Monday, March 18, 2019

Why are medicine prices so high?



Two weeks ago, the Employees Provident Fund (EPF) published “Belanjawanku” (My Budget), an expenditure guide for individuals and families living in the Klang Valley. It has generated some debate amongst the Malaysian public, with most doubtful of the fact that it is possible for a single youth to rent a room for only RM300 in the area. There was, however, no real public discourse on the RM30 budgeted for healthcare. Leaving aside those who have either purchased private health insurance or have health issues, respondents must be feeling very healthy and optimistic, and consequently likely did not think of allocating much of a health budget. RM30 would not be sufficient to secure any private insurance plan.

Granted, treatment for minor illnesses would likely be affordable under such a budget. This isn’t the case for more serious ailments, however. The 2019 Global Medical Trend Rates Report published by Aon, an international professional services consultant firm, forecasts net growth of 13.6% in Malaysia’s medical inflation rates for current year – almost 5.7 times the forecast for inflation in general (Figure 1). The 2017 Malaysia National Health Expenditure findings also indicate that expenditure on medical goods already comprised 8%, or RM4.55 billion, of total health expenditure. This is a conservative calculation, one which does not include similar expenditures for inpatients.


Source: “2019 Global Medical Trend Rates Report”, Aon


The federal government in 2017 provided approximately RM2.4 billion for the procurement of medical drugs. This took up 10% of the total MOH budget in 2017. This expenditure item saw an increase of 13% relative to the preceding year, but medical supply shortages remain a problem in some public clinics and government hospitals - especially during the end of the year. This implies that the demand for public medical supplies still exceeds supply.

Unlike ordinary commodities, such as soft drinks where consumers are spoilt with choices and could have always opt out from purchasing such products, the purchase of medicine is entirely different. Under normal circumstances, patients are left with no choice but to seek treatment, particularly if their illness demands immediate attention. There are no alternative products to very specific drugs, especially when originator drugs are still under the patent protection period. This further limits the choices of patient seeking alternative medicine. What really makes the difference is the phenomenon of asymmetric information within medicine, where the judgments and drug prescription decisions of doctors and pharmacists dictate or limit the choices a patient faces.

Some are led to believe that originator drugs must be more superior than generics in terms of quality, efficacy and safety, and are therefore willing to pay a much higher price for the originator even if they were told about the existence of its generic counterpart. In Malaysia, after the successful registration of a drug patent, a product will usually enjoy a period of 20 years of market exclusivity. When the originator drug is still under intellectual property protection, it may be the market’s only option for a particular disease, and this is when the price a drug can fetch is usually at its peak. Originator drug manufacturers normally consider the cost of drug production – including investment in R&D – and operating costs (including marketing), stakeholders’ interests, as well as consumers’ purchasing power and their willingness to buy the drug in a particular country, before they set the final price tag for their product.

The reality is that generic drugs have the same active pharmaceutical ingredient, dosage, administration route and functional effectiveness as originator drugs. It is only when the patent for the originator drug has expired that generic drugs are approved to be sold in the market. The production cost and sale price of generic drug is generally significantly lower than that of the originator, even if the latter would later adjust their price to compete with the generic alternative.

According to the Medicine Prices Monitoring 2017 report, the final retail prices for generics are on average 3 times cheaper than originators. Consequently, price-sensitive consumers typically choose generics. In 2017, the average availability of generics in the public sector was 74.8% compared to originators (19.4%) (Figure 2). This is in line with the national medicine policy which encourages the use of generic medicines. However, the private sector has a tendency to use originators more often, with an average availability of 52.2%. 



Source: Medicine Prices Monitoring 2017, Ministry of Health 

In neighbouring Philippines, the law stipulates that the doctors and pharmacists must provide at least two generics (if they do exist) to accompany a prescription of an originator drug. This approach expands the availability of drug choices for patients.
In a normal medicine supply chain, drugs are produced by the manufacturer, ordered and shipped by importers, before changing hands to wholesalers or distributors who are in charge of the delivery of the products to the retailers (hospitals, clinics and pharmacies). Finally, they will reach the hands of patients or consumers. Due to the many levels of transactions within the supply chain, drug prices are inadvertently marked up at every level. Public healthcare system eschews the final retail-level mark-up, as our public healthcare system is tasked with providing medicine to the needy at almost zero cost.
Malaysia has a pharmaceutical manufacturing sector which produces almost entirely generic drugs, with sales revenue amounting to only a quarter of the total revenue of the pharmaceutical industry in 2014-2015. Some 61 percent of drugs (of equivalent revenue value) are imported, and amongst those, 87 percent of revenues were in the hands of local proxy companies for the big multinational pharmaceutical manufacturing companies. The top five companies take 47 percent of total medicinal imports, and importantly, these big multinational pharmaceutical parent companies get to decide the drug prices across countries, and they normally sell originator drugs.
Although local importers and sales proxies representing the top five multinational pharmaceutical companies did not have a big net profit margin (in between 1.6 and 3.4 percent), the average net profit margin for their parental companies is 26.2 percent - about 10 times that of their local importers! This market phenomenon indicates that the drug price-setting practice and global sales has laid golden eggs for Big Pharma companies, and left a bitter taste for patients and governments who have to make these purchases. Critics often point out that the market behaviour of the pharmaceutical companies has a significant impact on global medical inflation.
Distributors only work for the clients, provide logistics, and storage and services support, but do not own any stock of medicine. This is so they would not have influence over market pricing. A market review report shows that the mark up by wholesalers or distributors was marginal, at 2-3%. However, when the products reached the retailers – such as medical institutions and pharmacies – the mark-up is different.
According to the Medicine Prices Monitoring 2017 report, the median mark-up for originators’ and lowest-priced generics’ retail price in private hospitals was 51% and 167%, respectively, whereas in pharmacies these figures were lower, at 22.4% and 94.7% (Figure 3). This shows that the mark-up range can be exceedingly large; in some extreme cases, in private hospitals these could even spike up to 117.4% and 900%! Due to the lower production or import cost of generic drugs, this in turn allows private hospitals, clinics and pharmacies the opportunity to further mark up the final retail price which results in higher prices across the board, but greater profits.


Those in the sector often claim that price setting operations for medical products are within the bounds of the free market, or in other words, that mark-up behaviour is totally within legal boundaries, although it is considered by many to be unethical. Particularly when the prices for prescription or controlled medicines are hardly transparent, it is difficult for consumers to clearly compare prices and make informed decisions. In fact, the free market dogma entails that prices be made transparent so that market could be made more efficient, with consumers making the best decision for themselves!

However, the situation we have now often ‘encourages’ retailers to raise their prices arbitrarily while patients or consumers are not properly informed. Patients receiving medical treatment services often find that medicinal purchases constitute the most significant expenditure item in medical bills; this indicates that the mark-ups set by medical institutions undeniably add to patients’ financial burdens.

Two months ago, I participated a conference on rising medical costs. Throughout the conference, representatives from the participating multinational pharmaceutical companies, local private hospitals, as well as chain pharmacies all claimed that their profits are entirely justifiable because margins are reasonably low. A representative of a local chain pharmacy even commented to the audience that the large volume of medical products they sold were only of such a small profit to them that they have to diversify and rely on selling ice cream to subsist! This claim blatantly contradicts what data indicates.

Dealing with the factors contributing to rising drug cost, the Ministry of Health (MOH) has mooted the introduction of a mechanism to control medicine prices. This would be an interesting, if complex and challenging, proposal. Besides this, the pharmaceutical services department under the MOH is making efforts to increasing the transparency of medicine prices. Therefore, since 2015 a Consumer Price Guide has been uploaded on their website to enable people to make price comparisons. In the name of fairness and transparency, I hope the private sector takes the initiative to display all retail medicine prices to allow the public to make informed judgments. After all, for a laissez-faire market to work efficiently and effectively, there should be a free flow of pricing information for consumers to make the most economical decisions.

The article was published here at Malaysiakini, Opinion, March 17, 2019


Sunday, March 10, 2019

为何药价会高?




不久前,公积金局公佈了一项巴生谷个人与家庭开销预算指南,引起了全城热门討论。其中最多人关注的是,如何让单身的年轻人每月只用300令吉来找房子住。较少人討论看似不太合理的是30令吉的健康预算。除了那些平时就有购买私人健保配套的消费者,不然就是有健康问题在身而购买药物或保健品的人士,笔者揣测大部分健康正常的受访者並不怎么会有健康预算,再况且30令吉也没法买到私人健保。
一旦生病起来,一般人小病还好可负担,大病就不得了。国际专业咨询服务公司AON的2019年《全球医疗趋势率》报告就估算今年我国的医疗通膨率可达13.6%净成长,差不多是一般通膨率的5.6倍!2017年的国家卫生账户(Malaysia National Health Accounts)报告指出,单单是医药开销就佔了卫生领域总消费的大约8%或45亿令吉,而且这还是最保守的计算,未包括入院病人的医药开销。
对药物认知不对称
政府提供的公共医疗就在同年消费了大约24亿令吉添购医药,或10%卫生部的整体预算。这笔开销相比起2016年虽已增加了13%,但民眾仍对公共诊所和政府医院的医药短缺现象常有听闻,这表示公共医药仍「求大于供」。
一般人得病就要医,购买药物不似购买汽水般可有眾多不同选择,或甚至决定不买。通常针对性的医药没有替代產品,特別是该原厂医药仍处于专利保护期。与日常货品不同,医生和药剂师,以及一般民眾对医药產品资讯的认知不对称,他们为病人配药的判断和决定往往就左右或限制了民眾可作出的选择。
不少民眾对医药存有误解或偏见,迷信认为原厂药一定比仿製药品质更好、更有效及更安全。在我国,一般医药专利成功註册后便可享有长达20年的市场独佔期。当原厂药仍处在知识產权保护期,它或许就是当时市场上针对某个特定的疾病症状唯一药品或「救命仙丹」,价格通常能达最高。药厂一般会胥视药物生產和公司营运成本、利益相关者盈利,再加上该国市场消费者的经济负担能力等因素,而制定药价。
一般使用仿製药
仿製药事实上是有效药剂成份、剂量、服用方式和功能成效一样的药物,通常是在原厂药的专利失效后才被批准打入市场。仿製药的生產成本和售价肯定比原厂药显著低很多(虽然后者也会调整价格来竞爭)。所以,一旦有选择,精明的消费者应要选择价格最低廉的药品。我国政府公共医疗系统下的药库,2017年一共有大约四分之三的药物是仿製药,反观私人医疗界倾向使用原厂药(佔药库的52%)。卫生部的2017年《药品价格调查》报告结果显示私人医疗的药品售价,仿製药要比原厂药平均便宜接近3倍!
在菲律宾,该国法律强制医生和药剂师必须为病人提供至少两种仿製药的额外选择(若有相关药品的存在),这措施间接把財务负担考量和斟酌选择权交回给病人。
药物其实从生產商,到进口商,再转手到批发商负责分销至医疗中心和药房,最后才卖给病人或消费者。药价因供应链物流转手而在每一层被抬价;公共医疗系统则省免了最后一层的涨价,因为政府几乎免费为人民提供药物。
我国有製药业,生產的都是仿製药,其销售收入额仅佔我国製药业的四分之一。61%(等值)的药物都是进口货,其中87%的销售收入由外国製药公司授权的本地代理所囊括(其中最大的5家公司就已佔据接近进口市场的47%)。这也意味著首先决定药价的是海外的製药公司,他们通常卖的是原厂药。
儘管五大国际药厂的本地进口和销售代理的生意赚幅不大(净利介于1.6至3.4%),可是母公司的净利平均是26.2%,大约10倍赚幅之多!可见药价制定和销售量为国际药厂下金蛋,苦的是买单的病人和政府。前者的市场行为往往牵动著全球的医疗费通胀,令人詬病。
零售抬价病人负担重
批发分销商仅为客户提供后勤、存货及支援服务,並没有实际拥有医药囤货支配市场能力,因此间中的抬价涨幅仅为2-3%。但货物到了最后的医疗中心和药房等零售商,抬价幅度又不同了。
根据以上所述的2017年《药》报告,我国私人医院的原厂药和最低价仿製药的零售中位抬价分別是51%和167%;而药行零售中位抬价分別为22.4%及94.7%。零售商的抬价赚幅范围其实非常大,有些私人医院的极端案例甚至可达117.4%和900%!由于仿製药的生產或进口原价价位低,这反而提供私人医院、诊所和药房空间和机会拉高零售价,尝试「厚」利多销。
目前私人医疗业与药剂业为药物定价乃是自由市场运作,意味著他们的抬价行为不算犯法,儘管可能不道德。处方药或控制药品的价格尤其不透明化,所以消费者要货比三家也困难,这往往更纵容零售商肆意抬价。病人接受医疗服务,通常账单里最显著的开销项目就是医药购买,医院诊所的抬价幅度无可否认將加重人民的负担。
卫部努力控制药价
两个月前,笔者出席一场攸关医疗费用上涨的研討会,见识到赴会的国际药厂、本地私人医院和连锁药房代表各自申诉他们的赚幅没有很大,反而自圆其说称很合理。一位连锁药房的代表甚至表示他们都尝试「薄利多销」,更多要靠卖杂货维持生意。这些说法与笔者的认知有出入。
针对以上所述的种种让药价高涨的原因和弊病,卫生部有意要探討落实控制药价的措施。笔者虽然乐见其成但也瞭解到其复杂困难度。此外,卫生部底下的药剂服务支部也欲为药品价格透明化付出努力,从2015年起就在网站架设了一个消费者价格指南(Consumer Price Guide)以方便人民作比较。笔者更期望私人界的所有药品零售价必须要公开展示给民眾检验和比较,以示公平和透明。要有自由市场,消费者的资讯也得要有自由。
刊登于《東方日報》東方文薈版2019年3月10日
(此po文修改了一些文字,编辑版本稍有不同)

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