors at uniform prices, thus eliminating opportunities for parallel trade and external referencing.The option of compulsory licensing of patented products to generic manufacturers may be important if they truly have lower production costs or originators charge prices above marginal cost, despite market separation. However, given the risks inherent in compulsory licensing, it seems best to first try the approach of strengthening market separation, to enable originator firms to maintain differential pricing. With assured market separation, originators may offer prices comparable to the prices that a local generic firm would charge, which eliminates the need for compulsory licensing.Differential pricing could go a long way to improve LDC access to drugs that have a high income market. However, other subsidy mechanisms will be needed to promote R&D for drugs that have no high income market.     

Value innovation: an important aspect of global surgical care

Introduction

Limited resources in low- and middle-income countries (LMICs) drive tremendous innovation in medicine, as well as in other fields. It is not often recognized that several important surgical tools and methods, widely used in high-income countries, have their origins in LMICs. Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these succesful innovations and their origins that have had an important impact in healthcare delivery worldwide.

Review

Examples of LMIC innovations that have been adapted in high-income countries include the Bogotá bag for temporary abdominal wound closure, the orthopaedic external fixator for complex fractures, a hydrocephalus fluid valve for normal pressure hydrocephalus, and intra-ocular lens and manual small incision cataract surgery. LMIC innovations that have had tremendous potential global impact include mosquito net mesh for inguinal hernia repair, and a flutter valve for intercostal drainage of pneumothorax.

Conclusion

Surgical innovations from LMICs have been shown to have comparable outcomes at a fraction of the cost of tools used in high-income countries. These innovations have the potential to revolutionize global surgical care. Advocates should actively seek out these innovations, campaign for the financial gains from these innovations to benefit their originators and their countries, and find ways to develop and distribute them locally as well as globally.