美国医药行业的伪难题

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.

在所有的行业，垄断和寡头垄断都会让市场上的选择变得有限并榨取经济租金。在医药领域，消费者是在自己最脆弱的时候面对这种状况的：这时的他们往往很害怕、无法彻底弃用这种产品，事事依赖专家作决定。

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，总部位于伦敦的制药商Hikma将一种液剂止泻药在美国的价格上调430%。这种药物已问世几十年，没有专利保护。

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.

然而竞争壁垒仍然存在。一家新的制药商需要获得监管批准并取得生产设施。相对于片剂药，这对于液剂药品、吸入式药品或注射用药品而言更难。市场新入者的药品价格将仅为垄断价格的一小部分。这项计划很可能会赔钱。

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并非唯一这么做的企业。最近几年，几家对非专利产品拥有实际垄断权的公司纷纷上调价格。图灵制药(Turing)把一种救命药的价格上调至原来的55倍。迈兰(Mylan)在6年里将蜂蜇过敏用药EpiPen的价格上调了500%。一度为股市宠儿的Valeant将抬高价格作为核心战略。这样的例子还有很多。

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.

总体而言，竞争在非专利药品领域很好地发挥着作用。出现大量提价行为的是那些前期成本高且目标市场相对较小的药品。监管加剧了这个问题：如果分销商在国内价格飙升时可以从国外进口药品，垄断可能会被打破。但它们不能。

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，监管规定和不合理的激励也提高了美国的专利药品价格。举个例子，为退休人员的用药买单的“联邦医疗保险”(Medicare)，需要为几乎所有癌症和其他致命疾病的获批治疗方法买单——即便有时存在更廉价、同时效果相同或近乎相同的治疗方法。这让政府无法有效地进行价格谈判。很多州对私人保险公司也有类似法规。同时，“联邦医疗保险”向开出其覆盖范围内药品的医生提供药价提成，这让他们有理由青睐更昂贵的药品。

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.

中间人也“雁过拔毛”。代表制药商和保险公司的药品福利管理机构(PBM)就药品上市价格的折扣进行谈判。它们随后将大部分折扣让渡给客户，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.

它们因此有理由争取更大折扣，但由于折扣是按药品上市价格的比例计算的，上市价格高也符合它们的利益。如果PBM竞争激烈，那就问题不大。但经过20年的行业整合，再加上反垄断监管机构不作为，3家PBM控制了近80%的市场份额。

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.

制药业辩称，如果采取行动降低美国药价，创新动力就会下降。这是一个伪难题。完全的价格控制——或者让政府成为唯一药品买家——将会损害创新。但在为切实创新维持丰厚回报的前提下，还可以采取许多措施来加剧竞争。

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.

遏制竞争的监管法规不只是“监管被俘”(regulatory capture)的结果。美国人要求保险覆盖他们或者他们的医生青睐的任何治疗方案。当那些最终支付的人可以决定哪些产品可以互换并在此基础上与制药商谈判的时候，竞争才会如火如荼地展开。法律应该为出现这种局面创造条件。