美國(guó)醫(yī)藥行業(yè)的偽難題

In all industries, monopolies and oligopolies limit choice and extract economic rent. In medicine, they do so when consumers are most vulnerable: often frightened, unable to forgo the product altogether, and dependent on experts in making decisions.

在所有的行業(yè)，壟斷和寡頭壟斷都會(huì)讓市場(chǎng)上的選擇變得有限并榨取經(jīng)濟(jì)租金。在醫(yī)藥領(lǐng)域，消費(fèi)者是在自己最脆弱的時(shí)候面對(duì)這種狀況的：這時(shí)的他們往往很害怕、無(wú)法徹底棄用這種產(chǎn)品，事事依賴專家作決定。

This month the London-based drugmaker Hikma increased the US price of one drug — a liquid form of a diarrhoea treatment — by 430 per cent. The drug is decades old and has no patent protection.

本月，總部位于倫敦的制藥商Hikma將一種液劑止瀉藥在美國(guó)的價(jià)格上調(diào)430%。這種藥物已問世幾十年，沒有專利保護(hù)。

Yet barriers to competition remain. A new manufacturer would need to win regulatory approval and secure production facilities. This is harder for liquid, inhalable, or injectable drugs than for pills. And the new entrant would receive only a fraction of the monopoly price. It is likely a lossmaking proposition.

然而競(jìng)爭(zhēng)壁壘仍然存在。一家新的制藥商需要獲得監(jiān)管批準(zhǔn)并取得生產(chǎn)設(shè)施。相對(duì)于片劑藥，這對(duì)于液劑藥品、吸入式藥品或注射用藥品而言更難。市場(chǎng)新入者的藥品價(jià)格將僅為壟斷價(jià)格的一小部分。這項(xiàng)計(jì)劃很可能會(huì)賠錢。

Hikma is not alone. In recent years several companies with effective monopolies on non-patented products have jacked up prices. Turing raised the price of a drug for cancer patients by 55-fold. Mylan pumped up the price of EpiPen, for bee-sting allergies, by 500 per cent over six years. Valeant, a one-time stock market darling, made price gouging a core strategy. The list goes on.

Hikma并非唯一這么做的企業(yè)。最近幾年，幾家對(duì)非專利產(chǎn)品擁有實(shí)際壟斷權(quán)的公司紛紛上調(diào)價(jià)格。圖靈制藥(Turing)把一種救命藥的價(jià)格上調(diào)至原來(lái)的55倍。邁蘭(Mylan)在6年里將蜂蜇過(guò)敏用藥EpiPen的價(jià)格上調(diào)了500%。一度為股市寵兒的Valeant將抬高價(jià)格作為核心戰(zhàn)略。這樣的例子還有很多。

In general, competition in non-patented drugs works very well. It is in products with high entry costs and relatively small target markets that gouging flourishes. Regulations make the problem worse: if distributors could import drugs from abroad when domestic prices spike, the monopolies could be broken. But they cannot.

總體而言，競(jìng)爭(zhēng)在非專利藥品領(lǐng)域很好地發(fā)揮著作用。出現(xiàn)大量提價(jià)行為的是那些前期成本高且目標(biāo)市場(chǎng)相對(duì)較小的藥品。監(jiān)管加劇了這個(gè)問題：如果分銷商在國(guó)內(nèi)價(jià)格飆升時(shí)可以從國(guó)外進(jìn)口藥品，壟斷可能會(huì)被打破。但它們不能。

Patented drug prices in the US are also inflated by regulations and perverse incentives. Consider Medicare, the government programme that pays for pensioners’ medications. It is required to pay for virtually every approved form of treatment for cancer and other life-threatening diseases, even when cheaper and therapeutically equivalent or near-equivalent treatments are available. This makes it impossible for the government to negotiate effectively on price. Many states have similar laws for private insurers, too. At the same time, Medicare pays doctors a percentage of the price of drugs they administer, giving them reason to prefer more expensive ones.

此外，監(jiān)管規(guī)定和不合理的激勵(lì)也提高了美國(guó)的專利藥品價(jià)格。舉個(gè)例子，為退休人員的用藥買單的“聯(lián)邦醫(yī)療保險(xiǎn)”(Medicare)，需要為幾乎所有癌癥和其他致命疾病的獲批治療方法買單——即便有時(shí)存在更廉價(jià)、同時(shí)效果相同或近乎相同的治療方法。這讓政府無(wú)法有效地進(jìn)行價(jià)格談判。很多州對(duì)私人保險(xiǎn)公司也有類似法規(guī)。同時(shí)，“聯(lián)邦醫(yī)療保險(xiǎn)”向開出其覆蓋范圍內(nèi)藥品的醫(yī)生提供藥價(jià)提成，這讓他們有理由青睞更昂貴的藥品。

Middlemen get in on the action. Pharmacy benefit managers (PBMs), which work on behalf of companies and insurance companies, negotiate discounts on drugs’ list prices. They then pass most of the savings on to their clients, keeping a portion for themselves.

中間人也“雁過(guò)拔毛”。代表制藥商和保險(xiǎn)公司的藥品福利管理機(jī)構(gòu)(PBM)就藥品上市價(jià)格的折扣進(jìn)行談判。它們隨后將大部分折扣讓渡給客戶，自己保留一部分。

They therefore have reason to secure bigger discounts — but because the discount is a percentage of the list price, they also have an interest in high list prices. If there was robust competition among PBMs this would be less of a problem. But after two decades of consolidation, with antitrust regulators sitting idle, three PBMs control nearly 80 per cent of the market.

它們因此有理由爭(zhēng)取更大折扣，但由于折扣是按藥品上市價(jià)格的比例計(jì)算的，上市價(jià)格高也符合它們的利益。如果PBM競(jìng)爭(zhēng)激烈，那就問題不大。但經(jīng)過(guò)20年的行業(yè)整合，再加上反壟斷監(jiān)管機(jī)構(gòu)不作為，3家PBM控制了近80%的市場(chǎng)份額。

The drug industry argues that if action were taken to lower US drug prices, the incentive to innovate would be diluted. This is a false dilemma. Outright price controls — or making the government the sole drug buyer — would hurt innovation. But much could be done to stiffen competition while maintaining rich rewards for real innovation.

制藥業(yè)辯稱，如果采取行動(dòng)降低美國(guó)藥價(jià)，創(chuàng)新動(dòng)力就會(huì)下降。這是一個(gè)偽難題。完全的價(jià)格控制——或者讓政府成為唯一藥品買家——將會(huì)損害創(chuàng)新。但在為切實(shí)創(chuàng)新維持豐厚回報(bào)的前提下，還可以采取許多措施來(lái)加劇競(jìng)爭(zhēng)。

Regulations that stifle competition are not only the result of regulatory capture. Americans demand paid access to whatever treatment they or their doctor prefer. Competition can only thrive when those who ultimately pay can decide which products are interchangeable and negotiate with manufacturers on that basis. The law should allow that to happen.

遏制競(jìng)爭(zhēng)的監(jiān)管法規(guī)不只是“監(jiān)管被俘”(regulatory capture)的結(jié)果。美國(guó)人要求保險(xiǎn)覆蓋他們或者他們的醫(yī)生青睞的任何治療方案。當(dāng)那些最終支付的人可以決定哪些產(chǎn)品可以互換并在此基礎(chǔ)上與制藥商談判的時(shí)候，競(jìng)爭(zhēng)才會(huì)如火如荼地展開。法律應(yīng)該為出現(xiàn)這種局面創(chuàng)造條件。