Kane N M
Harvard School of Public Health, Boston, MA 02215, USA.
Health Policy. 1997 Sep;41 Suppl:S71-89. doi: 10.1016/s0168-8510(97)00048-1.
In the United States, government has played a limited role in containing the costs of pharmaceuticals. There are no price controls, no national drug formularies, no universal cost-sharing policies, and perhaps most important, no national coverage of prescription drugs. Rather, pharmaceutical cost containment was historically left to private insurers and managed care companies, while consumers paid out of pocket for close to 62% of all drug expenditures. US utilization has historically been relatively low and prices by far the highest of the four industrialized countries. The major change in pharmaceutical cost containment in the 1990s has been the consolidation of purchaser power at the level of the insurer and managed care companies. These 'whole sale' purchasers now represent 70% of direct manufacturer sales, and they are demanding and receiving deeper price discounts. Meanwhile these same players are implementing formulary policies, utilization controls, and disease management programs, the outcomes of which have not yet been systematically evaluated. Failure to pass on savings to consumers, cost shifting by manufacturers to vulnerable consumer groups, and potential under-utilization of cost-effective drugs remain of concern.
在美国，政府在控制药品成本方面发挥的作用有限。没有价格管制，没有国家药品处方集，没有普遍的成本分摊政策，也许最重要的是，没有国家处方药覆盖范围。相反，药品成本控制在历史上一直由私人保险公司和管理式医疗公司负责，而消费者自掏腰包支付了近62%的药品总支出。美国的药品使用量在历史上一直相对较低，而价格却是四个工业化国家中最高的。20世纪90年代药品成本控制的主要变化是在保险公司和管理式医疗公司层面上购买方权力的巩固。这些“批发”购买方现在占制造商直接销售额的70%，他们要求并获得了更大幅度的价格折扣。与此同时，这些参与者正在实施处方集政策、使用控制和疾病管理计划，其结果尚未得到系统评估。未能将节省的费用转嫁给消费者、制造商将成本转嫁给弱势消费群体以及可能对高性价比药品使用不足等问题仍然令人担忧。
