Cervellino Juan C, Corazza Sandra B, Bignone Inés M I, Fligman M Diana, Figueroa Silvana, Roldán Rubén, Morici Pablo, Diez Roberto A
National Institute of Social Services for Retirees and Pensioners, Department of Medicines, Buenos Aires, Argentina.
Rev Panam Salud Publica. 2003 Apr;13(4):203-13. doi: 10.1590/s1020-49892003000300002.
The National Institute of Social Services for Retirees and Pensioners (NISSRP) is a nationwide health care financing agency and service provider in Argentina. Among its services, the NISSRP provides outpatient drug coverage to more than 3.3 million beneficiaries, mainly senior citizens and disabled persons. In 1997, to help cope with its rising costs, the NISSRP agreed to transfer the risk for the cost of outpatient medications and cancer-treatment drugs to a consortium of pharmaceutical companies in exchange for a fixed monthly payment. The objective of this study was to determine the impact that this new approach had on three things: (1) the level of expenditures for the medicines that were included in the agreement, (2) the pattern of nonrational prescribing for NISSRP beneficiaries, and (3) this pattern's relationship with macroeconomic variables and the pattern of prescribing for Argentina as a whole.
We compared outpatient-medicine consumption in 1999 with consumption before the agreement went into effect.
The actual amount that NISSRP beneficiaries spent out-of-pocket climbed from US$ 336.13 million in 1996 to US$ 473.36 million in 1999, an increase of almost 41%. The nominal amount "spent" by the NISSRP in 1999 was US$ 601.11 million, versus a real amount of US$ 374.75 million in 1996, an "increase" of 60% (that increase for the NISSRP was only theoretical since the agreement specified the fixed monthly amount that the NISSRP would have to pay to the pharmaceutical consortium). In contrast with the increased real spending by NISSRP beneficiaries, Argentina's economy remained stable over the assessed period, with the consumer price index even falling by 0.8%. We found high levels of nonrational drug use in the NISSRP system in both 1996 and 1999, indicating a serious ongoing problem.
An agreement with pharmaceutical companies, like the one we have described, might add an element of financial predictability for institutions such as the NISSRP. However, such an agreement can easily result in an increased economic burden for health care beneficiaries, and without any improvement in the services that they receive. This type of agreement requires extensive mechanisms for control, follow-up, and updating, and it also risks making nonrational drug prescribing the accepted rule. While perhaps feasible, the requirements for this kind of agreement are actually very difficult to put into place, requiring additional efforts from institutions such as the NISSRP.
阿根廷国家退休人员和养老金领取者社会服务研究所（NISSRP）是一家全国性的医疗保健融资机构和服务提供商。在其服务中，NISSRP为超过330万受益人提供门诊药物保险，主要是老年人和残疾人。1997年，为帮助应对成本上升问题，NISSRP同意将门诊药物和癌症治疗药物成本风险转移给一个制药公司财团，以换取每月固定付款。本研究的目的是确定这种新方法对以下三件事的影响：（1）协议中所涵盖药物的支出水平；（2）NISSRP受益人的不合理用药模式；（3）这种模式与宏观经济变量以及阿根廷整体用药模式的关系。
我们将1999年的门诊药物消费与协议生效前的消费进行了比较。
NISSRP受益人自掏腰包的实际支出从1996年的3.3613亿美元攀升至1999年的4.7336亿美元，增长了近41%。1999年NISSRP“支出”的名义金额为6.0111亿美元，而1996年的实际金额为3.7475亿美元，“增长”了60%（NISSRP的这种“增长”只是理论上的，因为协议规定了NISSRP每月必须向制药财团支付的固定金额）。与NISSRP受益人实际支出增加形成对比的是，在评估期内阿根廷经济保持稳定，消费价格指数甚至下降了0.8%。我们发现1996年和1999年NISSRP系统中都存在高度的不合理用药情况，这表明这是一个持续存在的严重问题。
与制药公司达成的协议，如我们所描述的这种，可能会为NISSRP等机构增加财务可预测性的因素。然而，这样的协议很容易给医疗保健受益人带来经济负担的增加，而他们所获得的服务却没有任何改善。这种类型的协议需要广泛的控制、跟进和更新机制，并且还存在使不合理用药成为公认规则的风险。虽然也许可行，但这种协议的要求实际上很难落实到位，需要NISSRP等机构付出额外努力。
