第三方报销仿制药：在最高限价成本报销环境下，低于成本的报销盛行。

Third-party reimbursement for generic prescription drugs: The prevalence of below-cost reimbursement in an environment of maximum allowable cost-based reimbursement.

出版信息

J Am Pharm Assoc (2003). 2018 Jul-Aug;58(4):421-425. doi: 10.1016/j.japh.2018.04.018. Epub 2018 May 31.

DOI:10.1016/j.japh.2018.04.018

Abstract

OBJECTIVES

To examine average prescription gross margin (GM) for prescriptions and to evaluate the prevalence of below-cost reimbursement for generic prescriptions across different third-party payers and therapeutic categories.

DESIGN

A retrospective descriptive study using 2015 dispensing data from a single independently owned pharmacy in Iowa. To calculate GM, the pharmacy's actual acquisition cost was subtracted from the third-party reimbursement rate for each generic prescription. The frequency of negative GMs was calculated for the top 6 plans and the top 10 therapeutic categories by prescription volume.

SETTING

A single, independently owned community pharmacy in Iowa.

PARTICIPANTS

Prescription dispensing records for the pharmacy's largest private and public payers by prescription volume.

INTERVENTION

Gross margins were calculated on a payer and United States Pharmacopeia (USP) medication category level.

MAIN OUTCOME MEASURES

GM for generic prescriptions reimbursed under cost for specific payers and USP medication categories.

RESULTS

The 2015 prescription volume for the study pharmacy was 70,866 prescriptions, of which 88% were generic. For all prescriptions, the mean GM was $6.63 per prescription, and the median GM was $3.49 per prescription. Generic medications had a mean GM of $4.66 (median, $2.86), and brand name medications had a mean GM of $21.83 (median, $16.15). The percentage of generic prescriptions paid below acquisition cost was 15.1% overall and ranged from 4.1% for Iowa Medicaid to 25.9% for one of the private payers. The most common USP medication category by prescription volume was cardiovascular agents, representing 25.2% of generic prescriptions. For the 10.9% of these prescriptions reimbursed below cost, the mean GM was -$6.80. The 2 USP medication categories with the largest negative mean GM for generic prescriptions were analgesics and anticonvulsants, with mean GMs of -$10.10 and -$11.30, respectively.

CONCLUSION

The current maximum allowable cost-based reimbursement system often results in inadequate payment for generic prescription drugs. The amount of underpayment varies substantially by payer and therapeutic class.

摘要

目的

考察处方的平均处方毛利（GM），并评估不同第三方支付者和治疗类别中通用处方的成本补偿率。

设计

这是一项回顾性描述性研究，使用爱荷华州一家独立拥有的药店 2015 年的配药数据。为了计算 GM，从每个通用处方的第三方报销率中减去药店的实际收购成本。根据处方量，计算了前 6 个计划和前 10 个治疗类别的负 GM 频率。

地点

爱荷华州的一家独立社区药店。

参与者

根据处方量，该药店最大的私人和公共支付者的配药记录。

干预措施

按支付者和美国药典（USP）药物类别级别计算毛利。

主要观察指标

特定支付者和 USP 药物类别下按成本报销的通用处方的 GM。

结果

研究药店 2015 年的处方量为 70866 张，其中 88%为通用处方。对于所有处方，平均 GM 为每张处方 6.63 美元，中位数 GM 为每张处方 3.49 美元。通用药物的平均 GM 为 4.66 美元（中位数，2.86 美元），品牌药物的平均 GM 为 21.83 美元（中位数，16.15 美元）。总体而言，通用处方支付低于收购成本的比例为 15.1%，范围从爱荷华州医疗补助计划的 4.1%到其中一个私人支付者的 25.9%。按处方量计算最常见的 USP 药物类别是心血管药物，占通用处方的 25.2%。对于这些按成本补偿的处方中有 10.9%，平均 GM 为-6.80 美元。对于通用处方平均 GM 为负的最大的 2 个 USP 药物类别是镇痛药和抗惊厥药，平均 GM 分别为-10.10 美元和-11.30 美元。