【作者】 厉李；

【导师】 李野；

【作者基本信息】 沈阳药科大学 ， 药事管理学， 2009， 博士

【摘要】 药品费用的快速增长是世界各国面临的难题,我国同样面临这样的问题。“看病难,看病贵”已然成为民生问题之一,这其中药品费用过高占有很大的比例,在我国综合医院中药品费用一度占到医疗费用比重的52%左右,目前仍然占到大约40%的比例。我国在1999年到2008年住院病人人均医疗费用和药品总费用,增长速度分别是8%和7%左右。2008年我国的次均医疗费用为146.5元,比1995年的39.9元提高了3.67倍,比2000年提高了60.6元,次均药品费用在2008年已经达到74.0元,高出1995年48.6元,高出2000年23.7元。药品费用在一定幅度上的增长是合理的,随着经济的发展和居民收入的增加,整个社会对医疗服务需求的增长必然加快;人口增长与老龄化、疾病谱的改变和医学模式的转变、科学技术进步等因素必然会拉动医药费用的较快增长。但是,由于补偿机制的不完善所产生的“以药养医”的问题,药品流通中的不正当竞争手段产生的“药价虚高”问题,以及医生对病人的不合理用药问题所产生的费用增长才是最为严重的。药品费用的有效控制可以降低总的医疗费用,使有限的卫生资源提供更多更好的医疗卫生服务,优化卫生资源的配置;可以提高医疗服务的公平性和可及性,让人人享有基本的医疗服务和药品需求;可以实现个人、政府、医疗保险机构支付医疗费用的降低,减轻经济负担。因此要解决我国“看病难,看病贵”的问题,其中非常重要的就是要控制药品费用的问题,如何建立良好的机制合理的控制药品费用成为我国医疗体制改革中的关键问题。由于药品本身的特殊性和经济特性使控制药品费用非常困难。目前,我国对于药品费用的研究也与日俱增,但真正对我国药品费用的影响因素和控制机制进行定性、定量、全面的研究还为数不多。本研究力图从经济学观点出发,分析一个国家的药品生产、采购、分配、消费的经济形势,找出解决问题的主要矛盾,按照经济学的理论和原则指导控制药品费用政策的制定与实施,组织药品消费的筹资和管理,综合运用经济学和社会学等相关理论,以及国内外先进的定量研究方法,为药品费用的研究提供一个比较完善的范本,接轨于国际相关研究。本研究通过基于北京、佛山、昆明三市的药品消费数据进行药品费用影响因素分析发现药品消费数量与药品价格和新药的引入同样是非常重要的影响因素,而不能仅仅考虑药品价格政策,而忽视对药品消费使用数量的控制。对药品消费中的相关利益方及其博弈进行分析,发现医生处于重要的地位,他既具有帮助和代替药品需求方选择药品的权利,又是医疗机构销售药品的中介。可以说医生具有双重身份,既是需方,又是供方,控制医生的处方种类和处方数量是控制药品费用的关键所在。研究中还发现如果没有人监督医生的诱导需求行为,病人因无法识别医生的诱导需求而不加选择地雇用医生,则无论病人给医生多高的工资,也无法控制医生诱导需求的行为。目前的医疗体制更是促进药费猛涨的添加剂:“以药养医”的补偿制度,药品流通环节的杂乱无序,医疗保险制度的不完善,医疗机构的薪酬制度等都成为了药品费用不合理增长的土壤。在理论研究的基础上,本研究结合了国外的药品费用控制经验并具体分析各个政策的理论和实践,而后对我国的药品费用控制政策进行分析和评述。药品费用控制的理论基础包括了政府对价格的规制理论,信息不对称理论,供方诱导需求理论和医患委托代理理论,而第三方支付方的介入是药品费用控制的最佳主体,改变了医患双方的关系,成为药品处方监督和价格谈判强有力的主体。关于药品费用控制的国内外经验,本研究分析了国外的药品价格政策、参考价格制度、药品费用共付制度和药物经济学的应用。我国的政策评价包括了药品降价政策、药品零差率政策和药品招标采购政策。研究的最后提出了药品费用的控制机制的综合框架,并在微观和宏观层面提出了若干具体的政策建议,微观上对控制关键点医生行为要从约束和激励两方面入手,宏观上,从药品市场的供方和需方入手,有效控制价格虚高和用量不合理,进而控制药品费用的不合理增长,以改善和解决目前的医生处方药品的价格高和数量多的问题,有助于分析和解决医疗改革中的现实问题,缓解药品费用不断高涨的问题和老百姓“看病贵”的问题,让有限的卫生资源更加合理的应用。更多还原

【Abstract】 Pharmaceutical expenditure rapidly rising is a difficult problem that many countries have confronted with,China is not exceptional.Difficult Medical Services and Expensive Medical Cost has became one of the Three Livelihood Problems,and pharmaceutical cost accounted for a large propotion.Because pharmaceutical expenditures had contributed for above eighty percent of health care expenditures ever before,visibly higher than other countries,and recently,it also contribute for above forty percent in general hospitals in China. The growth rate of total pharmaceutials expenditure is about twenty to thirty percent. Pharmaceutical expenditure growth would reasonably speed up in certain extent,as economic developing and residents’ income rising,the health service demand rising.Population increasing and aging,change of disease spectrum and medical model,science and technology innovation inevitably would make the medical expenditure increase rapidly.But,it is severity that the inperfect compensation mechanism problem,pharmaceutical circulation complexity and irrational drug use produced the expenditure increase.And the efficient control of pharmaceutical expendture could reduce the health expenditure,optimize the health resouce, improve the equity and acquirablity of health sevices and lighten people’s burden.So the key to settle the problem of difficult medical services and expensive medical is to settle the rapid increasing of drug expenditure.How to constitute a efficient mechanism to control the drug expenditure irritionality increasing has been a stricking point of health care reform.It is more difficult to control drug expenditure in most countries,because of the particularities of drug and economic particularities of drug market.More researchers expanded the research about drug expenditure,but few carried out qualitative analysis, quantitive analysis and comprehensive research.This research will try to base on economic theory,to analysis the drug produce,perchase,distribution and consumption in our country, according to the principle to rudder the establishion and implemention of governmental policies and to organize capital collection and management of drug consumption.It will provide a relative perfect sample of drug expenditure research that integratively use economic and society theories and more advance research methods. Fistly,the research analysed the relational parts in drug market and their gaming,and finded that the doctor was in a most important status,he can help and replace the demand part to chose the drug,and become the agency of hospital to sale the drugs.We can say he has a double status that was demand part and suply part of drug market.So we could control the generics and quantitis of drug in doctors’ prescription to reach the aim to control the drug expenditure.The research also found that if there was no one to supervise the doctors’ induce demand behaviors,and the patients choiced the doctor because they could not identify the doctors’ hehaviors,the doctors’ behaviors would not be controlled.The faulty health care system made the drug expenditure increase more severity.And also people mostly care the drug price policies.From the research that drug expenditure affective facors modol according to the drug consuming of three cities,we find that the quantity and introduce new drug is as important facors as the price factor,so we can’t consider the price policies only,but to igore controling drug consuming quantity.The research based on the drug expenditure control theories,combined many contries’ experiences,and analysed the theories and practises,and then construed the policies in China. This research figured the economic theories including government drug price restrict, information asymmetry theory,supply part inducement theory and principal-agent theory. The third party interpositon is the optimal control principal part,it changes the relationship of doctor and patient,becomes the strong part to supervise the prescription and to negotiate drug price.Concerning the international experience of pharmaceutical expenditure control,this research emphasized to analyse drug price policy,reference price program,co-payment of pharmaceutical expenditure and pharmacoeconomics application.Chinese polycies include depreciate drug price,zero added drug price,and incite public bidding and stock.Finally it is puted forward that an integrative frame of drug expenditure control mechanism,and proposed many suggestions.We should proceed with inspirit and inhibit doctors’ behaviors in microcosmic arrangement and control the suply and demand part of drug market in mocrocosmic arrangement to control the quantity and price irrationality,it will help us to analyse and setle the realistic problems,and to rationally use the limited resourse.更多还原