3 reasons why medications are so expensive in the US - Kiah Williams

譯者: Lilian Chiu 審譯者: Shelley Tsang 曾雯海

After helping develop the first insulin therapy in 1921,

在 1921 年協助開發出 最早的胰島素療法之後，

Canadian physician Frederick Banting transferred his patent rights

加拿大醫生弗雷德里克‧班廷

以一美金的價格將他的專利權 轉讓給多倫多大學，

to the University of Toronto for $1,

stating that insulin belonged to the world— not to him.

他表示胰島素屬於 全世界——而不是他個人。

A century later, insulin medications remain essential in treating diabetes,

一個世紀後，胰島素藥物 對於治療糖尿病仍然至關重要，

and have relatively low production costs,

且生產成本相對較低，

with a vial generally costing less than $6 to make.

每瓶的製造成本通常不到六美金。

But how much it costs a patient to buy varies greatly by country.

但病人購買的費用 則因國家而有很大的差異。

Those in the US may pay thousands for insulin annually—

在美國的病人每年可能要花 數千美金購買胰島素——

on average 10 times more than those in many other countries—

是其他許多國家病人 平均花費的十倍。

leading some patients to take less than prescribed.

導致有些病人未依照處方， 自行減少用量。

And this is part of a much larger trend.

這只是更大的趨勢的一部分。

Let’s take a look at the US drug supply chain to understand why.

咱們來看看美國的藥物 供應鏈以了解背後的原因。

First, there’s research and development,

首先是研發，

which ranges widely in cost, depending on the drug.

研發成本高低差異很大， 取決於藥物。

Expenses incurred by the many drugs that don’t make it to market

許多未成功上市的藥物所花費的成本

also need to be factored in here.

也要算在這裡面。

And almost every approved drug has been subsidized by taxes.

且幾乎所有被核准的藥物 都有得到稅金補助。

Before pharmaceutical companies actually release a drug,

在藥廠實際推出藥物之前，

they set its price.

會先設定其價格。

Historically, they haven't been required to justify the pricing they land on.

藥廠一直以來都不需要 為定價提出解釋。

Pharmaceutical companies are also allowed terms of drug patent protection

此外，藥廠也受到 藥物專利條款的保護，

and exclusivity rights that prevent other manufacturers

且擁有專屬權，防止其他製造商 在特定時間內推出相同的藥物。

from launching identical drugs for a set period of time.

Once patents expire, competition usually causes prices to drop,

專利到期之後，競爭 通常會讓價格下降，

so some companies invest heavily to extend their patents.

因此有些藥廠大量投資在 延長其專利上。

They may make tweaks—

它們可能會做微調——比如 在劑量和服用方式上的小改變——

like small changes in dosage and modes of delivery—

to obtain new patents and sue competitors

以取得新專利，並透過訴訟迫使 競爭對手延緩推出類似的藥物。

into delaying the release of similar drugs.

The companies responsible for Humira, the best-selling autoimmune drug,

最暢銷的自體免疫藥物是復邁， 以它背後的藥廠為例，

for example, have defended its patents and raised its price 27 times since 2003.

從 2003 年開始就不斷維護其專利 並提高價格高達二十七次。

Without insurance, it can cost over $96,000 a year.

若沒有保險，病人每年的花費 可能超過九萬六千美金。

And as three pharmaceutical companies have dominated the insulin market

三家藥廠用類似的戰略 主宰胰島素市場，

with similar tactics,

average insulin list prices have tripled over the last two decades.

胰島素的平均定價在過去 二十年間已經漲為三倍。

Once a drug is approved, there are two main distribution channels it can take:

一旦藥物被核准，可以採用 兩種主要的分銷管道：

the retail route includes drugs you pick up at pharmacies;

零售途徑包括你在藥房取得的藥物；

the other consists of drugs administered at hospitals and clinics.

另一個途徑則是醫院 和診所使用的藥物。

This includes many of the more expensive,

這包括許多其他更昂貴、 研究密集的罕見疾病療法。

research-intensive therapies for rare conditions.

Each channel involves unique businesses.

每個管道涉及的相關業者 都是獨一無二的。

Most drugs— including insulin— follow the retail channel.

大多數藥物——包括胰島素——

都走零售管道。

It starts with a pharmaceutical company selling the drug to wholesalers,

一開始是藥廠把藥物賣給批發商，

which buy in bulk and sell to pharmacies, which sell to patients.

批發商會批量購買，再賣給藥局，

藥局再賣給病人。

But the US doesn't provide universal health care,

但美國沒有提供全民健康照護，

so many Americans use health insurance.

因此許多美國人會使用健康保險。

When an insured patient picks up their prescription,

有保險的病人在領取處方藥時，

they often pay a portion while the pharmacy bills their insurer the rest.

通常要負擔部分費用，藥廠會向 他們的保險公司收取剩下的部分。

Pharmacy benefit managers, or PBMs,

藥品福利管理公司（PBM）

which are companies unique to the US market,

是美國市場特有的公司，

negotiate on behalf of insurers to get discounts from manufacturers

它們代表保險公司 和製造商協商取得折扣，

in exchange for insurance coverage.

用承保範圍來做交換。

PBMs may pass some of the negotiated discount to insurers—

PBM 可能會將部分由協商 取得的折扣轉讓給保險公司——

but they may also take a considerable portion.

但它們自己拿走的部分並不少。

Their role tends to limit patient choice,

它們的角色通常會限制病人的選擇，

and they’ve sometimes covered more expensive branded drugs

它們有時會給付較昂貴的原廠藥，

instead of cheaper generics because it earns them a greater profit.

而非較便宜的學名藥， 因為能獲得的利潤更大。

Without insurance, patients may be expected to foot the bill entirely,

沒有保險的病人可能得以未經 協商的價格負擔全額費用。

at non-negotiated rates.

Money flows between the different businesses as fees, rebates, discounts,

資金在不同業者之間流動， 形式包括費用、回扣、

折扣、共付扶助金。

and copay assistance.

If it feels hard to follow, that's because it is.

如果覺得很難理清， 那是因為事實的確如此。

And it's tough to know exactly how much money goes where

很難知道究竟有多少錢到哪裡去，

because these transactions lack transparency.

因為這些交易都缺乏透明度，

But for insulin in 2018, of all that was spent on the medication:

但就 2018 年的胰島素來說，

所有花在藥物上的錢被這樣分配：

manufacturers received about 46%; wholesalers got about 8%; pharmacies, 20%;

製造商拿到約 46%；批發商約 8%；

藥局 20%；

insurance companies, 10%; and PBMs, 14%.

保險公司 10%；PBM 14%。

Interestingly, as insulin list prices increased between 2014 and 2018,

有趣的是，

在 2014 年到 2018 年間 胰島素的定價提高，

the amount manufacturers retained decreased,

製造商保有的金額卻下降了，

and more than half went to intermediaries.

超過一半流向中介業者。

Where the US has businesses negotiate at various steps,

美國在各個階段都有業者在做協商，

other countries generally have government agencies evaluate a drug’s benefit,

其他國家則通常是由政府機構 來評估藥物的益處、

make bulk purchases, and regulate pricing.

進行批量購買，並監管定價。

The US sees the most drug development— and profit— of any country.

美國是藥物開發和獲利最多的國家。

But about 1 in 4 Americans reported trouble affording prescriptions in 2019.

但 2019 年，四個美國人中就有 一個表示自己無法負擔處方藥。

Many experts have called for measures like increased regulation

許多專家呼籲要採取措施， 如加強管理訂價、

in drug pricing, patenting, and intermediary profits,

專利核准，和中介利潤，

along with more national health and research funding.

以及增加全民健康和研究的資金。

This way, the US could ideally lower prices

這麼一來，理想上， 美國就能壓低價格，

and encourage more innovative, lifesaving drug development.

並鼓勵開發更多創新、救命的藥物。

And by making medications affordable,

讓藥價降至病人可以負擔得起，

pharmaceutical companies could theoretically maintain profits.

理論上藥廠是可以維持獲利的。

In 2023, one of the largest insulin manufacturers announced

2023 年，最大的胰島素製造商之一

宣布會大幅度降低藥物的定價，

it would substantially decrease the drug’s list price,

and two others followed suit.

另外兩間藥廠也跟進。

This should make insulin more affordable.

這應該會讓病人更負擔得起胰島素。

But system-wide changes would have to be instated

但也必須進行全系統的變革，

to make sure patients are getting the medications they need.

才能確保病人都能取得 他們需要的藥物。