4 1 論文 TheUseo fP h a r m a c o e c o n o m i c s i nt h eUSH e a l t h c a r eS y s t e m G r e g gL .Mayer , P h . D .*1 H a k u g iKi y o n ol 牢 H i r o y u k iS a k a m a k i , M . B . A .*2 H e a l t h c a r ee x p e n d i t u r e si nt h eU n i t e dS t a t e sa r eg r o w i n gb ya l m o s t1 0 %ay e a r , a n dr e a c h e da p p r o x i m a t e l y$ 1 . 3t r i l l i o ni n ,t h em a r k e tf o rp r e s c r i p t i o nd r u g si sg r o w i n ga tar a t eo f 2 0 0 1 .D r u g sa c c o u n t e df o ra b o u t1 0 %o ft h i sa m o u n tH o w e v e r ,a n dh a se x h i b i t e dmuchh i g h e rg r o w t ht h a no v e r a l lh e a l t he x p e n d i t u r e s .T h ee x p a n s i o no fm a n a g e dc a r es i n c et h e 1 5 . 7 % a r i e t yo fm e a n st oc o n 仕0 1h e a l t hs p e n d i n g .O r i g i n a l l yj u s ti nh o s p i t a l s , MCOs , PBMs ,a n d n i n e t i e sh a sb r o u g h tw i t h比av p h y s i c i a n sg r o u p sh a v enowa l s of o r m e dp h a r m a c e u t i c a la n dt h e r a p e u t i c s( P & T )c o m m i t t e e si no r d e rt ol i s tnewd r u g si na n d u p d a t ef o r m u l a r i e s .Theu s eo fp h a r m a c o e c o n o m i c sb yP&Tc o m m i t t e e si nf o r m u l a r yc o n t r o lh a sb e e ni n c r e a s i n gi nr e c e n t 甘n gp h y s i c i a na c t i v i t i e s , s u c ha st h ec o s t e f f e c t i v e n e s so fp r e s c r i b i n gh a b i t s , i s y e a r s .P h a r m a c o e c o n o m i ca p p r o a c h e st oe v a l u a a l s og r o w i n gm o r ecommoni nh o s p i t a l sa n do t h e rm e d i c a lc a r es e t t i n g s .P h a r m a c i s ta s s o c i a t i o n sa n da c a d e m i cs o c i e t i e sw i t h ,a sw e l la s a ni n t e r e s ti nm a n a g e dc a r ea r enowp r o v i d i n ge d u c a t i o n a lp r o g r a m sf o rt h e i rm e m b e r sa n dr e l a t e dp r o f e s s i o n s g u i d e l i n e st os t a n d a r d i z et h eu s eo fp h a r m a c o e c o n o m i ca n a l y s i s .O b s e r v i n gp r a c t i c a la p p l i c a t i o n so fp h a r m a c o e c o n o m i c s ,a n d , i nt h eUSp r o v i d e su s e f u l l e s s o n sf o ri m p r o v i n gt h eu s eo fp h a r m a c o e c o n o m i c si nt h eh e a l t hs e r v i c e si nJ a p a na s i t sr e s u l t s w e l l . , USA , drugd i s t r i b u t i o n , f o r m u l a r y [ k e y w o r d s ] pharmacoeconomics * 1G r e g g1 .M a y e r&C o m p a n y , I n c . 申 2I n s t i t u t ef o rH e a l t hE c o n o m i c sa n dP o l i c y 4 2 医療経済研究 v o 1 . 14 2 0 0 4 1 .PharmaceuticalSalesand (2) USHeal↑hcareExpendi↑ures DistributionintheUS A l 血o u g ht h er a t eo fi n c r e a s eh a sd r o p p e db e l o w 10% i nr e c e n ty e a r s,n a t i o n a lh e a l t h c a r e (1)I n↑roduction e x p e n d i t u r e s加pped$ 1 .4 2 5凶 l l i o n血 2 0 0 1, a n8 . 7 % P h a r m a c e u t i c a lp r o d u c t sa r ei m p o r t a n tt o o l s i n c r e a s efromt h ep r e v i o u sy e a r .A p p r o x i m a t e l y u s e dbyp h y s i c i a n sa r o u n dt h ew o r l d .N e a r l yh a l f $ 1 .3 7 3佐世ionw ぉ s p e n tonh e a l t h c a r es e r v i c e sa n d , o fw o r l d w i d ep h a r m a c e u t i c a ls a l e so c c u ri n出eUS , o ra b o u tt e n s u p p l i e s . Oneh u n d r e df o r t yb i l l i o n w i 出 J a p a nad i s t a n ts e c o n da ta b o u t1 5 % . 官l eUS , w ' 部 s p e n tonp h a r m a c e u t i c a lp r o d u c t sa s p e r c e n t sl a r g e l yaf r e ea n d班 r r e g u l a t e d h e a l t h c a r em a r k e ti showni nF i g u r e1 . Figure2showst h em a j o r h e a l t h c a r emarket , p u t t i n gb u y e r sands e l l e r so f c a t e g o r i e so fn a t i o n a lh e a l t h c a r ee x p e n d i t u r e s . , s u c h回 p r e s c r i p t i o nd r u g s, ono p p o s i t e p r o d u c t s W h i l et h el a r g e s ts p e n d i n gc a t e g o r i e ssucha s s i d e so fat o u g hn e g o t i a t i n gt a b l e .T h i sc h a p t e r andp h y s i c i a n h o s p i t a lc a r es e r v i c e s( $ 4 5 1b i l l i o n ), d e s c r i b e st h eUSh e a l t h c a r emarket, h e a l t h andc l i n i c a ls e r v i c e s( $ 3 1 3b i l l i o n )i n c r e a s e dby , t h em a r k e tf o rp r e s c r i p t i o nd r u g s , and i n s u r a n c e 8 . 3 % and 8.6% compared t op r e v i o u s year o u g h tandp a i df o rw i t h i nt h eU S ' howt h e y紅 eb r e s p e c t i v e l y , t h er a t eo fi n c r e a s e担 p r e s c r i p t i o n f r a g m e n t e dr e i m b u r s e m e n ts y s t e m . d r u gs p e n d i n g( $ 1 4 0b i l l i o n )r o s eby1 5 . 7 % .The paceo fp r e s c r i p t i o nd r u gi n c r e a s e se a s e dfrom $ b i l l i o n s 1 4 0 0 1 2 0 0 1 0 0 0 図 N a t i o n a l H e a l t h c a r e E x p e n d i t u r e 醐 P r e s c r i p t i o n D r u g s E x p e n d i t u r e 8 0 0 6 0 0 4 0 0 2 0 0 。 1 9 8 0 1 9 9 0 1 9 9 5 1 9 9 6 1 9 9 7 1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 nNationalHealthcareandPrescription Figure1 Growthi DrugExpenditures . t a L .( 2 0 0 3 )“ T r e n d si nU . S .H e a l t h c a r eS p e n d i n g2 0 0 1, "H e a l t hA f f a i r sJ a n u a r y / F e b r u a r y S o u r c e :L e v i te T h eU s eo fP h a r m a c o e c o n o m i c si nt h eU SH e a l t h c a r eS y s t e m 4 3 (3 )U SH e a l t h l n s u r a n c eS y s↑em Th eU n i t e dS t a t e si s山首q u ei nt h a ti td o e sn o t 副o n a lh e a l t hi n s u r a n c ep r o g r a ma n d1 5 % h a v ean o f血ep o p u l a t i o nh a sn oi n s u r a n c ec o v e r a g ea ta l l . 血c a r ef o r吐l eu r 由lS u r e di sp a i df o rd i r e c t l yo u t H e a l o fp o c k e t , o rb yac o m p l e xp a t c h w o r ko ff e d e r a l , s t a t e, l o c a lgovernment, andp r i v a t e l yf u n d e d 町e dp r i m a r i l yt o w a r dt h el o wi n c o m e p r o g r a m sg e u n i n s u r e d .F e d e r a la n ds t a t egovemmentsw e r e 血ep a y e r sf o ra b o u t26%o f血ep o p u l a t i o nt h r o u g h M e d i c a i d , a n do t h e rp u b l i cp r o g r a m s . M e d i c a r e, Ther e m a i n i n g59%o fAm e r i c a n sa r ec o v e r e db y p r i v a t eh e a l t hi n s u r a n c et h a tt h e ye i t h e rr e c e i v ea l l o r恒 p町 t部 ab e n e f i tf r o m出e i re m p l o y e r , o rp a y 圏 図N u r s i n gH o m eC a r e m s e l v e s .Ov e r a l l , p u b l i cf u n d sp a yf o ra b o u t f o r由e O t h e rS p e n d i n g 臼P h y s i c i a na n dC l i n i c a lS e r v i c e s 46%o fh e a l t h c a r es p e n d i n g( i .e .t h esumo f A d m i nC o s t 口P r e s c r i p t i o nD r u g s M e d i c a r e, M e d i c a i d , a n do t h e rp u b l i cs p e n d i n g ), H o s p i t a lC a r e ・ 国 w h i l ep r i v a t es p e n d i n ga c c o u n t sf o r54% , a sshown F i g u r e2 Componentso fN a t i o n a l HealthExpenditures・ 2001 S o u r c e :C e n t e r sf o rM e d i c a r e&M e d i c a i dS e r v i c e s :H e a l t h 吐l i nt h ep r i v a t es p e n d i n gc a t e g o r y , i nF i g u r e3 . Wi p r i v a 民 h e a l 出i n s u r a n c ep a i df o r35%o fh e a l t h c a r e s p e n d i n g , w h i l eo u to fp o c k e ts p e n d i n gp a i df o r A c c o u n t sw e bs i t e F i g u r e sd on o ta d dt o100%d u et or o u n d i n g . O t h e rS p e n d i n gi n c l u d e sd e n t a ls e r v i c e s , o t h e rp r o f e s s i o n a l s e r v i c e s , h o m eh e a l t h c a r e ,d u r a b l em e d i c a lp r o d u c t s ,o t h e r n o n d u r a b l em e d i c a lp r o d u c t s ,g o v e r n m e n tp u b l i ch e a l t h a c t i v i t i e s , r e s e a r c h , a n dc o n s t r u c t i o n . p r e s c r i p t i o nd r u g s, w h i l et h ep r i v a t es e c t o r, . 4 %i n2 0 0 0, b u twass t i l lt w i c e 1 9 . 7 %i n1 9 9 9a n d1 6 i n c l u d i n go u to fp o c k e ts p e n d i n ga n dp r i v a t eh e a l t h 部 a n o t h e r1 4 % .I nt e r m so fp r e s c r i p t i o nd r u g s p e n d i n g, p u b l i cf u n d sp a i df o ra b o u t23%o f l. h l g h部 a l lo t h e rs p e n d i n gc a t e g o r i e s1 , p a i df o r7 7 % , a sshown恒 F i g u r e 4 .P紅 t i n s u r a n c e A c c o r d i n gt o出 eO r g a n i s a t i o nf o rE c o n o m i cC o - o ft h er e a s o np r i v a t es p e n 品n go nd r u g si ss oh l g h , o p e r 瓜i o na n dD e v e l o p m e n t(OECD), 担1 9 9 8, t h e i st h a to u t p a t i e n td r u g sa r en o tc u r r e n t l yc o v e r e d USh a dt h eh l g h e s tp e rc a p i t ah e a l t h c a r ec o s ti n出e 3 ) . I n2 0 0 3 , C o n g r e s sp a s s e d b yt r a d i t i o n a lM e d i c a r e w o r l d , $ 4 , 1 6 5 .S p e n d i n gonp h a r m a c e u t i c a l sp e r l e g i s l a t i o nt ob e g i nt op r o v i d ep r e s c r i p t i o nd r u g ac l o s es e c o n dt oF r a n c e, who c a p i t awas$ 4 2 2, 4 ) . c o v e r a g ei n2 0 0 6 o r l d . s p e n d st h em o s tp e rc a p i t ao nd r u g s担 血ew TheUSh e a l t hi n s u r a n c esystemh a sgone ec o s to fp h a r m a c e u t i c a l s回 as h a r eo ft o t a l B u t吐l 部 t d e c a d e .Upu n t i l t h r o u g hd r a s t i cc h a n g e si nt h e1 U S h e a l 血c a r ee x p e n d i t u r ewaso n l y1 0 % , o n eo f t h e t h ee a r l y1 9 8 0 ' s, t r a d i t i o n a li n d e m n i t y, f e e f o r - USp e r l o w e s tamongOECDc o u n t r i e s . By2 0 0 1, s e r v i c ei n s u r a n c ec o v e r a g ed o m i n a t e d .Ast h ec o s t , 0 4 5 勾. c a p i t ah e a l t h c a r ec o s t sh a dr i s e n ω $ 5 , p u r c h a s e r so f o fh e a l t h c a r es t a r t e dt or i s er a p i d l y TheU s eo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m 6 3 C l i r u c a lManagemento fP h a r m a c e u t i c a l s( C M o P ) . f l u v o x a n l I n e仏u v o x )a t$ 1 2 0 / m o n t ho rp a r o x e t i n e DRUGw o r k sw i t hd o c t o r sona no n g o i n gb a s i st o ぉd l )a t$ 3 7 7 / m o n t h . The ywant由ed o c t o rt ob e ( P gu s eh a b i t st o d a y , w h i l e p r o m o t ec o s t e f f e c t i v eむu a b l et os e e吐l ed i 宜' e r e n c e si np r i c e, w e i g h抗inwi 出 CMoPt a k e sah i s t o r i c a ll o o ka tp a t i e n t sono f f - 由 eb e n e f i t s , andmakeup也 位 o w n m i n d s . f o r m u l a r yd r u g sf o rl o n gp e r i o d so ft 凶e andworks DRUGand Tot r a c kr e s u l t so ft h e s ee f f o r t s, h ed o c t o rt ot r yt ou n d e r s t a n dt h er e a s o n sf o r w抽 t CMoPp r o v i d ew e e k l yr e p o r t so fnewS S R I“ s 阻r t s " t h eo f f f o r m u l a r yp r e s c r i p t i o n . ( i . e .newp a t i e n t sonS S R I s )t oe a c hr e g i o n , f a c i l i t y , K P ' spharmacyhasundertakenanumbero f andi n d i v i d u a lp r o v i d e r .官邸 a l l o w se v a l u a t i o no f g s . f o r m u l a r ys t r a t e g i e st or e d u c et h ec o s to fむu f o r m u l a r yc o m p l i a n c ea ta l l l e v e l s , andt h er e a s o n s , i nt h e紅 e 加 o fa n t i d e p r e s s a n t sknown F o re x a m p l e behindnon-compliancet obee x a m i n e d . The a ss e l e c t i v es e r o t o n i nr e u p t a k ei n h i b i t o r s(SSR I s ) , r e s u l t so ft h e s ee f f o r 臼f o rS S R I si st h a tn e a r l y70% 出e r ea r emanyp r o d u c t sont h em a r k e t , b u t血e y a l l o fnewp r e s c r i p t i o ns t a r t sa r eg e n e r i cf l u o x e t i n e, h a v eb a s i c a l l yt h esamee f f e c ta c c o r d i n gt ot h e a c c o u n t i n gf o ro n l y16%o ft o t a la n t i d e p r e s s a n t l u o x e t i n e( P r o z a c )h a snow s c i e n t i f i cl i t e r a t u r e .F , w h e r e a st h eo t h e r30%o fnews t 紅t sb e i n g c o s t s g o n eo f fp a t e n tandi sa v a i l a b l ei ng e n e r i cf o r mf o r f i . l l e dbyb r a n dnamep r o d u c おa c c o u n t f o r血eo t h e r I s .I nturn, al o w e rp r i c et h e nt h eb r a n dnameSSR 踊.O v e r a l l , 70%o fK P ' sp r e s c r i p t i o n s間 84%ofco K P ' sph 細 l a c yp u r c h a s i n gg r o u ph加 n e g o t i a t e da f i l l e dbyg e n e r i c s, whicha c c o u n tf o ro n l y15%o f f a v o r a b l ep r i c e with a g e n e r i cf l u o x e t i n e 凶 世u gc o s t s , w h e r e a s30%a r ef i . l l e dw i 由 b r a n d t o manufactureri nexchangef o rpromotingt h e ta c c o u n tf o r85%o ft o t a lむu gc o s t s .I n name出a p r o d u c tamongt h e i rp h y s i c i a n s . Thep u r c h a s i n g c a t e g o r i e swhereg e n e r i c sa r ea v a i l a b l e, 98%o f d e l i v e r " groupf e e l st h e yneedt obea b l et o“ d r u g sd i s p e n s e da r eg e n e r i c . markets h a r e "w i t h i nKPo fa betweena5 0 9 0 %“ 由i nKP , p h a r m a c o e c o n o m i ca n a l y s i sp r o v i d e s Wi s i n g l eproducti nordert og a i naf a v o r a b l e a d d i t i o n a lp e r s p e c t i v e swhenc o n s i d e r i n gnew 血m a n u f a c 加r e r s . n e g o t i a t i n gp o s i t i o nwi r eo n l ym a r g i n a l l yd i 宜e r e n t社l a nt h e i r d r u g s位協ta Thepharmacyd e p a r t m e n tu s e sanumbero f b u ts o l da ts u b s t a n t i a l l yh i g h e r p r e d e c e s s o r s, m e t h o d st op r o m o t ef o r m u l a r yp r o d u c t samongKP t r a d i t i o n a lNSAIDshave p r i c e s . Forexample, p h y s i c i a n si no r d e rt og a i nn e c e s s a r ym a r k e ts h a r e , a n dc o m p a n i e sh a v ed e v e l o p e da comeo f fp a t e n t f o rf a v o r a b l en e g o t i a t i o n s . Pharmacyo f f e r s newg e n e r a t i o no fNSAIDsknowna sCOX-2 組o n a l l i t e r a t u r e , h a sat e l e p h o n e l e c t u r e sa n de d u c i n h i b i t o r s .T h e s ep r o d u c t sa r es o l dp r i m a r i l ya s c o n s u l t a t i o ns e r v i c ewhered o c t o r scanask b e 加g s a f e r血a nt r a d i t i o n a lNSAIDs , d u et or e d u c e d q u e s t i o n sa b o u ta l l世 ugu s ei n出 位 p a t i e n t s , and G Ib l e e d i n g , a n dnowa c c o u n tf o ra b o u t1 / 2t h eUS h a sd e s i g n e dt o o l sj u s tf o rKPp h y s i c i a n s . For t . Thec o s to ft h enewd r u g sf a r NSAIDmarke p o c k e ts i z e dc a r d sf o rd o c t o r sl i s tt h e e x a m p l e, d i t i o n a lN S A I D s .U s i n gt h e e x c e e d st h a to ft h e位a 可 , s u c ha sS S R I s ,a n d c h o i c e so fd r u g si nac a t e g o n o t et h emuchl o w e rp r i c ep e rmontht oKPo f r e s u l t so fap e e r r e v i e w e ds t u d yp u b l i s h e dby 3 l, ph 紅 m配 i s t sa n d S t a n f o r dU n i v e r s i t yr e s e a r c h e r s p r e s c r i b i n gf l u o x e t i n e,$44/month,v e r s u s t h e i rp h y s i c i a nr h e u m a t o l o g i s tc o l l e a g u e s 4 4 医療経済研究 v o 1 . 14 2 0 0 4 1 0 0 % = $1 . 4 2 4t r i l l i o n 1 0 0 % = $1 . 4 2 4t r i l l i o n ///-ノ 、 戸 ﹃ ¥、/、 1¥ 、、 、¥﹄ 11 ,, ,、、〆, ,、、 ノ、-〆 島,E¥l 一¥ 1 、-1 1 、 -I 'l¥ 'I¥ 声 〆 、 -、 〆 JBJ 〆、、 、- / e 1 J 町 i /¥/ll ¥/-、-¥/司 〆頃〆 〆l' 旬、〆 l' ス ノ - u f - L ¥ W吻 / p r / - u J J -4 ﹂ ﹃ /¥/l / 、 - 、 - 〆 引 山 1 / 、-、-ノ 司、、、 也 /¥l' 、 / ¥ l 司、¥ ¥//¥/ - ー 、 、 〆 ノ 、 、 - l 、、〆 //ノ-〆///-〆 〆 ¥t¥ 、〆¥ li¥ l 、 、¥/, , 〆 、 、 -¥l/¥ ¥-ノ巴 、 ¥ 1 F I 、 -l-、 ' l ¥ F i 31% ノ ノ J 〆¥ J¥ 、 J ¥、 、 、 、 , ¥I ノーー- 1 、 ¥ 、 ー 、 、 、 1 . 〆 1 . 1 / ¥I 、 , ,、 1 / ノ¥'¥,戸、 ¥ ' ¥ J ノ 戸 ノ 、ー‘'¥〆 :¥1、ー、'¥〆 ー/、 /,ノー/、ーノ, / I、 、 ー 〆 ¥ 一一 、 , 、,、¥〆ー〆、、,、¥ノ『ー 、 ¥ 、 、 ノ ¥J ー 、 ノ 司 、 I 〆 ¥ ー ¥/ A ヴ0 1-.ノ¥ーー¥/、イ I / 、 ¥ ι企 I/ υ 、 , ¥ 『 〆 ¥ 、 , ι 、 、 ¥ : il : 14% 、 、 ¥ / ¥I ご 、 、 、 、、、 ノ ー l 、、 、 ノ ー J 、、 ‘ ノ 、 一 、 、 ー ¥ ι 、 、 ー ¥ /I I. 〆 1, ¥I 、 ' 〆 、 r / ¥I 、 , ,、 1 / d ¥ ¥ / ¥ /戸 、 ¥ / ¥ / 戸 // 戸 戸 ーー/ ¥ l 、 一句 、' ¥ 〆 ¥ l 、 ー/、一、ノ'/ー ¥ I - ¥l 一〆、 e d i c a i d 日P r i v a t eI n s u r a n c e 国M e d i c a i d 日P r i v a t eI n s u r a n c e 国M 口O u t o fP o c k e t • O t h e rP u b l i c 口O u t o fP o c k e t 回O t h e rP r i v a t e 図 騒 M e d i c a r e • O t h e rP u b l i c M e d i c a r e F i g u r e3 Sourceso fN a t i o n a lH e a l t h E x p e n d i t u r e s-2001 F i g u r e4 Sourceso fPaymentf o rD r u g s : 2001 e d i c a i dS e r v i c e s :H e a l t h S o u r c e :C e n t e r sf o rM e d i c a r e& M A c c o u n t swebs i t e . t , a . l( 2 0 0 1 )“ T r e n d si nU . S .H e a l t h c a r e S o u r c e :L e v i te "H e a l t hA f f a i r sJ a n u a r y / F e b r u a r y S p e n d i n g2 0 0 1, h e a l 白 血s u r a n c e , p a r t i c u l a r l ye m p l o y e r s , b e g a nt o h e a l t h c a r ei nac o s t e 百' e c t i v emanner"5J• Nowo v e r s e e kwayst og a i nc o n t r o lo v e rt h eg r o w t h .H e a l t h u r e dp o p u l a t i o ni sc o v e r e d 93%o ft h ep r i v a t e l y加s i n s u r e r srespondedbyi n t r o d u c i n gav a r i e t yo f 血e rw h i l eO I U y byonef o n no fmanagedc a r eo ra n o i n n o v a t i v eh e a l t h c a r ec o s tr e d u c t i o nt e c h n i q u e s, sc o v e r e dby位a d i t i o n a lf e ef o rs e r v i c e 7%p e r c e n ti t i l i z a t i o nr e v i e w , c a s emanagement , and s u c h部 u e d i c a r eand a sshowni nFigure5 .M i n s u r a n c e, b e t t e rp r e v e n t i v eh e a l t h c a r ei no r d e rt or e d u c e Medicaidprogramsa l s obothhaves u b s t a n t i a l f f o r t sl e dt ot h edevelopmento f c o s t s . 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T r a n s i 註o nt omanagedc a r eb r o u g h tc h a n g e s加 The1 9 9 0 ssawar a p i de x p a n s i o ni nmanaged p a y e r sandp u r c h a s e r sa sw e l l出 加 p r o v i d e r sa n d whichcanbedefineda s“asystemo f c a r e, p a t i e n t s .P u r c h a s e r sa r et y p i c a l l ye m p l o y e r st h a t tu s e s h e a l t h c a r er e i m b u r s e m e n tandp r o v i s i o n由a p u r c h a s eh e a l 出p l a n sfromp a y e r su s u a l l yknown f i n a n c i a li n c e n t i v e sanda d m i n i s t r a t i v eandc l i n i c a l o rtoday, a s a sh e a l t hinsurancecompanies, managementc o n 仕o l s加 d i r e c tp a t i e n t st oe 宜i c i e n t r o v i d e r s managedc a r eo r g a n i z a t i o n s( M C O s ) .P p r o v i d e r swhoa r er e s p o n s i b l ef o rd e l i v e r i n g c 1 udef a c i l i t i e s , s u c ha sh o s p i t a l s , s k i l l e dn u r s i n g i n T h eU s eo fP h a r m a c o e c o n o m i c si nt h eU SH e a l t h c a r eS y s t e m 4 5 f a c i l i t i e s , o rn u r s i n ghomes , a sw e l l回 p e r s o n n e l a c t i o n si n v o l v i n gn u m e r o u sp a r t i e ss t a r t i n gf r o m , t h a tp r o v i d em e d i c a ls e r v i c e ss u c ha sp h y s i c i a n s t ow h o l e s a l e r s, pharmacy t h em a n u f a c t u r e r s, p h a r m a c i s t s, d e n t i s t s, n u r s e sando t h e ra l l i e d b e n e f i t managers,h e a l t hp l a n s,h o s p i t a l s, p r o f e s s i o n a I s . p h y s i c i a n s, p h a r m a c i s t s , 組df i n a l l yt h ep a t i e n . t W h i l ep h a r m a c e u t i c a l sa c c o u n tf o ro n I y1 0 %o f h e a l t h c a r es p e n d i n g, t h e ya r ek e yt o o l si nt h e p r o v i d e r ' st o o l k i t , a n dt h e$ 1 4 0b i l l i o ns p e n ti nt h e USl a s ty e a rmakesi tal a r g eandi m p o r t a n t 位y .P h a r m a c e u t i c a lp r o d u c td e v e l o p m e n ti sa i n d u s (4) P r e s c r i p ↑ i o nDrugM a r l くe ↑ : ManufacturersandS e l l e r s ①M a n u f a c t u r e r s P h a r m a c e u t i c a lc o m p a n i e sc a nb ec a t e g o r i z e d complex, l o n g( 1 01 5y e a r s ), ande x p e n s i v e i 加 n t ω ot 伽 h r e 白em 悶 1 悶 叫 a 伐 吋 刈 抑 j j w i t ht h ea v e r a g enewd r u gnowc o s t i n g p r o c e s s, 1 c o m p a n i e ss u c h邸 P f 白 i z e 町r a 加n dL i 凶 j ] J 町 l y紅 e加V 刊0 1 討 v e 吋d i 泊 n 8 0 0 m i l l i o nt o d e v e l o p . a p p r o x i m a t e l y $ a l la s p e c t sぱ 0ft 由 hep r o d u c t仕 f romr e s e a r c h, P r e s c r i p t i o n , d i s p e n s i n g , a n da d m i n i s t r a t i o no ft h e d 白e V 刊 I e l o p m e 凶 n 此 1 t , m a n u f a c t u r i n g , t os e l l i n gt h ed r u g . gt ot h er i g h tpa 世e n ti sac o m p l e xc h a i no f r i g h tむu Wh e r e a s, s m a l l e rs c a l eb i o t e c h n o l o g yc o m p a n i e s 司 圏P O S 口P P O 瞳H MO 図I n d e m n i t y M a n a g e dC a r e 1 9 8 0 1 9 9 6 1 9 9 8 2 0 0 1 Figure5 Changesi nHealthPlanEnrollment :1980~200 1 S o u r c e :M a y e r&T a n a k a( 1 9 9 7 )M a n a g e dC a r eD e v e l o p m e n ta n dI n n o v a t i o n si nt h eU S , a n dt h e i rP o l i c y I m p l i c a t i o n sf o rJ a p a n ;G a b e le . ta , . l( 2 0 0 1 )“ J o b B a s e dH e a l t hI n s u r a n c ei n2 0 0 1 :I n f l a t i o nH i t sD o u b l ed i g i t s , M a n a g e dC a r eR e t r e a t s , "H e a l t hA f f a i r s , V o . 1 2 0, N o . 5S e p t e m b e r / O c t o b e r 4 6 医療経済研究 v o 1 . 14 2 0 0 4 a n d n i c h eむu gd i s c o v e r yc o m p a n i e s, f o c u son世 u g I n s t e a d,t h e ya r ed e l i v e r e dd i r e c t l yt ot h e d i s c o v e r yf o rc e r t a i nt a r g e td i s e a s e s, o rs p e c i f i c c u s t o m e r ' sw a r e h o u s e .I nt h e s et r a n s a c t i o n s, p l a t f o r mt e c h n o l o g i e s .Thed r u g sd i s c o v e r e dby w h o l e s a l e r sg e n e r a t er e v e n u efromb o t he n d s . nl i c e n s e do u tt om a j o r t h e s ec o m p a n i e sa r e0立e i .e .t h er e t a i lpharmacyc h a i no r Customers( p h a r m a c e u t i c a lc o m p a n i e sf o rm a n u f a c t u r i n ga n d h o s p i t a l )p a yt h ew h o l e s a l e ra n“ u p c h a r g e ", af e e F i n a l l y,g e n e r i c drug companies f o rt h ec o s to fd i s t r i b u t i o n , ando t h e rb r o k e r a g e m a n u f a c t u r ed r u g swhosep a t e n t sh a v ee } 中i r e d . f e e s .百l eむu gm a n u f a c t u r e sp a y st h ew h o l e s a l e ra T h e s ec o m p a n i e sc a np r o d u c ea n ds e l lt h ep r o d u c t b u y s i d em a r g i nt h a tc o n s i s t so fc a s hr e b a t e sa n d a tal o w e rp r i c eb e c a u s et h e ya r en o tburdened d / o re a r l ypaymen . t d i s c o u n t sf o rp r o m p ta n s a l e s . w i t ht h er e s e a r c ha n dd e v e l o p m e n tc o s t s血atwent Thew h o l e s a l e ra l s op r o v i d e snumerouso t h e r i n t o吐l ep r o d u c . tMajorp h a r m a c e u t i c a lc o m p a n i e s s e r v i c e st om a n u f a c t u r e r s, d i s p e n s e r sa n do t h e r andg e n e r i cd r u gc o m p a n i e sh a v ev e r yd i f f e r e n t customerssucha sPharmaceuticalB e n e f i t s v i e w sont h ep h a r m a c e u t i c a lmarke . t ManagementC o m p a n i e s( P BMs), c o n 位a c t r e s e a r c h o r g a n i z a t i o n s(CROs)c o n d u c t i n gc l i n i c a lt r i a l s, ②W h o l e s a l e r s i n t e g r a t e dd e l i v e r yn e t w o r k s( I D N s )andg r o u p N i n e t yp e r c e n to fp r e s c r i p t i o nd r u gw h o l e s a l i n g p u r c h a s i n go r g a n i z a t i o n s( G P O s ) .T h e s es e r v i c e s i sp e r f o r m e dby出e官 i g官官e e "むu g .w h o l e s a l e r s : i n c l u d ep r i v a t el a b e landc o n t r o ll a b e lp r o g r a m s McKessonHBOC, I n c ., Company , C a r d i n a lH e a l t h , wherebyt h ew h o l e s a l e rpackagesandl a b e l s I n c ., 組dAm e r i S o u r c eB e r g e n .P r e s c r i p t i o nd r u g s p r o d u c tt omeett h eFooda n dD r u gA d m i n i s t r a t i o n a r ep u r c h a s e di nb u l kf r o mt h em a n u f a c t u r e r sby ( F D A ) ' ss t r i c tGoodM a n u f a c t u r i n gP r o c e d u r e s t h e s ew h o l e s a l e r s . Thed r u g sa r es t o r e di nt h e (GMP)g u i d e l i n e sf o ri n v e s t i g a t i o n a ld r u gt r i a l s . w h o l e s a l e r s 'w a r e h o u s e s, andt h e nr e s o l dt or e 臼2 W h o l e s a l e r ss u p p o r t pharmacies t h r o u g h pharmacyc h a i n sandh o s p i t a l s .S i n c ew h o l e s a l e r s promotional programs,such a sp r o v i d i n g 勿p i c a l l yp u r c h a s el a r g eq u a n t i t yo fd r u g sa tat i m e , , s i 伊s , a n dr e i m b u r s e m e n tf o rt h er e 句i l p a m p h l e t s m a n u f a c 加r e r sb e n e f i tf r o mr e d u c e ds m a l lv o l u m e p h a r m a c y ' sa d v e r t i s i n ge x p e n d i t u r e sf o rs p e c i f i c t r a n s a c t i o n sl e a d i n gt or e d u c e ds e l l i n g, h a n d l i n g p r o d u c t sb e i n gpromoteda tt h a tt i m e .G e n e r i c a n dl o g i s t i c sc o s 凪Pur c h a s e r sont h eo t h e rh a n d s o u r c i n gprogramse n a b l et h ew h o l e s a l e rt o a r er e l i e v e dfromt h ecumbersomep r o c e s so f n e g o t i a t el o w e rp r i c e sw i t hg e n e r i cm a n u f a c t u r e s buyingo n l yafewd r u g seachfroms e v e r a l onb e h a l fo fi t sc u s t o m e r s , byp o o l i n gmanyo r d e r s m a n u f a c t u r e r s , a n d社l ehighc o s to ft y i n gupc a p i t a l t o g e t h e r .Thish a sc o n t r i b u t e dt omorec o m p e t i t i v e . i nl a r g ea m o u n t so fi n v e n t o r y . g e n e r i c世 u gp r i c i n g .A u t o m a t e d血i r d 予a r t yc l a i m s The B i g Three a l s os e r v ea sb r o k e r si n p r o c e s s i n gs e r v i c e sf a c i l i t a t er e a l出n er e v i e wa n d 回n s a c t i o n sb e t w e e nt h em a n u f a c t u r e r sa n dr e t a i l a d j u d i c a t i o no fp r e s c r i p t i o n sbyt h i r dp a r t yp a y e r s c h a i n so rh o s p i t a l s .I nt h e s ec a s e s , せl ew h o l e s a l e r sucha si n s u r a n c ecompanies. T h i sa l l o w s purchasest h ed r u g si nbulkonb e h a l fo ft h e p h a r m a c i s t st op e r f o r md r u gu t i l i z a t i o nr e v i e w , b u td o e sn o tt a k ethemi n t oi n v e n t o 町 ・ c u s t o m e r (DUR)i nr e a lt 加 e肌 dn o t i 命t h ep a t i e n t sont h e TheU s eo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m s p o to fc u r r e n tf o r m u l a r yr e q u i r e m e n t san d ! o rp r i o r 4 7 8 ) . o f血.ei rmembers 祖且 z o n i n gs y s t e m se n a b l e a u t h o r i z a t i o nr u l e s . Re p r o d u c t st obes h e l v e di m m e d i a t e l ybyt h er e t a i l ② Pharmaceutical B e n e f i t sManagemen↑ pharmacy部 t h e ycomed e l i v e r e dt o由 es t o r ewi 血 Companies( P B M s ) p r i c el a b e l sa l r e a d yoneachp a c k a g e . Some , i n s u r e r s PBMsc o n t r a c tw i t hm a j o re m p l o y e r s w h o l e s a l e r sa l s op r o v i d ep o i n to fs a l ec a s hr e g i s t e r a n dMCOst oa d m i n i s t e randp r o v i d ememberswi 出 systemswherepharmaciesa r eb e t t e ra b l et o p r e s c r i p t i o nd r u gb e n e f i t sa tal o w e rc o s tt h a n manage i n v e n t o r y,through d i r e c t,r e g u l a r c o u l dbea c h i e v e dbyt h eh e a l t hp l a na l o n e .The 位' a n s m i s s i o no fi n v e n t o r yn e e d s加 t h ew h o l e s a l e r , a l s o e n s 田恒g upωdated r u gp r i c i n t ) . PBMt y p i c a l l yc h a r g e s血eh e a l t hp l a naf i . x edp e r e memberp e rmonthf e ef o ra l ld r u g sc o v e r e d . 官l h e r ea r er e g i o n a l Undert h eB i g Three,t PBMmakesap r o f i tbya c q u i r i n gandd i s p e n s i n g andnumerouss m a l l e rs u b r e g i o n a l w h o l e s a l e r s, d r u g sneededbyt h o s emembersa tal o w e rc o s t and s p e c i a l t yw h o l e s a l e r s . The r e g i o n a l t h a nt h ememberf e e s .Whileb e a r i n gsomer i s k , t h e w h o l e s a l e r ss e r v eas i m i l a rc l i e n tb a s ea st h eB i g PBMg a i n sn e g o t i a t i n gc l o u tw i t hm a n u f a c t u r e r s o f t e np r o v i d i n gsomeo ft h ea b o v ev a l u e T h r e e, andw h o l e s a l e r sa si tg r o w si nmembersc o v e r e d addeds e r v i c e sr e g i o n a l l y .I na d d i t i o n , t h e r ea r e f o rむu gb e n e f i t s .I no r d e rt op r o f i t a b l ymanage仕l e s e c o n d a r yw h o l e s a l e r swho, i n s t e a do fc a r r y i n ga 世u gb e n e f i tf o ri t smembers , PBMsn e g o t i a t ef o r f u l lp r o d u c tl i n e, f o c u sonma 油1 9s p o tp u r c h a s e s a n u f a c t u r e r si ne x c h a n g ef o r r e b a t e sw i t h世ugm o fd r u g so c c a s i o n a l l yons a l ebym a n u f a c 加r e r sa ta l a r g ev o l u m es a l e s , d e v e l o ppharmacyn e t w o r k sf o r l a r g ed i s c o u n t.官l e s ed r u g sa r et h e ns o l dt oo t h e r i t smembers, manageac o s t e f f e c t i v ef o r m u l a r y , w h o l e s a l e r sa st h e y訂 eneeded 7 ) . p e r f o r mp r o s p e c t i v eandr e t r o s p e c t i v eDUR , a n d 9 p r o m o t eg e n e r i c世 ugsubs 出l t i o n ) . (5 ) PrescriptionDrugMarket:Purchasers ①H e a l↑hcareI n s t i t u↑i o n s ③R e t a i l e r s H e a l t h c a r ei n s t i t u t i o n si n c l u d eh o s p i t a l s , c l i n i c s , R e t a i l e r si n c l u d ei n d e p e n d e n t批 ugs t o r e s , r e t a i l n u r s i n ghomes, homeh e a l t h c a r ep r o v i d e r s, c h a i npharmacies, andm a i lo r d e rpharmacies managedc a r ep r o v i d e r s, g o v e 町 田l e n ta g e n c i e s , and wherep a t i e n t st a k et h ep r e s c r i p t i o nt h e yr e c e i v e v a r i o u sa l t e r n a t ec a r ep r o v i d e r s .T h i sg r o u pi n 位 p h y s i c i a na n dh a v ei tf i l l e d .Ame r i c ah a s f r o mt h 1 9 9 8purchasedapproximately$ 2 5b i l l i o ni n 00%“ bungyo'¥ i .e .s e p a r a t i o no f v i r t u a l l y1 75%fromw h o l e s a l e r s, t h e p r e s c r i p t i o nd r u g s, i ti sa l s o p r e s c r i b i n gandd i s p e n s i n g .I nt h eUS, r e m a i n i n g25%d i r e c t l yfromm a n u f a c t u r e r s .I n commonp r a c t i c ef o rp h y s i c i a n st ouset h e o r d e rt oi n c r e a s ep u r c h a s i n gpowerf o rn e g o t i a t i n g , t e l e p h o n et oo r d e rap r e s c r i p t i o nf o rap a t i e n t h e a l t h c a r ei n s t i t u t i o n shave l a r g e rd i s c o u n t s, u s u a l l ya f t e rat e l e p h o n ec o n s u l t a t i o na n do f t e nf o r formedi n t e g r a t e dd e l i v e r yn e t w o r k s( I D N s )and ,血u ss a 吋n g吐l e ar e f i l lo fane x i s t i n gp r e s c r i p t i o n grouppurchasingo r g a n i z a t i o n s(GPOs)t h a t p a t i e n tat r i pt ot h ed o c t o r ' so f f i c e . Als o, most 出 m a n u f a c t u r e r sa n ds e l l e r sonb e h a l f n e g o t i a t ewi r e f i l l s ", a sd e c i d e dby p r e s c r i p t i o n sh a v es e v e r a l“ 4 8 医療経済研究 v o 1 . 14 2 0 0 4 , 仕l ed o c t o rw h e r eap a t i e n tc a ns i m p l yr e t u r nt o出 e i n c r e a s i n g l y ,血ep h a r m a c o e c o n o m i cb e n e f i to f出e pharmacyf o rana d d i t i o n a ls u p p l yo fm e d i c i n e p r o d u c . t Who l e s a l ep r i c e sa r en o tr e g u l a t e d .T h e tb a t c hr u n so u t .T h i si sp訂 t i c 凶町l y whent h e世 s f a c tt h a tm a n u f a c t u r e r sa r ei n c r e a s i n g l yu s i n g who commonf o rp a t i e n t sw i t hc h r o n i cd i s e a s e, p h a r m a c o e c o n o m i c st os e l lt h e i rp r o d u c t s , means mayt a k et h esamem e d i c i n ef o ry e a r s . These 血a tMCOs , PB M s ,h o s p i t a l s , a n do t h e r st h a tmake p a t i e n t smaya l s ot a k ea d v a n t a g eo fl o w e rp r i c e s p u r c h a s i n gd e c i s i o n s , e s p e c i a l l yp h a r m a c i s t s, m u s t o f f e r e dbym a i lo r d e rp h a r m a c i e s . b ek n o w l e d g e a b l e加 出ef i e l da n da b l et od i s c e r n goodandbada s s e r t i o n so fb e n e f i t , b a s e dont h e (6 )D i s t r i b u t i o nandP r i c i n go f d a t ap r e s e n t e d . hせl ef i r s tt r a n s a c t i o n担 T a b l e1 , t h ew h o l e s a l e r P r e s c r i p↑i o nDrugs R e g a r d l e s so ft h e i rh e a l t hi n s u r a n c ec o v e r a g e p u r c h a s e st h ed r u g sf r o mt h em a n u f a c t u r e r sa ta s t a t u s, mostp e o p l ep u r c h a s ep r e s c r i p t i o nd r u g s d i s c o u n t企omAWP , t y p i c a l l ya b o u t2 0 % .F r om血e 企omap h a r m a c y .S a l e sf o rr e t a i lp h a r m a c yo u t l e t s , t h er a t eo fd i s c o u n t s s e c o n dt r a n s a c t i o nf o r w a r d a c c o u n t e df o r90%o ft o t a lo u t p a t i e n tp r e s c r i p t i o n andr e b a t e sb e g i nt ov a r ya c c o r d i n gt ot h e 世u g s a l e s阻 p u r c h a s i n gpowero ft h ep u r c h 節 目1 1 ) 1 9 9 8 . t h eDepartmento fH e a l t hand I nA p r i l2 0 0 0, HumanS e r v i c e s(DHHS)c o n d u c t e das t u d yon ② CashCus ↑ omers p r e s c r i p t i o n世 u gp r i c i n g .Ones e g m e n to f吐l es t u d y T y p i c a l l y , c a s hc u s t o m e r s( b o t ht h o s ew i t h o u t r e p o r t sont h ep r i c i n go fp r e s c r i p t i o nd r u g s .T a b l e c o v e r a g eandt h o s ew i t hl e s sr e s t r i c t i v emanaged 1i sani l l u s t r a t e dh y p o t h e t i c a le x a m p l ef r o m出 s c a r eh e a l t hp l a n s )p a yn e a r l y1 5 %moret h a n出 e s t u d ys h o w i n ghowt h eb r a n d n a m eむugp r i c ei s c u s t o m e rw i t h出i r dp a r t y世 ugc o v e r a g e .I ft h e s e s e tf o re a c ht y p eo fp u r c h a s e ra n dt h eamountp a i d t h e yw i l lp a yc a s h c a s hc u s t o m e r sh a v ei n s u r a n c e, l O bye a c he n du s e r ) . upf r o n t , t h e nl a t e rs u b m i tt h er e c e i p tf o ri n s u r a n c e r e i m b 町 s emen . tP l a n ss u c h加Pr e f e r r e dP r o v i d e r ① L is ↑P r i c e O r g a n i z a t i o n s(PPOs)t y p i c a l l yr e i m b u r s et h e “ ,averagewholesaleprice" D e s p i t ei t sname memberf o r80%o ft h ep u r c h a s ep r i c e, b u tt h i s ( A WP)i sn o tt h ea v e r a g eo ft h eamountp a i dt o d e p e n d sont h es p e c i f i ch e a l t hp l 加.百l ec u s t o m e r w h o l e s a l e r sbyr e t a 且p h a r m a c i e s .I n s t e a di ti st h e maybef r e et og ot oa n ypharmacyt og e tt h e i r “ l i s tp r i c e "o rs u g g e s t e dw h o l e s a l ep r i c ep r o m o t e d p r e s c r i p t i o nf i l l e d , o r血e ymayb ed i r e c t e dbyt h e i r byt h em a n u f a c t u r e r . Asshowni nTable1 , t h e h e a l t hp l a nt oas p e c i f i cp h a r m a c y , d e p e n d i n gon a c t u a ls a l eo c c u r sa tad i s c o u n tfromt h eAWP, 出 eh e a l t hp l a n . which i s used p r i m a r i l ya s a benchmar k . h e Upon purchasing t h e drug a t AWP,t M a n u f a c t u r e r sa r ef 世間加 s e t吐l ep r i c eo fd r u g sa t w h o l e s a l e rw i l ls e l l抗 t ot h ep h a r τ n a c yw i t has l i g h t 出el e v e lt h e yb e l i e v et h em a r k e tw i l lb e 民 basedon markup, u s u a l l ya r o u n d2t o4 % . Thepharmacy f a c t o r ss u c h泊 c o m p e t i t i o n , p e r c e i v e ds u p e r i o r i t y h ec o n s u m e ra tap r i c et h a t t h e ns e l l st h e世 略 的 t v e r s u s e a r l i e rg e n e r a t i o n products,and i n c l u d e si t sc o s tf o ra c q u i r i n gt h ed r u gf r o mt h e TheU s eo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m 4 9 who1esa1erp1usar e t a i lmarkup. R e t a i 1markup 1 0 s 8 discountf o rcommonlyusedmedicationsas“ , butmarkupsi n血erangeof20t o v a r i e sbyむug 1 e a d e r s "i nordert oa t t r a c tcashcustomerst obuy 25%a r ecommon. othermedicationsandnon-medica1products. Variousp r i c i n gs t r a t e g i e sa r euseds i n c er e t a i 1 Recent1y , discountwarehouses t o r e shavea 1 s o pharmaceutica1pricingtoconsumersi saf r e e openedpharmacieso f t e ns e l l i n gbrandnamedrugs marketandnotregu1ated. Forexamp1e, the cheaper位l a nmanyr e t a i lphannacies12l • phannacymays e ta10wermarkupf o rmaintenance i rr e g u 1 a rcustomers medicationst oencourage出e ③ InsurersandPBMs , whiles e t t i n gah i g h e rmarkup t or e t u r nr e g u l a r 1 y Mscannegotiatediscountsandrebatesfrom PB eymaya l s os e tadeeper f o ra c u t em e d i c a t i o n s . Th i .e .fromboth bothendsofthepricingchain( I l u s t r a t i v eExampleo fP r i c i n gf o rBrandNameP r e s c r i p t i o nDrugs Table1 I byCustomerType CashC u s t o m e r s , dp a r t y ( N o3 I n s u r e r sand paymenta tpomt PBMs o fs a l e s ) L i s tP r i c e(AWP) M a n u f a c t u r e r ' sp r i c e : M a n u f a c t u r e rt o w h o l e s a l e ro ro t h e re n t i t y HMOs' M e d i c a i d $ 3 4 (AWP ・ 3 3 % ) $ 4 0 * * F e d e r a lS u p p l y S c h e d u l e $ 5 0 $ 4 0 (AWP2 0 % ) 司 $ 4 0 'ホ (AWP-20%) A c q u i s i t i o nP r i c e : W h o l e s a l e rt opharmacy $ 4 1 R e t a i lp r i c ea tp h a r m a c y : T o t a lo famountsp a i dby c u s t o m e ra n dr e i m b u r s e d byt h i r dp a r t yp a y e r $ 5 2 (AWP+4%) $ 4 6 * (AWP1 3 % + $ 2 . 5 0 ) R e t a i lp r i c e , l e s st y p i c a l m a n u f a c t u r e rr e b a t e N/A $30-$44 ( 5 %t o35% r e b a t e ) U l t i m a t e( n e t )amount p a i dbyf i n a lp u r c h a s e r a n d / o rconsum巴r $ 5 2 $30-$44 $ 2 4 ・ 5 2 % ) (AWP $ 4 1 事 N/A $ 4 1 + $ 2 . 5 0 N/A $30-$37 . 1% t o30% ( 1 5 r e b a t e ) $ 3 4 ( a v g . ) $30-$37 $ 3 4( a v g . ) $ 2 4 *Columnr e f e r so n l yt oHMOst h a tbuyd i r e c t l yf r o mm a n u f a c t u r e r s w i t h o u tr e b a t e N o t e s : nac o m p o s i t eo fs e v e r a lc o m m o n l yp r e s c r i b e db r a n d n a m ed r u g sf o rat y p i c a lq u a n t i t yo fp i l l s .F o r .P r i c e sa r eb a s巴do s o m ec e l l si nt h et a b l e , t h er e l a t i v er e l a t i o n s h i p sh a v eb e e nc a l c u l a t e db a s e do nr e l a t i o n s h i p sr e p o r t e di nHowI n c r e a s e d ' ec t e dP r i c e sa n dR e t u r n si nt h eP h a r m a c e u t i c a lI n d u s t r y(CBO,1 9 9 8 )s t u d y C o m p e t i t i o nf r o mG e n e r i cD r u g sH a sA妊 a n do t h e rr e l a t i o n s h i p sw i d e l yr e p o r t e db yi n d u s t r ys o u r c e s .P r i c e sa r eu s e df o ri l l u s t r a t i v ep u r p o s eo n l ya n dd on o tr e p r e s e n ta n yt y p eo fo v e r a l la v e r a g e 1 u d巴 b o t ha m o u n t sp a i db yt h i r d p a r t yp a y e r sa n da m o u n t sp a i db yt h ec o n s u m e r sa s .P r i c e sr e p o r t e di nt h et a b l ei nc c o s ts h a r i n g . e r v i c e s,( 2 0 0 0 )R e p o r tt ot h eP r e s i d e n t :P r e s c r i p t i o nDrugC o v e r a g e, S o u r c e :Departmento fH e a l t h&HumanS S p e n d i n g ,U t i l i z a t i o n ,a n dP r i c e s 帥 5 0 医療経済研究 v o L 14 2 0 0 4 manufacturersandpharmacies), s i n c et h e y d r u g st h a tt h ePBMe s t a b l i s h e da st h ep r e f e r r e d r e p r e s e n tal a r g enumbero fp a t i e n t sa n d出e r e f o r e p r o d u c t st ob eu s e dbyi t sm e m b e r s .l ft h e r ea r ea w i e l ds i g n i f i c a n tp u r c h a s i n gp o w e r .官l ef i r s tt y p e o r“ m e t o o "d r u g s numbero fs i m i l a rb r a n d n a m e, o fd i s c o u n ti sf r o m出ep h a r 百l a c y . Al吐lOu g he x a c t a v a i l a b l ef o rag i v e nc o n d i t i o n, t h ePBMmayo r f i g u r e sa r en o tp u b l i s h e dont h el e v e lo fd i s c o u n t mayn o ti n c l u d ec e r t a i nb r a n d s担 i おf o r m u l a r y .I n 宜e r e dbyせl er e 旬且 ph 創 百l a c y , i ti se s t i m a t e d出a t o a d d i t i o n , i fag e n e r i cp r o d u c ti sa v a i l a b l ef o rt h e 血ep r i c ep a i dbyt h ePBMonab r a n dnameむu gi s , t h ePBMmaye n c o u r a g eo rr e q u i r e白紙 c o n d i t i o n 1 3 1 5 %o f f血eAWPp l u saf i x e dd i s p e n s i n gf e eo f e n e r i cp r o d u c tb eu s e d . 血 eg nTable1, t h e a p p r o x i m a t e l y$ 2 . 5 0 . Asshowni T h e r ei sas 位o ngi n c e n t i v ef o rt h em a n u f a c t u r e r m訂 kupto出 ep h a r m a c yi sl o w e rt h 加 f o r吐l ec a s h o fsuchame-toobrand-namedrug, t og i v e , b u ts t i l lp r o v i d e sa p p r o x i m a t e l ya12% c u s t o m e r g d i s c o u n t st ot h ePBMi ne x c h a n g ef o rt h e i rむu markupf o rt h ep h a r m a c y . However , t h e r ea r e b e i n gi n c l u d e di nt h ef o r m u l a r y . Wheng e n e r i c i n s t a n c e swhenapharmacymaybef o r c e dt o b r a n d sa r ea l s oa v a i l a b l e, m a n u f a c t u r e r so f f e re v e n a c c e p tl o w e rp a y m e n t企om血ePBMf o ras p e c i f i c d e e p e rd i s c o u n t st omaket h 位 ownp r o d u c tmore p r o d u c t , p o t β n t i a l l ye v e nl e s s血 組 曲eph 紅 百l a c y ' s c o m p e t i t i v ew i 出 血eg e n e r i c . n せl e s ec a s e st h ep h a r m a c ymay a c q u i s i t i o nc o s t s .I 官l e r ea r ev a r i o u sa r r a n g e m e n t sf o r出 er e b a t et o h a v et or a i s ei t sp r i c e sf o rc a s hc u s t o m e r st os h i f t b ep a s s e dont o出 ePBM , b a s e donp e r f o r m a n c e, c o s t s,o r句 Tt or e d u c ei t so p e r a t i n gc o s t s, ぜi t w a n t s e . g .t h e market s h a r e achieved among a l l t o k e e p血ePBM'sb u s i n e s s . p r e s c r i p t i o n so fat y p ef o rt h a tm a n u f a c t u r e r ' s Approximately 75%o fg e n e r i cd r u g sa r e p r o d u c t .I nonesucharrangement, t h ePBM reimbursedbyt h ePBMu s i n gl i m i t sknowa s r e p o r t st h enumbero fp r e s c r i p t i o n sf o rag i v e n “ maximuma l l o w a b l ec o s t "(MAC). MACi s 世 ugωthem a n u f a c t u r e r . Them a n u f a c t u r e rt h e n e s t a b l i s h e dbyt h ePBMa n di st y p i c a l l y5 0t o60% pays t h e PBM an agreed amountf o reach belowt h eAWP. Theo t h e r25%o fg e n e r i c sa r e p r e s c r i p t i o n . PBMst h a ta r ec o n t r a c t e dt oan r e i m b u r s e du s i n gas i m i l a rschemea sf o rb r a n d - i n s u r e ro rs e l f i n s u r e demployera r et y p i c a l l y 1 3 l. r e q u i r e dt op 加 s on70ω90%of血er e b a t e s namedrug,b u tmayhaveas l i g h t l yh i g h e r d i s p e n s i n gf e et oe n c o u r a g eg e n e r i cs u b s t i t u t i o nby t h ep h a r m a c i e s . ④HMOsandHealthcareI n s↑i ↑ u t i o n s 官l es e c o n dt y p eo fd i s c o u n ti sam a n u f a c t u r e r ' s 官l ed i r e c tp u r c h a s i n gHMOi n血et a b l er e c e i v e s r e b a t et ot h ePBM, whicht h ePBMn e g o t i a t e s ad e e p e rd i s c o u n t由 組 曲atofaPBM.官 邸 g r o u pi s d i r e c t l yw i t ht h ed r u gm a n u f a c t u r e r .T h i si sa , s u c ha s r e p r e s e n t e dbyar e l a t i v e l yfewl a r g eHMOs s e p a r a t et r a n s a c t i o nf r o mt h er e g u l a rp r i c i n go fa K a i s e rPermanente,t h a to p e r a t et h e i rown 世u gi n v o l v i n gt h ew h o l e s a l e randt h epharmacy , andbuyd r u g s p h a r m a c i e sandi n t e r n a lPBMs, a n d a f f e c t s吐l e印 刷 amounts p e n tbyt h ePBM.官 l e d i r e c t l y仕omt h em a n u f a c t u r e r s . Them a j o r i t yo f k e yd e t e r m i n i n gf a c t o ri nt h ea v a i l a b i l i t ya n dt h e HMOsmanageむu gc o s t sandu t i l i z a t i o nt h r o u g h h ef o r m u l a r y , al i s to f amounto ft h er e b a t ei s担 t e x t e r n a lPBMsanddon o tr e c e i v et h e s ed e e p e r T h eU s eo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m d i s c o u n t s 叫 5 1 m a n u f a c t u r e rp r i c e(AMP), whlchi st h ea v e r a g e p r i c ep a i db y仕l ew h o l e s a l e r s , a n d出e“ b e s t "p r i c e, ⑤F e d e r a lF a c i l i ↑ i e sandAgencies whichi ss i m p l yt h el o w e s tp r i c eo f f e r e dbyt h e 官l ef e d e r a lg o v e r n m e n ti st h el a r g e s tp u r c h a s e r m a n u f a c t u r e rt oa n yp u r c h a s e ra ta n y曲 n ed u r i n g o fd r u g si nt h eUS , mosto fw h l c hi su s e dbyt h e t h ey e 民 e x c e p tf o rf e d e r a lp u r c h a s e r ss u c ha st h e V e t e r a n sH e a l t hA d m i n i s t r a t i o n(VHA). P r i c e so f 5 . 1 %o f出 eAMP. VHA. Theminimumr e b a t ei s1 d r u g sp u r c h a s e dbyt h eVHAando t h e rf e d e r a l Form u l t i p l es o u r c em e t o od r u g s, t h er e b a t ei s 6 1 s i m p l y11%o . l f t h eAMP a g e n c i e sa r es e tbyt h eF e d e r a lS u p p l yS c h e d u l e ( F S S ) . 百l eVHAn e g o t i a t e s出 eFSSp r i c ew i 血t h e , andg e n e r a l l yt h ep r i c e sc a n n o tb e m a n u f a c t u r e r (7) T r e n d si nDrugP r i c e s h i g h e r血 加 t h el o w e s tc o n t r a c t u a lp r i c ec h a r g e dt o Asm e n t i o n e de a r l i e r , t h er a t eo fi n c r e a s ei n a n yn o n f e d e r a lp u r c h a s e r .I nd e t e r m i n i n gt h e p r e s c r i p t i o nd r u gc o s t snowe x c e e d st h er a t eo f p r i c e, t h em a n u f a c t u r e rp r o v i d e st h eVHAw i t h i n c r e a s ei no t h e rcomponentso fh e a l t h c a r e i n f o r m a t i o nond i s c o u n tandr e b a t e so f f e r e dt o s p e n d i n g . P a y e r s have c r i t i c i z e d t h e o t h e rp u r c h a s e r s . FSSp r i c e sa r eg e n e r a l l yl e s s p h a r m a c e u t i c a li n d u s t r yf o rt h ed i s p r o p o r t i o n a t e t h a nh a l fo ft h ep r i c e sp a i dbyo t h e rn o n f e d e r a l 1 5 l e n t i t i e s. i n c r e a s eandu l t i m a t e l yf o rt h ei n c r e a s ei n h e a l t h c a r ee x p e n d i t u r e s . They c l a i mt h a t manuf 配 加r e r s 'e f f o r ぉt o p r o m o t e血e i rp r o d u c t st o ⑥M edicaidPrograms consumerst h r o u g hb i l l i o n so fd o l l a r ss p e n ton Thep r i c er e i m b u r s e dt or e t a i lp h a r m a c i e sby d i r e c tt o c o n s u m e r(DTC)a d v e r t i s i n gf u r t h e r M e d i c a i di sd e t e r m i n e dbyc o s tl i m i t sandf i x e d i n c r e a s e sb o t ht h ep r i c eo fands p e n d i n gonnew d i s p e n s i n gf e e s .I nt h ec a s eo fb r a n d n a m ed r u g s d r u g s . Thep h a r m a c e u t i c a li n d u s t r yi nr e s p o n s e whereg e n e r i ce q u i v a l e n t sa r en o ta v a i l a b l e, t h e s 胞t e st h a tt h eむu ge x p e n d i 加r ei ss 凶1o n l y a b o u t 宣c c o s tl i m i ti st h ep h a r m a c y ' sc o s tf o rt h es p e c i 1 0 %o f加 t a lh e a l 出c a r ec o s t s .T h e ya l s oc 1 aim出a t むu g .F o rd r u g sw i 出 o t h e rb r a n d n a m eo rg e n e r i c 加a li n c r e a s ei n世u gp r i c e si sas m a l lp a r to f t h ea c e q u i v a l e n t ,出el i m i ti sb 錨 e donMAC. TheMACs i n c r e a s e担 世u ge x p e n d i t u r e , w h e r e a sm o s to ft h e f o rM e d i c a i da r ep u b l i s h e dbyTheC e n t e r sf o r i n c r e a s e加 世uge 却 e n d i t u r ei sc a u s e db yi n c r e a s e s M e d i c a r e&M e d i c a i dS e r v i c e se v e r ys i xmonths i nv o l u m ea n ds w i t c h i n gf r o mo l d e rl e s se 首e c t i v e a n ds e ta t1 5 0 %o f血el o w e s tp u b l i s h e dp r i c ef o r d r u g s,t o newer, 日lOr e e f f e c t i v e, and a n ye q u i v a l e n td r u g, p l u sad i s p e n s i n gf e e .The commensurately more e x p e n s l v e,d r u g s . OmnibusBudgetR e c o n c i l i a t i o nActo f1 9 9 0 Accordingt oIMSH e a l t h, druge x p e n d i t u r e s s t i p u l a t e st h a tMedicaidprogramsa l s omust 4 . 7 %i n2 0 0 0, b u tl e s st h a n4%o ft h a t i n c r e a s e d1 r e c e i v er e b a t e s企ommanufac 加r e r s, j u s tl i k ePB Ms i n c r e a s ewasd u et op r i c ei n c r e a s e17). a n do t h e rp r i v a t ep u r c h a s e r s .F o rs i n g l es o u r c e G e n e r i cd r u gmanufacturersa l s oc r i t i c i z e d r u g sandm u l t i p l es o u r c ed r u g s, t h er e b a t ei s p h a r m a c e u t i c a lc o m p a n i e sc i t i n gs e v e r a lr e加 o n s s p e c i f i e da st h ed i f f e r e n c ebetweent h ea v e r a g e f o rp r e v e n t i n gg e n e r i cd r u g sfromgrowingi n 5 2 医療経済研究 v o L 14 2 0 0 4 m a r k e tp e n e t r a t i o n .G e n e r i cd r u gu t i l i z a t i o nh a s b u tconsumed$ 1 3 0b i l l i o no r92%o ft h et o t a lc o s t r a n g e d企om4 0t o45%o fa l lp r e s c r i p t i o n si nt h el a s t o fprescription 世ugs 22l • andh a sn o tg a i n e ds h a r ed u r i n gt h a t 7y e a r s, 官l el e a d i n gd r u g sbys a l e si nt h eUSa r eshown period18l • G e n e r i cd r u gm a n u f a c t u r e r sc o n s i d e rt h i s i nTable2 . Thenumbero n es e l l e rL i p i t o rand r a t ea r t i f i c i a l l ylowandblamep h a r m a c e u t i c a l numbert h r e eZ o c o ra r eb o t hl i p i dl o w e 血 g世 u g s . companiesf o re r e c t i n gb a r r i e r ssucha sbrand R e c e n ts t u d i e ss h o w i n g白紙 moreAm e r i c a n sc o u l d nameDTCa d s, l o b b y i n gc o n g r e s st oe n a c tl a w s b e n e f i t企om出 sk i n do ft h e r a p yh部 c o n 位i b u t e d加 d i s c o u r a g i n gg e n e r i c s, andm a n u f a c t u r e rr e b a t e s r o b u s ti n c r e a s e si ns a l e so ft h e s ec o m p e t i t i v e f o rb r a n dnameproducts19l• p r o d u c t s .P r i l o s e ca n dP r e v a c i da r ebo 由 p roωn However, w h i l eg e n e r i cd r u gm a n u f a c t u r e r s pumpi n h i b i t o r st h a treducestomacha c i di n p r o m o t et h el o w e rc o s to fg e n e r i cd r u g s , t h eNew p a t i e n t sw i t hg a s t r o e s o p h a g e a lr e f l u xd i s e a s e Y o r kTim e sr e c e n t l yr e p o 此e d由a tp r i c e so fg e n e r i c (GERD)ando t h e rs t o m a c hp r o b l e m sc a u s e dby d r u g sh a v ei n c r e a s e da l m o s tt w i c ea sr a p i d l ya s e x c e s sa c i d .P r i l o s e ci sc o m i n go f fp a t e n ts o o na n d p r i c e so fb r a n d n a m ed r u g sd u r i n gt h esamep e r i o d . w i l lmovet oo v e r由 ec o u n t e rs t a t u s .C e l e b r e xi sa 官l ea r t i c l er e p o r t st h a twhent h ep a t e n to fab r a n d - COX-2i n h i b i t o r, oneo ft h enewc l a s so fnon nameむu ge x p i r e s, g e n e r i c世 u gm a k e r sc h a r g ea 町 世u g s( N S A I D s )f o r由e s t e r o i d a la n t i i n f l a m m a t o h i g h e rp r i c ef o rt h ef r r s tg e n e r a t i o ng e n e r i c s .B u t p a i no fa r t h r i t i s . Thesed r u g shavefewerGI p r i c e sono l d e rg e n e r i cd r u g sa r ea l s oi n c r e a s i n g . b l e e d i n gs i d e e f f e c t s,though have s i m i l a r F o re x a m p l e, p r i c eo ft h eg e n e r i cv e r s i o no ft h e e 飴c t i v e n e s si np a i nr e l i e f .Epogena n dP r o c r i t紅 e a n t i h i s t a m i n eP h e n e r g a nr e c e n t l yi n c r e a s e d900% e r y t h r o p o i e t i n p r o d u c t s made by t h e t o$ 3 0 9f o rat h o u s a n dp i l l sf r o m$ 3 0p e rt h o u s a n d b i o p h a r m a c e u t i c a li n d u s t r yf o ra n e m i ac a u s e dbya pillS 20l numbero fc o n d i t i o n ssucha sc a n c e r, k i d n e y • C o n s o l i d a t i o no fg e n e r i cm a n u f a c t u r e r sh a s f a i l u r e, andm a j o rs u r g e r y .Z y p r e x ai sana n t i - r e s u l t e di nf e w e rc o m p a n i e sa n dl e s sc o m p e t i t i o n p s y c h o t i ci n d i c t e df o rs c h i z o p h r e n i aa n db i p o l a r m血emarket 官l e直v el a r g e s tm a n u f a c t u r e r snow d i s o r d e r .Z o l o 立a n dP a x i la r ec o m p e t i t i v es e l e c t i v e a c c o u n tf o rmore由 加 50%o fg e n e r i cむu gsales s e r o t o n i nr e u p t a k ei n h i b i t o r s( S S R I s )u s e dt ot r e a t 21l • D e s p i t e仕l e s ef a c t o r s , g e n e r i cd r u g sa r es t i l lt h elow d e p r e s s i o nando b s e s s i v ec o m p u l s i v ed i s o r d e r . c o s ta l t e m a t i v et ob r a n d n a m ep r e s c r i p t i o n批 u g s . N o t et h a tmostt o pt e nd r u g sh a v em e t o ob r a n d Ona v e r a g e , p r i c eo fap r e s c r i p t i o nd i s p e n s e dwi 血 namec o m p e t i t o r sa l s oi nt h et o pt e n , i l l u s t r a t i n g ag e n e r i cdrugi n2000was$ 1 9 . 9 3, w h i l et h e 他 ef i e r c e l yc o m p e t i t i v en a t u r eo ft h em a r k e ta n d a v e r a g ep r i c eo fap r e s c r i p t i o nd i s p e n s e dw i t ha i m p o r t a n c et ot h em a n u f a c t u r e r so feconomic brand-named r u gwas$ 6 5 . 2 9 .I n2 0 0 0, 42%o f i n c e n t i v e s, sucha sd i s c o u n t sandr e b a t e s, t o p r e s c r i p t i o n swered i s p e n s e dw i t hg e n e r i cd r u g s , p r o m o t et h e i rp r o d u c t s . b u tconsumedo n l y8%o f由e$ 1 4 1b i l l i o ns p e n ton p r e s c r i p t i o nd r u g s . Ont h eo t h e rh a n d , b r a n d n a m e , d r u g swered i s p e n s e df o r58%o fa l lp r e s c r i p t i o n s (8) Summary eupa b o u t1 0 %o ft h eU S ' P h a r τ n a c e u t i c a l sm叫( T h eU s eo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m 5 3 Table2 LeadingPrescriptionDrugSales:2 001 P r o d u c t(Manufacturer)TotalD o 1 1 a r s 市 %Growth 柿 1 IL i p i t o r ( P E z e r ) 8 5 , 22425 2 IP r i l o s e c( A s t r a Z e n e c a ) 8 4 , 6 1 1 %MarketS h a r e * 紳 3 -2 2 . 6 3 IZ o c o r( M e r c k ) $ 3 , 68031 2 . 1 4 IP r e v a c i d( T A P ) 8 3 , 5 5 3 1 2 2 5 IC e l e b r e x( P h a r m a c i a ) 8 2 , 6 1 5 2 1 1 . 5 6 IE p o g e n(AInge1~ $ 2 , 56324 1 . 5 7Pmerit(0rthoB i o t e c h ) $ 2 , 55637 1 . 5 8 IZ y p r e x a ( L i l l y ) 8 2 , 5 1 0 2 9 1 . 4 9 IZ 0 1 o f t ( P f i z e r $ 2 , 27014 1 . 3 1 0 IP a x i l( G 1 a x oS m i t h K l i n e ) 1 . 2 $ 2 , 15416 ,R e t a i la n dP r o v i d e rP e r s p e c t i v e , 2 0 0 2 S o u r c e :I M SH e a l t h *R e p r e s e n t sp r e s c r i p t i o np u r c h a s e s , i nm i l l i o n s ,a tp h a r m a c ya c q u i s i t i o nc o s t sb yr e t a i lf o o ds t o r ec h a i n s , m a s s m e r c h a n d i s e r s , i n d e p e n d e n tp h a r m a c i e s ,m a i ls e r v i c e s , n o n f e d e r a la n df e d e r a lh o s p i t a l s ,c l i n i c s ,c l o s 鈴e d . 叩 a l lHMOs , l o n g ,h o m eh e a l t h c a r ea n dp r i s o n s / u n i v e r s i t i e . s t e r mc a r ep h a r m a c i e s V e r s u sp r e v i o u sy e a r 制,*A sap e r c e n t a g eo fa l lp r e s c r i p t i o nd r u gs a l e s 柿 o ni nn a t i o n a lh e a l t he 却 e n d i t u r e s .H e a l t h $ 1 .4位由i governmentc o n t r a c t u a l l ya l w a y spays由 el o w e s t insurancei nt h eUSi sprovidedmostlybyt h e p r i c ef o rd r u g s , whereasconsumers出atpayo u to f p r i v a t es e c t o r , thoughaboutoneq u a r t e ro ft h e pocketpayt h emos . t Drugpricesaree s c a l a t i n g p o p u l a t i o ni se n r o l l e di nag o v e r n m e n t s p o n s o r e d f a s t e rthanothercomponentsofhealthcare p l a nl i k eM e d i c a r eo rM e d i c a i d , anda b o u t15%have e x p e n d i t u r e s , a tl e a s ti np a r tduet oh i g h e rc o s t so f noh e a l 社1i n s u r a n c e .P r i v a t eh e a l t hi n s u r a n c ei s d r u gd e v e l o p m e n t .I ti sa r g u a b l ewhethero rn o t a d m i n i s t e r e da l m o s te x c l u s i v e l ybyMCOs , whou s e i n c r e a s e si nvolumeo f世 ugu s eands w i t c h i n gfrom av a r i e t yofmechanismst oc o n t r o lc o s t sand l e s se 宜' e c t i v ed r u g st onewermoree f f e c t i v ed r u g s i m p r o v ee 百' e c t i v e n e s s, i n c l u d i n gmanagingt h eh i g h i sc a u s i n gs l o w e rgrowthi no t h e ra r e a s, sucha s c o s to fd r u g s出roughPBMs. PBMsc o n t r a c tw i t h h o s p i t a l i z a t i o n . Thetoptendrugsi n c l u d ea h e a l 出 p加lSωsupplyt h ep r e s c r i p t i o nd r u gneeds numbero fproductsmadebyc o m p e t i t o r st h a t o fmembers. Bypoolingmembersfrommany competef o rs i m i l a rp a t i e n t s, i l l u s t r a t i n gt h eh i g h p l a n s , PBMsg a i ni n f l u e n c e , andwind i s c o u n t sfrom l e v e lofcompetitioni nthemarket, andt h e bothsupplyingmanufacturersandd i s p e n s i n g 加l p O 此a n c eo feconomici n c e n t i v e sa ss a l e st o o l s . p h a r m a c i e s . Wh o l e s a l e r sp l a yani m p o r t a n tr o l e担 movingdrugsthrought h esupplychainand s u p p o r t i n g出 ea c t i v i t i e so fr e t a i lp h a r m a c i e s .O n l y 2 .TheUseofPharmacoeconomics intheUS t h e1 訂g e s tHMOsa r eb i genought op u r c h a s ed r u g s d i r e c t l y from manufacturers. The f e d e r a l (1)What1 5Pharmacoeconomic5? 5 4 医療経済研究 v o 1 . 14 2 0 0 4 ①D e f i n i t i o n s p l u so rm泊u s )i nu t i l i z a t i o nd u et obo 血 c h a n g e s( Pharmacoeconomicsh a sb o t hs p e c i f i cand e f f i c a c ya sw e l la ss i d ee f f e c t sanda d v e r s e g e n e r a lme 鉱山1 9 Si nt h eh e a l t h c a r ew o r l d .I nt h e r e a c t i o n s, andcomesupw i t hav a l u ef o rt h en e t i tr e f e r st os p e c i f i ca n a l y t i ct o o l s s p e c i f i cs e n s e, e f f e c to fanewd r u gi nah e a l t h c a r es y s t e m .T h i s ( e . g .c o s tm i n i m i z a t i o na n a l y s i s, c o s tb e n e f i t o re v e nt h emost s h o u l dn o tbecomet h eo n l y, , c o s t e 宜e c t i v e n e s sa n a l y s i s , a n dc o s tu t i l i t y a n a l y s i s i m p o r t a n t , wayt oj u d g ew h e t h e ro rn o tt oo f f e ra a n a l y s i s ) usedt op r e d i c tt h et o t a lc o s to f g .B u ti td o e sg i v ea na d d i t i o n a lmeansb y newむu i n t r o d u c i n gas p e c i f i cp r o d u c ti nah e a l t h c a r e whicht oe v a l u a t ep o t e n t i a lnewp r o d u c t si n d e l i v e r ys e t t i n g .I nt h emoreg e n e r a ls e n s e, , a d d i t i o nt ot h e i rc l i n i c a le f f e c t i v e n e s sa n ds a f e t y pharmacoeconomicsi saneconomicv i e w p o i n t e s p e c i a l l y担 加 e r aofbo 出 r i s i n gh e a l 血c a r ec o s t s a p p l i e d t o h e a l t h c a r e d e c i s i o n m a k i n g . andi n c r e a s i n gc h o i c e s amongmyriadnew Pharmacoeconomica n a l y s i si ss u p p o r t e dbya 宜' e r e n t p r o d u c t s . Then e te f f e c tonc o s tmayb ed i s e r i e so fo r g a n i z a t i o n s , p r o c e s s e s , a n do u t p u t st h a t wherec o s t sandp r a c t i c e f r o ms e t t i n gt os e t t i n g, l o o kbeyondt h ee f f i c a c yands a f e t yo fad r u g加 p釧 e r n s v 町y , 血u se a c hh o s p i t a la n dMCOn e e d st o r e p o r t e doni t sFDA-approvedl a b e l, t oh e l p ft h ee c o n o m i ce 宜' e c t s maket h e i rowna n a l y s i s .I d e t e r m i n ewhata r e出em o s te 宜e c t i v ep r o d u c t st o a r es i m i l a rf o rm u l t i p l eme-toop r o d u c t s( i .e . u s ei nah e a l t hc a r es e t t i n g . Keyt ob o t hs p e c i f i c p r o d u c t s t h a t have s i m i l a r i n d i c a t i o n s, p h a r m a c o e c o n o m i ca n a l y s e s , a n d社1 emoreg e n e r a l e f f e c t i v e n e s s, ands a f e t y ), t h i sg i v e sp u r c h a s e r s pharmacoeconomicv i e w p o i n t , i st h a tonemust s i g n i f i c a n tl e v e r a g eonp r i c ed u r i n gp u r c h a s i n g l o o k p 加t 出 ep r o d u c t ' ss a l e so ra c q u i s i 乱o np r i c et o n e g o 伽 : t i o n s . 出eo v e r a l lc h a n g ei nr e s o u r c e se x p e n d e di no r d e r P訂 t so fp h a r m a c o e c o n o m i ca n a l y s e sa r ea p p l i e d t oj u d g ew h e t h e rt h ee f f e c to fanewp r o d u c to r bye a c hc o n s t i t u e n ti nt h ep h a r m a c e u t i c a lv a l u e s e r v i c ei se c o n o m i c a l l yf a v o r a b l ei nas p e c i f i c , f r o mm a n u f a c t u r et h r o u g hc o n s u m p t i o nb y c h a i n s e 岡崎・ i n d i v i d u a lp a t i e n t s, f o rd i f f e r e n tr e a s o n sandt o Newd r u ge f f e c t i v e n e s smayhavenumerous 必宜' e r i n ge x t e n t s .M a n u f a c 加r e r sむytome 路 町e 血e e f f e c t sonh e a l t h c a r eu t i l i z a t i o nandu l t i m a t e l y e c o n o m i cb e n e f i to fanewp r o d u c tv e r s u s加 o l d o r , ad r u gf o r紅白r i t i sp a i nr e l i e f c o s t s .F o re x a m p l e c o m p e t i t i v ep r o d u c t , andu s et h a ti n f o r m a t i o nt o mayr e d u c eo u t p a t i e n tv i s i t so re v e nd e l a y由eneed h e l ps e l li t .P h y s i c i a ng r o u p sandh o s p i t a l sm u s t f o rj o i n tr e p l a c e m e n ts u r g e r y . A世 u gf o ra s t h m a c o n s i d e rt h ep o t e n t i a le f f e c to fanewp r o d u c ton mayr e d u c ee m e r g e n c yh o s p i t a l i z a t i o n s .A tt h e 血e i rc o s t swhend e c i d i n gw h i c hw h e t h e r加 u s ei t samet i m e, a l ld r u g sh a v es i d ee 宜e c t so ra d v e r s e i ns u r g e r i e s血a ta r er e i m b u r s e da: f i x e df e eu n d e r r e a c t i o n s凪 as m a l lnumbero fp a t i e n t s . 百1 e s et o o p r o s p e c t i v epaymen t .P a t i e n t smusti n d i v i d u a l l y a f f e c th e a l t h c a r eu t i l i z a t i o n and c o s t s,by w e i g h t血ec o s t , s a f e t ya n db e n e f i t so fanew世 u g n e c e s s i t a t i n ganu n e x p e c t e do u t p a t i e n tv i s i to r recommendedby出 e i rd o c t o r , some 吐l i n g血e y a r e e v e nh o s p i t a l i z a t i o n . Thepharmacoeconomic l i k e l yt obei l l e q u i p p e dt odoa l o n e . PBMsu s e v i e w p o i n tl o o k sa tt h ea c q u i s i t i o nc o s t , p l u sa l l pharmacoeconomica n a l y s e st oh e l pd e t e r m i n e TheU s eo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m 5 5 w h i c hd r u g st or e 加b u r s eu n d e rt h 位 f o r r n u l a r i e s . r e q u i r e sminimums t a n d a r d sf o rc l i n i c a ld a 阻.官l e , e v e nt h et e r r n“c o s t "meansad i f f e r e n t However FDAa l s oh a ss t a n d a r d sf o rhowc l i n i c a lt r i a l sa r e t h l n gωeacho ft h e s ec o n s t i t u e n t s , d e p e n d i n gon performed, andhowoutcomesa r er e p o r t e d . t h e i rv i e w p o i n t sa n di n c e n t i v e s . Thep a t i e n tmay Pharmacoeconomict r i a l sando u t c o m e sa r en o t c a r emostaboutt h ec o s to fh i sco-payment, r e q u i r e dby血eFD A .B u t , manyc l i n i c a lt r i a l sd o w h e r e a st h emanagedc a r eo r g a n i z a t i o nmayh a v e i n c l u d eo u t c o m e s吐mtmayb er e l a t e dt op o t e n t i a l a l l也 ed a t an e c e s s a r yt od oac o m p l e t ep r o s p e c t i v e e c o n o m i cb e n e f i to fp r o d u c tu s e .F o re x a m p l e , a a n a l y s i so ft h et o t a lc o s tt ot h esystemo f p r o d u c tmayh a v eb e e nshownt od i r e c t l yr e d u c e t . i n t r o d u c i n ganewp r o d u c u t 出z a t i o no fs p e c i f i ch e a l t h c a r er e s o u r c e ss u c h描 h o s p i t a l i z a t i o n . Ac l i n i c a lo u t c o m es u c ha sp a i n (2 ) OrganizationsAc↑i v ei n a t ei n t oe c o n o m i cb e n e f i t , 江 r e l i e fi sh a r d e r加佐沼lSl PharmacoeconomicsP o l i c yand t h emanufacturerd i dn o tmeasurer e s o u r c e s Promo ↑ i o n u t i l i z e dp r o s p e c t i v e l y . However , m a n u f a c t u r e r sd o ①I n t r o d u c t i o n p r o v i d e pharmacoeconomic d a t at o P&T Anumbero fo r g a n i z a t i o n sh a v ea ni n t e r e s ti n c o m m i t t e e sando t h e rd e c i s i o nmakers, andt h i s s t a n d a r d s and promotion o ft h e use o f h 槌 r a i s e dq u e s t i o n s加 t ow h e t h e r也eFDAshould pharmacoeconomics by Pharmacy and 四g u l a t es u c ha n a l y s e s . T h e r a p e u t i c s(P&T)committees, ando t h e r s 官l eFDAM o d e r n i z a t i o nA c to f1 9 9 7d o e sc o n t a i n r e s p o n s i b l ef o rd r u gs e l e c t i o n .T h i ss e c t i o nw i l l as e c t i o np e r t a i n i n gt opharmacoeconomic r e v i e wFDAr e g u l a t i o no fpharmacoeconomic S e c t i o n1 1 4 :H e a l t hc a r ee c o n o m i c i n f o r r n a t i o n :“ c l a i m s, t h ei m p o r t a n c eo fpharmacoeconomic 加f o r r n a t i o n " .T h i ss e c t i o nwaso r i g i n a l l ywl批.ena s a n a l y s i st om a n u f a c t u r e r s, a n dt h ev i e w p o i n ta n d ad r a f tg u i d a n c ef o rt h eFDAb yaw o r k i n gg r o u po f e f f o r t so ftwop h a r m a c i s t s 'o r g a n i z a t i o n s, t h e o r g a n i z a t i o n s under t h ea u s p i c e so ft h e Academyo fManagedC a r eP h a r m a c y( 品I I C P )a n d I n t e r n a t i o n a lS o c i e t yf o rP h a r m a c o e c o n o m i c sa n d Am e r i c a nS o c i e t yo fH e a l t h S y s t e mP h a r m a c i s t s OutcomesR e s e a r c h( I S P O R ) . Thes e c t i o ns t a t e s (ASHP). These s e c t i o n sa r e based on a t h a th e a l t hc a r eeconomici n f o r m a t i o nt h a ti s combinationo fi n t e r v i e w sconductedbyt h e providedbyamanufacturert oaf o r m u l a r y a u t h o r si nt h ew i n t e ro f2 0 0 3, e x c e p tf o rt h eFDA , c o m m i t t e eo rs 面世紅 e n t i t y“ s h a l ln o tb ec o n s i d e r e d a n dl i t e r a t u r er e v i e w . t ob ef a l s eo rm i s l e a d i n gu n d e rt h i sp a r a g r a p hi ft h e h e a l t hc a r ei n f o r m a t i o nd i r e c t l yr e l a t e st oa n ②FDA i n d i c a t i o na p p r o v e du n d e rs e c t i o n5 0 5o ru n d e r TheFoodandDrugA d m i n i s t r a t i o n(FDA) s e c t i o n3 5 1 ( a )o ft h ePu b l i cH e a l 血S e r v i c eA c tf o r r e g u l a t e sp r o d u c t i o n, s a l e s, andm a r k e t i n go f s u c hd r u ga n di sb a s e do nc o m p e t e n ta n dr e l i a b l e p h a r m a c e u t i c a lp r o d u c t si nt h eU S . TheFDA s c i e n 姐 ce v i d e n c e " . r e v i e w sanda p p r o v e sa l lc l a i m smadeont h e p r o d u c tl a b e lr e g a r d i n ge f f i c a c yands a f e t y , and B u tt h eFDAd o回 n o th o l dt h ecompanyt o血e sames t a n d a r d sf o rp h a r m a c o e c o n o m i cr e s u l t s踊 5 6 医療経済研究 v o 1 . 14 2 0 0 4 t h e yd of o re f f i c a c yands a f e t y ,部出es e c t i o ng o e s c u r r e n t l yt o g e t h e rs p e n dmoret h a n$ 3 0b i l l i o np e r ont os a yt h a t “ ,Therequirementss e tf o r t hi n y e a ronr e s e a r c ha n dd e v e l o p m e n . t1 tt a k e st e nt o s e c t i o n5 0 5 ( a )o ri ns e c t i o n3 5 1 ( a )o ft h eP u b l i c 自 立e e ny e a r st ob r i n ganewp r o d u c t加 m a r k e t , y e t H e a l t hS e r v i c eA c ts h a l ln o ta p p l yωhealthc a r e o 叫y2 5 0o f5 , 0 0 0compoundss c r e e n e dw i l le n t e r economic i n f o r m a t i o np r o v i d e dt o such a n l y5o ft h o s e2 5 0w i l l p r e c l i n i c a lt e s t i n g . Ando committeeo re n t i t yi naccordancew i t ht h i s e n t e rc l i n i c a lt r i a l s, w i t ho n l yonee v e n t u a l l y p a r a g r a p h " . While i n f o r m a t i o nr e l a t e dt o 2 3 g a i n i n gFDAa p p r o v a l ) . pharmacoeconomicsc l a i m sdon o tneedt obe Th a tnewd r u g sa r ee x p e n s i v ed u et oh i g hR&D s u b m i t t e dt ot h eFDAf o rp r i o ra p p r o v a l, t h e c o s t si sn o ti nd e b a t e . I n f o r m a t i o nt h a ti sr e l e v a n t s e c t i o nd o e ss t a t et h a t“ pharmacoeconomice v i d e n c et oshowt h a tnew t o血es u b s t a n t i a t i o no ft h eh e a l t hc a r ee c o n o m i c d r u g s, e v e na th i g hp r i c e s , c a nl e a dt ol o w e ro v e r a l l i n f o r m a t i o np r e s e n t e dp u r s u a n tt ot h i sp a r a g r a p h , aM e d i c a i dp r o g r a m h e a l t h c a r ec o s t s .F o re x a m p l e s h a l lbemadea v a i l a b l et ot h eS e c r e t a r yupon i nV i r g i n i ar e p o r t e d l ys a v e d$ 2 8 5, 0 0 0i na v o i d e d r e q u e s t " . Th u st h eFDAc a na s km a n u f a c t u r e r st o e m e r g e n c yroomc o s t sandu r g e n tc a r ev i s i t sby s u b s t a n t i a t et h e i rpharmacoeconomicc l a i m s, i n i n c r e a s i n gasthmad r u gu s eamongi t sc h i l d c a s eo fq u e s t i o n s . p o p u l a t i o n .P a t i e n t ss u f f e r i n gfromd e p r e s s i o n PhRMA u s e s whow e r eona n t i d e p r e s s a n tm e d i c a t i o nf o ra tl e a s t ③PhRMA Them a n u f a c t u r e r so fb r a n dnamed r u g sa r e r e p r e s e n t e dbyt h eP h a r m a c e u t i c a lR e s e a r c hand 6m o n t h sh a dar e d u c t i o ni n血 位 a n n u a lh e a l t h c a r e 2 4 c o s t so f$ 1 1, ) . P 0 0 0 hR MAc i t e sn u m e r o u ss i m i l a r e x a m p l e s . M a n u f a c 加r e r so fAm e r i c a( P hR M A ) .Wi 白 血ec o s t Onah i g h e rl e v e l , PhRMAa l s oc i t e sworkby o fnewd r u g sr i s i n gf a s t e rt h a no t h e rh e a l t hc a r e C o l u m b i aU n i v e r s i t ye c o n o m i s tF r ankL i c h t e n b u r g c o m p o n e n t s , m a n u f a c t u r e r sa r ean a t u r a lt a r g e t加 s h o w i n gt h a te a c h$ 1i n c r e a s ei nd r u gs p e n d i n gi s ac a u s eo fh e a l t hc a r ei n f l a t i o n , p a r t i c u l a r l yby a s s o c i a t e dw i t ha$ 3 . 6 5r e d u c t i o ni nh o s p i t a l p a y e r sa n dc o n s u m e ra d v o c a t e s . Th u si ti sc r i t i c a l e x p e n d i t u r e st o d a y .A l s o, w h i l ep r e s c r i p t i o n世 u g s f o r PhRMA and i t s members t o use a sap o r t i o no ft o t a lh e a l t hc a r es p e n d i n ghas pharmacoeconomic a n a l y s e st o show t h a t 部 e df r o mt e ny e a r sa g o, h o s p i t a le x p e n d i t u r e s i n c r e i n n o v a t i v e,new p h a r m a c e u t i c a lp r o d u c t s haved e c r e a s e dfromn e a r l y37%t oo n l y33%, c o n t r i b u t et oo v e r a l llowerh e a l t h c a r ec o s t s, s u g g e s t i n gt h a tnewandimprovedd r u g sa r e d e s p i t eh i g ha c q u i s i t i o nc o s t s( i . e .p u r c h a s ep r i c e s ) . 2 o s u b s t i t u t i n gf o rmorec o s t l yi n p a t i e n tc a r e tc a n ) .I E s c a l a t i n gd r u gp r i c e sa r ed r i v e nbyt h er i s i n g c o s t so fr e s e a r c handdevelopmento fnew b ea r g u e dt h a ts h o r t e rh o s p i t a ls t a y sh a v ebeen e n a b l e da tl e a s tp a r t l yb yi n n o v a t i v enewd r u g s . p r o d u c t s . PhRMAe s t i m a t e st h a t抗 nowc o s t sa n Wh i l en o tr e q u i r e dbyt h eFDA , m a n u f a c t u r e r s a v e r a g eo f$ 8 0 2m i l l i o nt ob r i n go n enew世 u gt o musti n c r e a s i n g l yb u i l dpharmacoeconomic m a r k e t , c o m p a r e dt oj u s t$ 2 3 1m i l l i o ni n1 9 8 7 , a n d a n a l y s e si n t ot h e i rc l i n i c a lt r i a l s, i no r d e rt o j u s t$ 5 4m i l l i o ni n1 9 7 6 . Memberso fPhRMA g e n e r a t ep r o s p e c t i v ee c o n o m i co u t c o m e st oshow TheUseo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m 5 7 p a y e r s . PhR MAh a stwos i t t i n gc o m m i t t e e sr e l a t e d f o r m u l a r yo rl i s to fd r u g sa p p r o v e df o ru s ewi 出i n t og e n e r a t i o no fd a t ao f担t e r e s tt op u r c h a s e r sa n d t h ei n s t i t u t i o n . Theydot h i sbyc o n s i d e r i n ga l l t h eFD A .T heH e a l t hOutcomesandP r o m o t i o n d r u g ss u g g e s t e df o ru s ebyt h o r o u g ha n a l y s i so fa Committee, composedo fas m a l lnumbero f d r u gmonograph, f o l l o w e dbyd i s c u s s i o n, and manufacturerr e p r e s e n t a t i v e st h a tperform f i n a l l yad e c i s i o no fw h e t h e ro rn o tt oi n c l u d et h e , m e e t sr e ♂ . l l a r l yw i t ht h eFDA o u t c o m e sr e s e a r c h d r u gi nt h ef o r m u l a r y .O f t e ni tw i l lb eap h a r m a c i s t t od i s c u s sw h a t胞 r e q u i r e di nt h ewayo fq u a n t i t y i l lp r e p 紅 e血eむ u gmonograph , w h i c hi sa whow andq u a l i t yo fd a t a, i no r d e rt oc l a i ms p e c i f i c S田 町n 紅 yo fk e yp e e r r e v i e w e dd a t aone f f i c a c ya n d o u t c o m e s . T h i s knowledge may h e l p s a f e t y .I tw i l l l i k e l yc o n t a i nd a t aona c q u i s i t i o n a l st h a t m a n u f a c t u r e r sb u i l do u t c o m e si n t ot h e i r凶 . c o s t, and i n c r e a s i n g l y may c o n t a i n a w i l l prove more u s e f u l f o r showing pharmacoeconomicmodelp r o j e c t i n geconomic l R i s k pharmacoeconomicb e n e f i t s . TheB e n e f i t e 宜e c t so f血ep r o p o s e dnewp r o d u c t .F o r m u l a r i e s C o m m i t t e ew e i g h s出er i s k sa n db e n e f i t so fd r u g s, c a nb ee i t h e ro p e n( i .e .p h y s i c i a n sc a nu s eo t h e r a n dt r i e st od e t e r m i n ewhyc e r t a i nd r u g sa p p e 紅 t o d r u g s, b u ta r ee n c o u r a g e dt ou s et h ef o r m u l a r y , r e c e n ts t u d i e sshow b eu n d e r u t i l i z e d .F o re x a m p l e o rc l o s e d( i .e .o n l yt h ed r u g sont h e p r o d u c t s ), t h a ta smany部 3 2m i l l i o nAm e r i c a n sc o u l db e n e f i t f o r m u l a r ymayb eu s e da t血ei n s t i t u t i o n ;o rf o ra n b yt a k i n gdrugβknowna s“ s t a t i n s "t ol o w e rt h e i r MCOo rPBM, o n l yt h ef o r m u l a r yd r u g sw i l lbe c h o l e s t e r o l, y e to n l yaf r a c t i o na c t u a l l ya r e c o v e r e dbyi n s u r a n c e ) . p r e s c r i b e dt h ed r u g s . Apharmacoeconomic O t h e r匂p i c a lr e s p o n s i b i l i t i e so fP&Tc o m m i t t e e s argument, backedbyp e e r r e v i e w e dc l i n i c a l i n c l u d em o n i t o r i n ga d v e r s ed r u gr e a c t i o n si nt h e r e c o m m e n d a t i o n s , c o u l dbeu s e dt op r o m o t es t a t i n i n s t i t u t i o n , e s t a b l i s h i n ga n dm o n i t o r i n gp r e s c r i b i n g , u s et oMCOsa n d0血e r st h a tb e a rh e a l t h c a r ec o s t d i s p e n s i n g, anda d m i n i s t r a t i o np r o c e d u r e s, and ris~6). i n t e r a c t i n gw i t hanyl o c a li n s t i t u t i o n a lr e v i e w so fnewp r o d u c お b o a r d sc o n s i d e r i n gc l i n i c a l位協l ④' T h eP&TCommi 什eeandD rugMonograph ThePharmacyandT h e r a p e u t i c sCommittee w i 出血血ei n s t i 加t i o n .官 l e s e v ; 紅y bythese 岡 崎 組d i n s t i t u t i o n .I ti sp a r t l yt h r o u g ht h ei n c r e a s i n g (P&T committee) i s a committee t y p i c a l l y c o m p l e x i t y o f P&T committee a c t i v i t y, composedo fp h y s i c i a n s, p h a r m a c i s t s , n u r s e s, a n d n e c e s s i t a t i n gmoreworkf o rt h epharmacy a d m i n i s t r a t o r s, whoseo v e r a l lo b j e c t i v ei st o d e p a r 加l e n t , t h a tt h ei m p o r t a n c eo fp h a r m a c i s t s m a x i m i z et h eq u a l i t yo fc a r ei n v o l v i n gt h eu s eo f h a se x p a n d e d恒 t h eUS , i n c r e a s i n gt h e i ri n f l u e n c e . p h a r m a c e u t i c a lp r o d u c t sw i t h i nt h eo r g a n i z a t i o n . O r g a n i z a t i o n swithP&Tcommitteesi n c l u d e ⑤ASHP h o s p i t a l s, p h y s i c i a ng r o u p s, MCOs, PBMs, and The American S o c i e t yo f Health-System o t h e r swhoh a v ear o l eo ri n f l u e n c ei nc h o o s i n g P h a r m a c i s t s(ASHP)wasf o u n d e di n1 9 4 2a sa n p h a r m a c e u t i c a l s . o r g a n i z a t i o no fh o s p i t a l b a s e dp h a r m a c i s t s .Duet o P&Tcommitteesdevelopandm a i n t a i na t h ec h a n g i n gr o l eo fh o s p i t a lpharmaciesand 5 8 医療経済研究 v o 1 . 14 2 0 0 4 g r o w i n gr o l eo fo u t p a t i e n tpharmacyi np a t i e n t q u a l i t yg a pi npharmacoeconomicd a t au s e dby t h eo r g a n i z a t i o nc h a n g e di t so r i e n t a t i o ni n c a r e, 企u gc o m p a n i e st om a r k e tt h e i rp r o d u c t s . Whil e 1 9 9 5t o w a r d ss u p p o r t i n gp h a r m a c i s t si n出ee n t i r e 58%o ft h o s ep h a r m a c i s t ss u r v e y e ds a i dd r u g せ1c a r es y s t e m , t h o u g h60%o fmemberst o d a y h e a l c o m p a n i e su s ep h a r m a c o e c o n o m i cd a t at os e l lt o a r es t 皿h o s p i t a l b a s e d .V i r t u a l l ye v e r yh o s p i t a lh a s MCOs, o n l y33%s a i dt h a tt h ei n f o r m a t i o nwaso f 臼l 七回e dc o m m i t t e e s aP&Tc o m m i t t e eandh o s p i h i g hq u a l i t y .F u r t h e r m o r e , 9 4 9 もs a i dt h e yw o u l dl i k e weree s t a b l i s h e db e f o r et h o s ea tMCOs. The t o o r g a n i z a t i o ns u p p o r t si t smembersthrough , a n d p h a r τ n a c o e c o n o m i cs t u d i e sf r o md r u gm a k e r s p u b l i c a t i o no fi t sj o u r n a l , t h eAm e r i c a nJ o u r n a lo f 7 1 % f e l t血eirMCOwas血 ap o s i t i o nt op u tp r e s s u r e H e a l 血S y s t e mPharmacy , c o m p i l a t i o no fp h a r m a c y onmanufacturerst oconductmorer i g o r o u s ands a l e so fanumbero fb o t h s t a n d a r d so fc a r e, s t u d i e s .N i n e t yp e r c e n tf e l tt h a tt h eFDAs h o u l d r e f e r e n c eande d u c a t i o n a lb o o k sandv i d e o t a p e s . a p p l yt h esamer i g o r恒 a s s e s s i n gam a n u f a c t u r e r ' s TheASHPd e s c r i b e si t s e l fa sh a v i n gi t sp r i m a r y p h a r m a c o e c o n o m i cc l a i m sa s抗 d o e si na s s e s s i n g e m p h a s i sone f f i c a c ya n ds a f e t y , s i n c ep r o p e ru s e c l i n i c a lc l a i m s , a n d96%f e l tt h eFDAs h o u l da p p l y o fd r u g si na n do fi t s e l fl e a d st ol o w e rh e a l t hc a r e t h eFTC's“ competentandr e l i a b l e "e v i d e n c e 2 c o s t s 7 ) . 2 8 s t a n d a r di na s s e s s i n gp h a r m a c o e c o n o m i cc l a i m s ) . s e e more s c i e n t i f i c a l l y r i g o r o u s M e d i c a le r r o r sa r ec o s t l ya n do f t e na v o i d a b l e . C u r r e n t l ya b o u t45%o fp h a r m a c i s t ss u r v e y e d 官l eASHPe m p h a s i z e st h e加 po 此a n c e o f廿母国n g i n s a i dt h e i rMCOu s e s血ep h a r m a c o e c o n o m i cd a t a , b o o k s t h es a f eu s eo fm e d i c a t i o na n di t ss t a n d a r d s p r o v i d e dbym a n u f a c t u r e r s, i nmakingf o r m u l a r y ande d u c a t i o n a lm a t e r i a l sp r o v i d es u c hs u p p o r t . d e c i s i o n s .While76%o f p h a r m a c i s t ss a i dt h e yw e r e Q u a l i t yc o n 位0 1ands a f e t yp r o g r a m sh a v el e a d加 w e l l equipped t o r e l a t i v e l yl o wm e d i c a t i o ne 町o rr a t e si nd i s p e n s i n g , pharmacoeconomic v e r s u sp r e s c r i p t i o nandd r u ga d m i n i s t r a t i o n . m a n u f a c t u r e r s, o n l y38%f e l tt h a tt h ep h y s i c i a n A c c o r d i n gt ot h eASHP , 39%o fm e d i c a t i o ne r r o r s memberso ft h e i rMCOP&Tcommitteewere a r ed u eωmistakesi np r e s c r i b i n ga n d59%d u e加 s i m i l a r l yw e l l e q u i p p e d .F i f t yp e r c e n to ft h o s e m i s t a k e sd u r i n ga d m i n i s t r a t i o no ft h eむu gt ot h e s u r v e y e ds a i dt h a ta tl e a s to n ep h a r m a c i s ti nt h e i r p a t i e n t , w h i l eo n l y1 1 %o c c u r r e d担 t h ed i s p e n s i n g MCO was w e l l t r a i n e d t o conduct p r o c e s s .T h e s er e s u l t sd e m o n s t r a t et h en e e df o r pharmacoeconomics t u d i e s, and51%s a i dt h e i r e 却 a n d i n gt h er o l eo fp h a r m a c i s t s凶 o吐l ea r e a so f MCOsr o u t i n e l yu s e dt h 位 o wnp h a r m a c o e c o n o m i c p r e s c r i b i n ganda d m i n i s t r a t i o ns u p p o r t , w h e r e出 e i r a n a l y s e swhenmakingf o r m u l a r yd e c i s i o n s . The e x p e r t i s ec o u l dh e l preduceerrorsandt h e i r r e s 叫 : t so f由i ss u r v e ys u g g e s t e dt h a t担 1 9 9 8 , t h e r e a s s o c i a t e dhumana n de c o n o m i cc o 蜘. wasmuchworkωbed o n e祖 国p r o 吋n g由eq u a l i t y c r i t i c a l l y a n a l y z e d a t a s u p p l i e d by TheASHPs u r v e y e dMCOb a s e dp h a r m a c i s t si n o fd a t as u p p l i e d by manufacturers f o r 1 9 9 8t ot r yt ounderstandt h ec u r r e n tuseo f a sw e l la st h e pharmacoeconomica n a l y s i s, pharmacoeconomicsi nMCOf o r m u l a r yp o l i c y c a p a b i l i t i e so fMCO・based and o t h e r P&T f o r m u l a t i o n . Ther e s u l t sshowedap e r c e i v e d c o m m i t t e e st ob o t hc r i t i c a l l ya n a l y z ea n dp e r f o r m T h eU s eo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m t h e 廿 owna n a l y s e s .P h a n n a c i s t sn e e dt op 1 a yan i m p o r t a n tr o 1 eons u c hc o r n r r u t t e e sf o rt h e i rwork 2 9 l tobee 宜e c t i v e . 加 5 9 dt h eD e p a r t m e n to fV e t e r a n sA宜a i r s, j o i n e da c o a l i t i o no f5 0o r g a n i z a t i o n si ni s s u i n gt h e " P r i n c i p l e so faSoundD r u gF o r 百l u l a r y " .官 l e s ea r e t h eg u i d i n gp r i n c i p 1 e sfromt h i sdocument, ⑥AMCP p u b l i s h e di n2 0 0 0 : TheAcademyo fManagedCarePharmacy (AMCP)i samorer e c e n t l ye s t a b l i s h e dp h a n n a c i s t “ -Formu1arysystemdecisionsarebasedon o r g a n i z a t i o nt h a tpromotest h eu s eo fmanaged s c i e n t i f i candeconomicc o n s i d e r a t i o n st h a t h e a l t hc a r ec o n c e p t sbyt h ep r o f e s s i o n . The a c h i e v ea p p r o p r i a t e , s a f e , a n dc o s te 宜e c t i v eむu g o r g a n i z 組o np u b l i s h e saj o u r n a l , 0 宜e r sc o n 出lU i n g t h e r a p y m e d i c a 1e d u c a t i o n(CME)f o rp h a r m a c i s t s, and • The formu1ary system encompasses drug performsr e s e a r c h . Withoutknow1edgeand s e 1 e c t i o n ,世u gu t i l i z a t i o nr e v i e w ,a n do t h e rt o o 1 s t r a i n i n gi nmanagedc a r econceptssucha s t of o s t e rb e s tp r a c 世c e si np r e s c r i b i n g , d i s p e n s i n g , pharmacoeconomics, p h a r m a c i s t sa r el i m i t e dt o a d r 凶I U s t r a t i o n , a n dm o I U ω r i n go u t c o m e s t h et r a d i t i o n a 1r o 1 eo fd i s p e n s i n go fd r u g sfrom • The P&T Committee o re q u i v a 1 e n t body, e i t h e rh o s p i t a 1 b a s e do rr e t a i lp h a r m a c i e s . comprisedo fa c t i v e 1 yp r a c t i c i n gp h y s i c i a n s, However , w i t ha d e q u a t e回 i n i n g , p h a r m a c i s t sc a n p h a r m a c i s t s , a n do t h e rh e a l 由c a r ep r o f e s s i o n a l s , works i d ebys i d ew i t hp h y s i c i 紅1 8 , a n dh o s p i t 羽l and i s血 em echanismf o ra d m i n i s t e r i n gt h ef o r m u l a r y h e a l 出 p 1 a ne x e c u t i v e s,匝 s u c hr o 1 e s加 m a n a g i n g system,which i e v e 1 0 p i n g and n c l u d e sd t h em e d i c a t i o no ft h ec h r o n i c a l l yi l lt h r o u g ht h e m a i n t a i n i n gt h ef o r m u l a r yande s t a b l i s h i n ga n d p r a c t i c eo fc l i n i c a 1pharmacy, p 1 a n n i n gand imp1ementingp o l i c i e sont h euseo fdrug 加p 1emen 出1 9p a t i e n ts a f e t yp r o g r a m ss u c h加 むu g p r o d u c t s u t i l i z a t i o nr e v i e w, promotinge f f e c t i v ep a t i e n t e d u c a t i o n , d e v e 1 0 p i n gh o s p i t a 1, MCO, andPBM f o r m u l a r i e sa n dd e s i g n i n gh e a l t hi n s u r a n c eb e n e f i t s 3 0 p r o g r a m s ) . 官l eAMCPh a sa l s or e c e n t 1 ybecomeconcemed a b o u tt h eq u a l i t yo fp h a n n a c o e c o n o m i c sa n a l y s i s •P h y s i c i a n sando t h e rh e a 1 t hc a r ep r o f e s s i o n a l s p r o v i d eo v e r s i g h to f由ef o r m u l a r ys y s t e m ・官l ef o r m u l a r ys y s t e mmusth a v ei t sownp o l i c i e s , o ra d h e r et oo t h e ro r g a n i z a t i o n a 1p o l i c i e s, t h a t a d d r e s sc o n f l i c t so fi n t e r e s tandd i s c l o s u r eby P&Tc o r n r r u t t e emembers g o i n gi n t of o r m u 1 a r ydeve10pmentbyt h eP&T -官l ef o r m 叫a r ys y s t e ms h o u l di n c l u d ee d u c a t i o n a l c o r n r r u t t e e sa tMCOsa n dh o s p i t a l si n由eU S .B o t h p r o g r a m sf o rp a y e r s, p r a c t i t i o n e r s , andp a t i e n t s t h ei n p u t sandm e t h o d o 1 o g yv a r yg r e a t l yamong i rr o 1 e sa n dr e s p o n s i b i l i t i e s c o n c e m i n g出 e , a n dp o o r l yp e r f o r m e da n a l y s e s s u c ho r g a n i z a t i o n s • Thef o r m u 1 a r ysystems h o u 1 di n c l u d eaw e l l - c a n1 e a dt ounsoundf o r m u l a r yd e v e 1 o p m e n t .I n d e f i n e dp r o c e s sf o rt h ep h y s i c i a no ro t h e r 1 9 9 9, t h eAMCPt o g e t h e rw i t ht h eASHP, t h e トf o r m u 1 a r yd r u gwhen p r e s c r i b e rt ou s ean o r N a t i o n a 1 Committee f o rQ u a l i t yAssurance m e d i c a l l yi n d i c a t e d " (NCQA), t h eAm e r i c a nM e d i c a lAss o c i a t i o n(AMA), 6 0 医療経済研究 v o 1 . 14 2 0 0 4 W i t hr e g a r dt oeconomicc o n s i d e r a t i o n s, t h e P r i n c i p l e ss p e c i f i c a l l ys t a t et h a tf o r m u l a r y 3 .C o s t E f f e c t i v e n e s sandBudgetI m p a c tModel R e p o r t c o s tf a c t o r so n l y d e c i s i o n ss h o u l dbeb a s e don“ 4 .P r o d u c tVa 1 u ea n dOv e r a 1 1C o s t a f t e rt h es a f e t y , e f f i c a c y , a n d血e r a p e u t i cn e e dh a v e 5 .S u p p o r t i n gI n f o r m a t i o n :R e p r i n t s, B i b l i o g r a p h y , beene s t a b l i s h e d " . I tgoesont os t a t et h a t C h e c k l i s t , E l e c t r o n i cM e d i a , a n dA p p e n d i c e s " e v a 1 ua 曲1 9世 u gc o s ts h o u l db eb a s e don出ei m p a c t ont o t a 1he a 1 t hc a r ec o s t .F i n a 1 l yi tm e n t i o n s血a t I tg o e sont od e s c r i b et h erecommendeds t e p s f i n a n c i a 1i n c e n t i v e ss h o u l do n l yb eu s e d句 p r o m o t e f o rt h i sd o s s i e rs u b m i s s i o n, whosek e yp o i n t s c o s t m a n a g e m e n t泊 ap 町t o ft h ed e l i v e r yo fq u a l i t y i n c l u d e : m e d i c a lc a r e, ands h o u l dn o ti n t e r f e r ew i t ht h e d e l i v e r yo fm e d i c a 1 l yn e c e s s a r yc 町e .世間 Co a 1 i t i o n 1 ." A sm a n u f a c t u r e r ss h o u l dk e e pmanagedc a r e has d e f i n e d an i m p o r t a n t r o l e f o r o r g a n i z a t i o n sawareo ft h es t a t u so ft h e i r a 1 y s i s , b u to n l yt o出 ee x t e n t p h a r m a c o e c o n o m i ca n p i p e l i n e s, approximately6monthsb e f o r e t h a ti ti su s e d加 apa 凶o fd e 1 i v e r i n gh i g hqu a 1 i t y , t h epharmacy a n t i c i p a t e dnewp r o d u c tl a u n c h h e a l t hc a r e, andn e v e rt od e f e n dt h ed e l i v e r yo f s t a f fw i 1 1i s s u ear e q u e s tf o ri n f o r m a t i o nt ot h e s e c o n dr a t ec a r e .I ta l s op r o m o t e so p e nd i s c l o s u r e m a n u f a c 加r e r , w i t ha b o v e s p e c i f i e dc o n t e n . t o fp o t e n t i a lc o n f l i c t so fi n t e r e s tamongP&T 2 .官 l em a n u f a c t u r e ra n dp h a r m a c ys t a f fw i l lh o l da c o m m i t t e emembers, s i n c emanyp a r t i c i p a t ei n p r e s u b m i s s i o n meeting t od i s c u s st h e c l i n i c a lt r i a l sandc o n t i n u i n gm e d i c a le d u c a t i o n s u b m i s s i o no ft h er e q u e s t e dd a t a , e s t a b1 i s ha s p o n s o r e dbyt h esamem a n u f a c t u r e r s . These d e a d l i n e, andr e s o l v eanyi s s u e sa r o u n dd a t a a c t i v i t i e sa r enormal, b u thowt h ecommittee , e c o n o m i cmodela s s u m p t i o n s, e t c . s e c r e c y e n s u r e st h a tmanufacturers u p p o r tdoesn o t 3 .Them a n u f a c t u r e rs h o u l dp r o v i d et h er e p o r ti n i n f l u e n c ef o r m u l a r yd e c i s i o n si skeyt ot h e bo 出p a p e r加 de l e c 位o n i cf o r m st o血eph 紅 百l a c y c r e d i b i l i t yo ft h ep r o c e s s . 出s p r i o r加 仕l ep r o d u c tr e v i e w s t a f fa tl e a s t2mon TheAMCPh 加 g o n eo n es t e pf u r t h e ra n di s s u e d 4 .Thepharmacys t a f fr e v i e w sandr e q u e s t sany aFormatf o rF o r m u l a r yS u b m i s s i o n s , b e g i n n i n g n e e d e dc l a r i f i c a t i o no f出ed a t ab e f o r ep r e p a r i n g w i t hV e r s i o n1 .0i n2 0 0 0f o l l o w e dbyV e r s i o n2 . 0i n ap r o d u c tmonographf o rP&Tc o m m i t t e er e v i e w 2 0 0 2 .官 邸 s e r v e sa sag u i d ef o rP&Tc o m m i t t e e st o , 5 .C l i n i c a lp h a r m a c i s t sp r e p a r et h emonograph r e q u e s ti n f o r m a t i o n from pharmaceutical i n c l u d i n ga 1 1d a t a , anda r g u m e n t sb o t hp r oa n d r e p a r a t i o no fa世 u g m a n u f a c t u r e r st ob eu s e d匝 p p r o d u c t i n由e f o r m u l a r y c o ni n c l u s i o no f血e m o n o g r a p h .I td e s c r i b e st h es e c t i o n so fac o m p l e t e 6 .Uponr e a c h i n garecommendation, t h eP&T f o r m u l a r ys u b m i s s i o nd o s s i e ra sc o n t a i n i n gt h e c o m m i t t e ew i l li n f o r mt h em a n u f a c t u r e ro fi t s f o l l o w i n gs e c t i o n s : d e c i s i o n , 社l er a t i o n a 1 ef o rad e n i a 1o rr e s t r i c t i o n , a n d t h e細 川a r da p p e a 1 sp r o c e s s . " 1 . “D i s e a s ea n dP r o d u c tI n f o r m a t i o n 2 .S u p p o r t i n gCl i I 吐c a 1andEconomicI n f o r m a t i o n I ti sunknownj u s thowmanyP&Tc o m m i t t e e s TheU s eo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m 6 1 u s et h eAMCPg u i d e l i n e s , d o s s i e rr e q u e s tf o r m a t , b a s e d担 O a k l a n d , C a l i f o r n i a .Thenonp r o f i th e a l t h and s c h e d u l e,butt od a t e,more than 3 0 0 p l a nh a sa p p r o x i m a t e l y8. 4m i l l i o nmembers, p h a r m a c i s t shavebeent r a i n e di ni t su s e . The m o s t l yi nC a l i f o r n i a . Them e d i c a lg r o u p, s e r v i n g AMCPhopes出a t仕l e s eg u i d e l i n e sa n dt r a i n i n gw迦 K P ' smemberse x c l u s i v e l y , h a smoret h a n1 1, 0 0 0 movet h ef o r m u l a r yp r o c e s saway仕omd i s c u s s i o n s p h y s i c i a n so fa l ls p e c i a l t i e s . TheHMOi sf u l l y o fs i n g l ep r o d u c ta c q 凶s i t i o np r i c ea n dr e b a t e s , a n d i n t e g r a t e d , m e a n i n gi to p e r a t e si t sownh o s p i t a l s, ont o血ee 宜e c to ft h ef o r m u l a r yon血eh e a l 血a n d o u t p a 世e n tc l i n i c s , p h a r m a c i e s , l a b o r a t o r i e s , anda l l w e l l b e i n go f出 ep o p u l a t i o n .T r a n s p a r e n c i e si na l l o t h e ra n c i l l a r ys e r v i c e s . KPowns2 9h o s p i t a l sa n d t h e s ep r o c e d u r e scana l s oh e l pe r a s es u s p i c i o n 4 2 3o u t p a t i e n tc l i n i c se x c l u s i v e l yf o rt h eu s eo fi t s a b o u t出ei n a p p r o p r i a t eu s eo ff i n a n c i a li n c e n t i v e s m e m b e r s . Members( o rt h e i re m p l o y e r s )payan i nt h em u l t i b i l l i o nd o l l a rp h a r m a c e u t i c a land a n n u a lpremium , p l u sm o d e s tc o p a y m e n t sa tt h e managedc a r ei n d u s t r i e s .C l e a r l yt h i sAMCP t i m eo fs e r v i c e , f o ra l l出e i rh e a l t h c a r en e e d sf o rt h e i n i t i a t i v ei sa l s od o i n gmucht or a i s et h ei n f l u e n c e y e a r , i n c l u d i n gp r e s c r i p t i o nd r u g s . Them e d i c a l 3 1 ) . o fp h a r m a c i s t si nh o s p i t a l sa n dMCOS 司 g r o u p, h o s p i t a l s . , pharmacy , e t c .mustp e r f o r ma l l 吐l e i ra c t i v i t i e swi 出血血i sp r e d e t e r m i n e db u d g e to f (3 ) Pharmacoeconomicsi nUse t o t a lpremiumr e v e n u e .官 邸 伽 加c i a la r r a n g e m e n t ①I n↑rodudion a l i g n st h ei n c e n t i v e so f出 eh o s p i t a l , p h y s i c i a n , a n d MCOs, h o s p i t a l sandp h y s i c i a ng r o u p sa l lu s e P&Tc o m m i t t e e st od e t e r m i n eandmanaged r u g member ,加 k e e p仕l ep a t i e n th e a l 枕l ya n do u to ft h e 3 2 ) . h o s p i t a l f o r m u l a r i e s .K a i s e rP e r m a n e n t eandt h eV e t e r a n s Asd i s c u s s e da b o v e, p h a r m a c e u t i c a lp r o d u c t s H e a l t hA d m i n i s t r a t i o na r etwop a r t i c u l a r l y a r eas i g n i f i c a n ta n dg r o w i n gpo 耐o no f h e a l 血c a r e i n n o v a t i v ei n t e g r a t e dh e a l t h c a r ed e l i v e r ys y s t e m s s p e n d i n gi nt h eUS , andKPi snoe x c e p t i o n . KP 枕m th a v ef o c u s e dont h eo p p o r t u n i t yt oa c t i v e l y spendsa p p r o x i m a t e l y$ 2 . 5b i l l i o np e ry e a ron managed r u gs e l e c t i o nw i t h i nt h e i rs y s t e m s, and p r e s c r i p t i o nd r u g s .B u tKPh a su n i q u ea d v a n t a g e s employpharmacoeconomica n a l y s i s . Eachh a s comparedt ot h en o r m a l l yf r a g m e n t e ds y s t e mo f promotedt h er o l eo fp h a r m a c i s tfromm e r e l y h e a l t hc a r ef i n a n c i n ga n dd e l i v e r yi nt h eU S . Asa d i s p e n s i n gd r u g st op a t i e n t s, t oamoree q u a l l a r g ep u r c h a s e r , KPc a nn e g o t i a t ed i r e c t l yw i t h p a r t n e ri nt h ea n a l y s i s, s e l e c t i o n, andproper 印r e r s . Asac l o s e ds y s t e mo fh e a l t hp l a n , m a n u f a c a d m i n i s t r a t i o no fd r u g st ot h eb e n e f i to fboth d o c t o r s, h o s p i t a l s, andp h a r m a c i s t s, KPh a st h e p h y s i c i a na n dp a t i e n . tI na d d i t i o n , p h a r m a c i s t si n a b i l i t yt omorep r o a c t i v e l yu s et h er e s u l t so f botho r g a n i z a t i o n sa r ei n v o l v e di ni n n o v a t i v e pharmacoeconomica n a l y s i st omanaget h ec o s t - 宜e c t i v e l yu s e世 u g s . p r o g r a m st omoree e f f e c t i v e n e s so ft h ed r u g sd i s p e n s e dt om e m b e r s . KPc a ne x p o s ea l lo fi t sp h y s i c i a n st oi n f o r m 副o n ②K a i s e rPermanente K a i s e rPermanente(KP)i sal a r g e, group 出 m a i n t e n a n c eo r g a n i z a t i o n(HMO), p r a c t i c eh e a l onanongoingb a s i saboutwhichd r u g sa r e p r e f e r r e dandwhy , anda l s og i v e nf e e d b a c kon 血e i ru s eo fp r e f e r r e dv e r s u sn o n p r e f e r r e dd r u g s . 6 2 vo 1 . 14 2 0 0 4 医療経済研究 Theyc a na l s oc o n 位0 1配 c e s st oKPp h y s i c i a n sby a r ec o n s i d e r e df o ri n c l u s i o n . TheP&Tc o m m i t t e e d r u gcompanys a 1 e sr e p s .P h a r m a c i s t sp 1 a yan mee 飽 4t i m e sp e ry e 紅.Inせl ee n d , ac o n s e n s u si s i n t e g r a 1r o 1 ei npharmacoeconomica n a 1 y s i s, a c h i e v e d , a n d枕l ew h o 1 ec o m m i t t e eg e t sb e h i n d出e s e 1 e c t i o no fc o s t e f f e c t i v ed r u g sf o rt h ef o r m u l a r y , d e c i s i o no fw h e t h e ro rn o tt oi n c l u d eas p e c i f i c a n dd e v e 1 0 p m e n to fmethodst o部 s u r ef o r m 叫a r y 世u g .Thep r o c e s si sd y n a r 凶c ,恒出a t a n y出nenew c o m p l i a n c e . ad e c i s i o nc a nbe i n f o r m a t i o nbecomesa v a i l a b 1 e, KPh a sanumbero fo r g a n i z a t i o n ss u p p o r t i n g r e c o n s i d e r e da t出en e x tm e e t i n g .I nt h ei n t e 由民江 oi n t e r n a lr e s e a r c h c o s t e f f e c t i v eu s eo fd r u g s . Tw newd r u g sa r ea p p r o v e dbyt h eFDAt h e yc a nbe g r o u p sa r eDrugI n f o r τ n a t i o nS e r v i c e s( D I S )a n d usedi m m e d i a t e 1 ybyKPp h y s i c i a n sundert h e PharmacyOutcomesResearchGroup(PORG). e x c e p t i o nr u l e .S 泊l i l a r 1 y , 江s 培 凶f i c a n ts i d e e f f e c t s , i n c l u d i n g3p h a r m a c i s t s, who PORGh a sas t a f fo f5 a r ef o u n di nt h ei n t e r i mb e t w e e nm e e t i n g sd r u g s u n d e r t a k ep r o s p e c t i v eand即位o s p e c t i v es t u d i e s凪 c o u l db er e m o v e d企omtheform 叫 切 加l f f i e d i a t e 1 y . t h ea r e ao fc o s te f f e c t i v e n e s s, v a r i a t i o ni nd r u g 官l ef o r m u l a r yp r o c e s sb e g i n sbyp r e p a r a t i o no fa 箇 u 世i z a t i o n , p r o g r a me v a l u a t i o no fp h a r m a c yc l i n i c s , monographbyD I S . Theyg a t h e ra l li n f o r τ n a t i o n a n ds t u d yo fb o t hc l i n i c a lo u t c o m e sa n da s s o c i a t e d a v a i l a b 1 ea b o u tap r o d u c t, fromp e e r r e v i e w e d u s eo fh e a l 出 c a r er e s o u r c e s . PORGi se s s e n t i a l 1 y ぽ位c l e st oa d v e r t i s i n gp a r n p h l e t s . Theyr e q u e s ta n a ni n h o u s ep h a r τ n a c y吐unkt 紅l k . AMCPf o r m a td o s s i e rfromt h em a n u f a c t u r e r, , i n c l u d i n g2 0p h a r m a c i s t s , DISh a sas t a f fo f3 7 , i n c l u d i n ga n yp h a r m a c o e c o n o m i cm o d e l sonaCD- andi sap a r to ft h ePharmacyS t r a t e g yand ROM, s ot h e ycanbemanipu1ated, i n c l u d i n g O p e r a t i o n sG r o u p恒 K P ' sC a l i f o r n i aD i v i s i o n .N i n e a d j u s t i n gc o s ta s s u m p t i o n st omatchK P ' sa c t u a l o ft h ep h a r m a c i s t sa r es p e c i a l i s t si ns p e c i f i c c o s t s . Apparently 1 a r g e companies have t h e r a p e u t i ca r e a s,such a sc a r d i o v a s c u 1 a r, i m p 1 e m e n t e d血eAMCPf o r m a t , w h i l emanys m a l l e r a n e s t h e s i o 1 o g y / p a i n ,e t c .S i n c et h ep h a r m a c i s t s companieshaven o t . DISw i l lc o n s i d e rt h e s p e c i a l i z e , t h e yd e v e 1 0 pw o r k i n gr e 1 a t i o n s h i p sw i 出 economice f f e c t so fb o t ht h ee f f e c t i v e n e s sand s p e c i a l i s tp h y s i c i a n si nt h esamea r e a s .D I Sh加 s a f e t y( e . g .出 ec o s to fe x p e c t e ds i d e e 宜' e c t s )when r e s p o n s i b i l i t yf o ra d m i n i s t e r i n gt h ef o r m u 1 a r y m o d e l i n gt h ee c o n o m i ci m p a c to fa世 u g .官 leyw 曲 p r o c e s s .I na d d i t i o n , t h e yp r e p a r eaf o r e c a s to f u s et h em a n u f a c t u r e r ' smode1, i fa v a i l a b 1 e, and d r u g sl i k e 1 yt obea p p r o v e dn e x ty e a r , f o rwhat mode1howt h edrugchangest h eu s eo fa l l anda twhatc o s tt oK P . Theya1so i n d i c a t i o n s, 部 p r o v i d eanumbero fpharmacyi n f o r m a t i o n s e r v i c e st oKPmembersandp h y s i c i a n s . : s o c i a t e dr e s o u r c e s . K P ' sP h a r 百l a c yD i v i s i o no p e r a t e st h ep h a r m a c i e s a n dp u r c h a s e sp h a r m a c e u t i c a lp r o d u c t si nl i n ew i t h KPh a sanopenf o r m u 1 a r ywhichmeanst h a t P&Tc o m m i t t e ep o l i c i e s .W i t h i nt h ePharmacy w h i l eu s eo ff o r m u 1 a r yd r u g si se x p e c t e dand D i v i s i o n , t h eDrugUseD e p a r t m e n tc o n t a i n stwo e n c o u r a g e d , d o c t o r s町 es t i l 1企e et op r e s c r i b ea n y groupst h a tworkwitht h eP&Tcommittees 世u g , u n d e ra ne x c e p t i o nr u l e .A sap r i n c i p 1 e, a l l s p e c i f i c a l l yt opromotemorec o s t e f f e c t i v ed r u g 世u g ss u b m i t t e df o r出 eKPf o r m u l a r ybyp h y s i c i a n s use, t h eDrugUti l i z a t i o nGroup(DRUG)and 6 4 医療経済研究 v o 1 1 42 0 0 4 d e v e l o p e dag a s t r o i n t e s t i n a lb l e e dr i s ks c o r e c a r d , a l o n gw i t ha l l世 u gm o n o g r a p h s , VHAむu gp r i c i n g , 血a te 加盟Yf i t s加 ap h y s i c i a n ' sp o c k e t.官l ec a r dh a s a n dav a r i e t yo f0出e ri n f o r τ n a t i o na b o u tVHA世u g a ne a s yt ou s ef l o wc h a r tt h a td e t e r m i n e swhich p o l i c yi sa v a i l a b l eo n l i n ea tw w w . v a p b m . o r g .I n p a t i e n t sr e a l l yneedt h ea d d i t i o n a lG Ip r o t e c t i o n a d d i t i o n , e a c ho ft h e2 1r e g i o n sh a si t sownP&T f r o mt h eCOX-2i n h i b i t o r s .B a s e dont h ea s s e s s e d , b a s e dp r i m a r i l yont h e c o m m i t t e eandf o r m u l a r y , i trecommendsc a t e g o r i e so fd r u g s , andl i s t s r i s k n a t i o n a lf o r m u l a r y . Eachr e g i o n a lc o m m i t t e ec a n t h enameandp r i c eo fe a c hd r u ga v a i l a b l e .T h i s 血p e r m i s s i o no f出e addd r u g st oi t sf o r m u l a r ywi o c t o rt oe a s i l ya s s e s s出 ep a t i e n t s位u e a l l o w s出 ed i n a l l y , t h e r ea r e n a t i o n a lf o r m u l a r yc o m m i t t e e .F 2 0p e rmonth , needf o raCOX-2i n h i b i t o ra t$ 3 01 a l s oP&Tc o m m i t t e e sa te a c hVHAm e d i c a lc e n t e r 3 4 v e r s u sat r a d i t i o n a lNSAIDa t$ 25p e rmonth ) . gp o l i c yandu s e . t h a tr e v i e wl o c a l世 u ・ ・ R e c e n t l yp u b l i s h e dr e s u l t sshowedt h a tduet o Ab r i e fl o o ka tsomeo ft h eVHAN a t i o n a lPBM 吐l e s ee 宜 o r t s , u s eo fCOX-2i n h i b i 加r si nl o w e r r i s k n t e r n e ts h o w s D r u gM o n o g r a p h sa v a i l a b l eont h eI p a t i e n t s was reduced 66%i n KP No r t h e r n gi sl i s t e di n t h a ta c q u i s i t i o np r i c eo ft h enew世 u C a l i f o r n i ap a t i e n t s . T o t a l COX-2 i n h i b i t o r , ando t h e rc o s お 出a t c o m p a r i s o nt oe x i s t i n gd r u g s p r e s c r i p t i o n swereo n l y却も amongKPmembers, maychangea sar e s u l to fi n t r o d u c t i o na r e v e r s u s 4 5 9 もf o r p a 世e n t so u t s i d eKP d e s c r i b e d 3 5 ) . i n t h e c o n c l u s i o n s and r e c o m m e n d a t i o n s . Pharmacoeconomicb e n e f i ti s ③VHA a n a l y z e dwhenc o n s i d e r i n gd r u g sf o rt h en a t i o n a l sa n TheV e t e r a n sH e a l t hA d m i n i s t r a t i o n σ H A )i ,andcomparedwitha l l0曲目 p o t e n t i a l f o r m u l a r y i n t e g r a t e dh e a l t h c a r es y s t e ms e r v i n gt h en e e d so f o u t c o m e s .I nt h eS a nF r a n c i s c or e g i o n , t h eP&T eVHAh a sab u d g e to fmoret h a n USv e t e r a n s . 官l committeehasa l s obegunt oa n a l y z eo l d e r, 8 0, 000 h e a l t h c a r e $ 2 2 b i l l i o n,employs 1 e x p e n s i v ed r u g s, s u c ha sp r o t o np田 npi n h i b i t o r s ando p e r a t e s1 6 3h o s p i t a l s, 8 0 0 p r o f e s s i o n a l s, , t ol o o ka tw h e t h e r血e y訂 eu s e d andg a b a p e n t i n 並u c s, 1 3 5n u r s i n ghomes , andav a r i e t yo fo t h e r c e f f e c t i v e l ya n dd e t e r m i n eg u i d e l i n e sf o rmorec o s t - f a c i l i t i e sf o ri t sb e n e f i c i a r i e s . Ast h ef e d e r a l e 百' e c t i v et r e a 加l e n to fp a t i e n t sw i 社1c h e a p e rd r u g s l 訂g e s tp u r c h a s e ro fむu g si nt h e g o v e r n m e n ti s出e whenp o s s i b l e, s i m i l a rt oe f f o r t sa tK P .TheVHA t h eVHAi sa c t i v e l yi n v o l v e di ne f f o r t st o US, a l s op r o v i d e si t sownt o o l st op r o m o t ep h y s i c i a n p r o m o t ec o s t e f f e c t i v e世 uguse u s eo ft h ef o r m 叫紅ya n dc o s t e 宜' e c t i v ep r e s c r i b i n g , 3 s ) . TheVHAN a t i o n a lDrugF o r m u l a r yl i s t sd r u g s 出a tmustbea v a i l a b l ea ta l lVHAm e d i c a lc e n t e r s , s u c ha sp h y s i c i a np o c k e tg u i d e s . VHAp h a r m a c i e ss e r v eb o t hi n -ando u t p a t i e n t andc o n t a i n sa b o u t80%o fd r u g sd i s p e n s e dbyt h e , w i t ha b o u t90%o fp r e s c r i p t i o n sf i l l e d p o p u l a t i o n s t h eVHAPharmacy VHA. Att h en a t i o n a ll e v e l, f o ro u t p a t i e n t s . Thep h a r τ n a c i e sh a v ei n t r o d u c e d B e n e f i t sManagementS t r a t e g i cH e a l t h c a r eGroup , andf o rexample, t h eSanF r a n c i s c o a u t o m a t i o n a n dM e d i c a lA d v i s o r yP a n e lc o n s i s t so fp h y s i c i a n s VHAM e d i c a lc e n t e rf i l l sa p p r o x i m a t e l y2, 5 0 0 andp h a r m a c i s t st h a tm a i n t a i nt h ef o r m u l a r yand , 1 , 5 0 0o fw h i c ha r em a i l e d加 p r e s c r i p t i o n sp e rd a y VHApharmacyp o l i c i e s .T h i sn a t i o n a lf o r m u l a r y , p a t i e n t s . Thepharmacyd e p a r t m e n te m p l o y s5 5 TheUseo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m 6 5 p e r s o n s , h a l fo fwhoma r ep h a r m a c i s t sandt h e systemusedt ot r a c kt h ei n t e r v e n t i o n sand o t h e rh a l ft e c h n i c i a n s . Thee f f i c i e n c ya c h i e v e d 3 8 ) . snowi np l a c en a t i o n w i d e加 theVHA o u t c o m e si 由r o u g ha u t o m a t i o nh a sa l l o w e dt h ep h a r m a c i s t st o ④Summary:Pharmacoeconomicsi nt h eUSA c o n c e n t r a t e more on t h e work o fc l i n i c a l Pharmacoeconomicsr e f e r st ob o t hs p e c i f i c p h a r m a c y , s p e n d i n gt i m ec o n s u l t i n gw i t hp a t i e n t s e c o n o m i ca n a l y s e s , a n d仕l ev i e w p o i n to fi n c l u d i n g a n dp h y s i c i a n sa b o u t世 u gc h o i c e , d o s ea d j u s 加l e n t , c o s t swhenc o n s i d e r i n gt h epurchaseo fnew 3 7 ) . a n dp a t i e n tc o m p l i a n c e m e d i c a lp r o d u c t sands e r v i c e si na d d i t i o nt o Ar e c e n te x a m p l eo fap r o j e c ts p e a r h e a d e dby e f f e c t i v e n e s s and s a f e t y . However,each VHAc l i n i c a lp h a r m a c i s t se x p a n d i n gt h 位 r o l ea n d c o n s t i t u e n to ft h eh e a l t h c a r ew o r l du s e swhati s i n f l u e n c e担 由eVHAwas担 由e町 eaofむu g m i s u s e l o o s e l yr e f e r r e dt oa spharmacoeconomics andp o t e n t i a lb e n e f i to fc l i n i c a lpharmacy d i 宜' e r e n t l y , d e p e n d i n gonwhatt h e i rg o a l sa r e .The i n t e r v e n t i o n . TheVHAe s t i m a t e st h a tm i s u s eo f r e s u l ti so f t e nac o n f u s i n gm i x t u r eo fa n e c d o t e s d r u g sc o s t st h eUSh e a l t h c a r es y s t e mmoret h a n a n da n a l y s e s , t h a tmayb eo fl i t t l ev a l u e加 many $ 7 0b i l l i o np e ry e a ri na v o i d a b l em e d i c a lc o s t s . s t a k e h o l d e r s . P&Tc o m m i t t e e sa th o s p i t a l sand T h i ss t u d ye v a l u a t e dt h erecommendationsand MCOsmustc h o o s enewp h a r m a c e u t i c a lp r o d u c t s i n t e r v e n t i o n so fc l i n i c a lp h a r m a c i s t sonp a t i e n t f o rt h e i rp a t i e n t su s i n gd a t aone f f e c t i v e n e s s, o u t c o m e s, h e a l t h c a r ec o s t , p a t i e n tharma v o i d a n c e , s a f e t y , a n di n c r e 路加g l y , p h a r m a c o e c o n o m i c s . The a n dp h y s i c i a na c c e p t a n c eo f出 er e c o m m e n d a t i o n s , d r u gmonographi sad o s s i e rc o n t a i n i n gd a t at h a t i no u t, i n p a t i e n t, ands k i l l e dn u r s i n gf a c i l i t y t h eP&Tc o m m i t t e eu s e st oh e l pmakef o r m u l a r y s e t t i n g s .E x a m p l e so ft y p i c a li n t e r v e n t i o n sw e r e加 d e c i s i o n sr e g a r d i n gnewd r u g s . Anumbero f c a s e sw h e r euponp h a r m a c i s tr e v i e wo fap h y s i c i a n o r g a n i z a t i o n shaveas t a k ei nt h egrowtho f p r e s c r i p t i o n, t h epharmacistrecommendeda p h a r 賢 治c o e c o n o m i c s . TheFDAd o e sn o tr e q u i r e , o rb e c a u s eo f d o s a g ec h a n g et oo p t i m i z et h e r a p y p h a r m a c o e c o n o m i cs t u d i e sf o rnewむu ga p p r o v a l , p o t e n t i a ld r u gi n t e r a c t i o n s, recommendedc h a n g i n g b u td o e sr e g u l a t e出 eu s eo fo u t c o m e sd a t ac r i t i c a l 出 ed r u g t o m i n 卸 由e p a t i e n t ω x i c i t y . t oq u a l i t ya n a l y s e s . PhRMA , 邸 ar e p r e s e n t a t i v eo f , 9 2 %o f6 0 0s u c hi n t e r v e n t i o n sr e c o r d e d O v e r a l l , b r o a d l yp r o m o t e st h e l a r g ed r u gm a n u f a c t u r e r s d u r i n gt h es t u d yp e r i o dwerea c c e p t e dbyt h e u s eo fpharmacoeconomicsi np a r tt oj u s t i f yt h e p r e s c r i b i n gp h y s i c i a n , l e a d i n gt oi m p r o v e dc l i n i c a l h i g hp r i c eo fnewpha ロn a c e u t i c a lp r o d u c t s . The o u t c o m e si no v e r3 0 %o fc 出 e s , a n dnoc h a n g ei n ASHP i st h eo l d e s tp r o f e s s i o n a lpharmacy o u t c o m ei n4 0 % . Thei n t e r v e n t i o n ss a v e d$ 1, 0 0 0 , , r e p r e s e n 出1 9p r i m a r i l yh o s p i t a l b a s e d o r g a n i z a t i o n $ 3 2 5 , a n d$ 7 4 5 , 匝 担p a t i e n t , o u t p a t i e n t , a n ds k i l l e d p h a r m a c i s t s . Ar e c e n ts t u d yo ft h e i rmembers n u r s i n gf a c i l i t ys e t t i n g s, r e s p e c t i v e l y , f o ra na v e r a g e 8%o fp h a r m a c i s t ss a i dt h a t r e p o r t e dt h a tw h i l e5 s a v i n g so f$ 7 0 0 per c l i n i c a l pharmacist p h a r m a c e u t i c a lc o m p a n i e su s ep h a r m a c o e c o n o m i c i n t e r v e n t i o n . Evenwhena d d i n g凱 血ec o s to ft h e d a t at os e l lt ot h e i rMCOs , 9 4 %s a i d出e yw o u l dl i k e t h es t u d yshowedo v e r a l l c l i n i c a lp h a r m a c i s t, t os e emores c i e n t i f i c a l l yr i g o r o u ss t u d i e sfrom r e d u c e dc o s t so fe r r o r so f2 0 % . Thecomputer m a k e r s . TheAMCPpromotesmanagedc a r e 6 6 医療経済研究 v o 1 . 14 2 0 0 4 c o n c e p t s, i n c l u d i n gpharmacoeconomics, among pharmacoeconomicsi ngovernmentr e g u l a t i o n, i t sp h a r m a c i s tmembers , manyo fwhoms i tonP&T u n 1 i k ei nA u s t r a l i aa n dC a n a d a .However , t h e r ei s t 1 yp u b l i s h e da c o m m i t t e e s . TheAMCPr e c e n s t r o n gi n t e r e s ti npharmacoeconomicsamong s u g g e s t e df o r m a tf o rmorec o m p l e t ea n dr i g o r o u s m e d i c a lp r o f e s s i o n a l sandf a c i l i t i e s, i n c l u d i n g d o s s i e r st ob es u b m i t t e dbym a n u f a c t u r e r st os u c h g o v e r n m e n t r u ni n s t i t u t i o n ss u c ha s也eVHA , d u e committees, i nc 1uding more r i g o r o u s t ot h eh i g hl e v e lo fi n t e r e s t回 managedc a r ea n d血e pharmacoeconomic m o d e l s . e f f i c i e n c yo fm e d i c a lc a r ep r o v i d e dbym e d i c a l W i t h i nt h i s e n v i r o n m e n t , twoi n t e g r a t e dh e a l t h c a r ed e 1 i v e r y 加t i o n s . i n s t i o r g a n i z a t i o n s, KPandt h eVHA, a r ea c t i v e l y B e a r i n gi nmindt h ed i f f e r e n c e sbetweent h e 1 i c i e s, i n c l u d i n g p r o m o t i n ge f f i c i e n tf o r m u l a r ypo m訂 k e t si nt h etwoc o u n 凶e s, wen e e dt oc o n s i d e r 血eu s eo fp h a r m a c o e c o n o m i ca n a l y s e s .I n c r e a s e d t h ekeyp o i n t sf o rs u c c e s s f u l l yi n t r o d u c i n g a v a i l a b i l i t y o f both good and bad p h a r m a c o e c o n o m i c si nJ a p a n .L e tu sc o n s i d e r畳間t p h a r m a c o e c o n o m i ca n a l y s e sr e q u i r e sp h a r m a c i s t s t h ep o t e n t i a lf o ru s eo fp h a r m a c o e c o n o m i c si n出 e t r a i n e di nt h ea r tt oh e l pp r o v i d e r s, PBMsand i n c l u s i o no fd r u g si nt h ei n s u r a n c ef o r m u l a r ya n d MCOsu s es u c ha n a l y s e sωthemaximumb e n e f i to f d e t e r m i n a t i o no fo f f i c i a l l y飴 c e dp r i c e s .I nt h eU .S ., andn o tj u s tt oanyone t h ep a t i e n tp o p u l a t i o n, t h eFDAd o e sn o tu s ep h a r m a c o e c o n o m i c si ni t s s p e c i f i cs t a k e h o l d e r . a p p r o v a lo fnewd r u g s , a n dt h e r ei sl e s so u t p a t i e n t 世u gr e i m b u r s e m e n tu n d e rp u b l i ci n s u r a n c es u c h (4 )I m p l i c a t i o n sf o rJapan J a p a ni sf a c i n ga白加r eo fi n c r e a s i n gh e a l t h c a r e 部 M e d i c a r e, t h u st h e r ei sn o tmuch加 l e a r ni nt h i s s i t u a t i o n . , d u ep r i m a r i l yt oi t sa , 酔1 9s o c i e t y .I no r d e rt o c o s t s However, c o n s i d e r i n gt h ei m p a c to fp r i v a t e m a i n t a i ni t slowp r o p o r t i o no fGDPs p e n ton i n s u r e r sa n dmanagedc a r ei np町 t i c 叫a ron血ec o s t i l l have t oi n t r o d u c e h e a l t h c a r e,Japan w o fh e a l t he x p e n d i t u r e si nt h eU . S ., t h eu s eo f pharmacoeconomica n a l y s i sa so n enewp i l l a ro f p h a r m a c o e c o n o m i c si nd e t e r m i n i n gt h ei n c l u s i o n newp r o d u c te v a l u a t i o nfromt h ev i e w p o i n to f o fd r u g si nJ a p a n ' sn a t i o n a lf o r m u l a r yc o 叫d h e l pt o e f f i c i e n th e a l t h c a r er e s o u r c e sut i 1 i z a t i o n . c o n t r o lh e a l t he x p e n d i t u r e si nJ a p a n .Asi ti s A comparisono fd r u gu t i l i z a t i o nundert h e d i f f i c u l tt oc o n c e i v eo fo n l ysomenewd r u g s .S .h e a l t hc 紅'es y s t e m sr e v e a l su s e J a p a n e s ea n dU approved by t h e government becoming i nJapant obec h a r a c t e r i z e dbyan a t i o n a l recommendedf o rsuchan a t i o n a lf o r m u l a r y, f o r m u l a r y,t h ed e t e r m i n a t i o n by c e n t r a l pharm 配 o e c o n o m i c s 'r o l ew o u l dmostl i k e l ybea sa government o ff i x e dp r i c e s and n a t i o n a l . l g u i d ef o rd e t e r m i n i n gp r i c e sa tt h en a t i o n a l l e v e , t h e s t a n d a r d i z a t i o no fi n s u r a n c er e i m b u r s e m e n t For i n s u r e r s, a s p a y e r s, t o use s t i l li n c o m p l e t es e p a r a t i o no fm e d i c a lp r a c t i c ea n d pharmacoeconomicsr e q u i r e st h a te a c hi n s u r e r d r u gd i s p e n s a t i o n(bungyo), andanimmature s h o u l dh a v ei t sownf o r m u l a r yc o n t a i n i n gi t sown g e n e r i c世 ugmarket recommendedd r u g s .T h i swouldmeant h e I nt h eU .S ., v i r t u a l l ynou s ei sc u r r e n t l ymadeo f i n t e r v e n t i o no fi n s u r e r si nt h ep r e s c r i p t i o no fd r u g 湾 TheUseo fP h a r m a c o e c o n o m i c si nt h eUSH e a l t h c a r eS y s t e m 6 7 byp h y s i c i a n s , w h i c hwouldg i v eJ a p a n e s ei n s u r e r s d r u g sa tt h el e v e lo fp a y e r s( i n s u r e r s )andt h e g r e a t e rp o w e r st h a na tp r e s e n t ,出 w i t hr n a n a g e d c e n t r a lg o v e r n r n e n . tHowever ,出ei n c r e a s i n gu s eo f .S . c a r ei nt h eU p e rd i e r ni n s u r a n c eb e n e f i t s( e . g .w i t ht h er e c e n t I nt h eh e a l t h c a r es e r v i c er n a r k e t( i n c l u d i n g i n t r o d u c t i o no ft h eD i a g n o s i s Procedure むu g s ),出er n a r k e tr n e c h a n i s r ni sn o tc o n s i d e r e dt o C o r n b i n a t i o n(DPC)s y s t e r n )w i l li n c r e a s et h e f u n c t i o nw e l l , d u ee s p e c i a l l yt ot h ea s y r n r n e 位yo f i r n p o r t a n c eo fp h a r r n a c o e c o n o r n i cs t u d i e si n i n f o r r n a t i o n between n o n p h y s i c i a n s and r n e d i c a li n s t i t u t i o n si nJ a p a n 鈎 p h y s i c i a n s .Thosei n v o l v e di nt h es u p p l yand F i n a l l y , whent h er e i m . b u r s e r n e n tc h a n g e sa b o v e dernandf o rh e a l t h c a r es e r v i c e si nt h eU . S ., t a k ep l a c es u c ht h a ts a 叫n gr n o n e yi nh e a l t h c a r e however , u s ep h a r r n a c o e c o n o r n i c s拙 as o u r c eo f b e c o r n e s i r n p o r t a n t t o t h e i r c u s t o r n e r s, d a t ac o r n p l e r n e n t i n gr n a r k e tr n e c h a n i s r n si no r d e r r n a n u f a c t u r e r sw i l l have t op r o v i d er n o r e t oe n g a g e恒 r n o r ee f f i c i e n td e c i s i o n r n a 油1 9 . p h a r r n a c o e c o n o r n i cd a t at os e l lt h e i rp r o d u c t s I nJ a p a n , t o o, t h eo p t i r n u r nt y p e sandu s e so f a h e a do ft h ec o r n p e t i t i o n , andt oj u s t i 町t h eh i g h d r u g sn e e dt obes e l e c t e dbyr n e d i c a li n s t i t u t i o n s , c o s to fnewp r o d u c t s .官 出 c h a n g ew i l le r n p h a s i z e a st h ep a t i e n t s 'p r o x i e s,u s i n ga p p r o p r i a t e t h en e e d f o r出 ep h a r r n a c i s tp r o f e s s i o nωbecornea i n f o r r n a t i o n i n c o r p o r a t i n g d a t a on c o s t l e a d e ri np h a r r n a c o e c o n o r n i c s, andg u i d et h e i r p e r f o r r n a n c e .I nt h i sc a s e,出ep r o c e s so fb u n g y o i n s t i t u 世o n sawayf r o r nr n a k i n gd e c i s i o n sb a s e do n t r n u s tb ec o r n p l e t e dont h ep r o v i d e rs i d es u c h血a pooro ri n a d e q u a t ea n a l y s e s, t os o l i de v i d e n c e - t h e r ea r enor e r n a i n i n g匝c e n t i v e sf o rp h y s i c i a n st o b a s e d o n e s . d i s p e n s eo n e世 u go v e ra n o t h e r , o ra n y世 u ga ta l l , t o出 e i ro u t p a t i e n t s .官l enewp r o s p e c t i v epa ; 戸n e n t References s y s t e r nw i l la l s on e e dt ob es p r e a dt oa l lh o s p i t a l s , sucht h a td r u g su s e df o ri n p a t i e n tc a r eb e c o r n e 1)L e v i te . ta l ., ( 2 0 0 1 )“ T r e n d s恒U.S .H e a l t h c a r e , n o ts o u r c e so fi n c o r n e .W i t ht h e s e v i e w e da sc o s t s Spending2 0 0 1, "Heαl t hAff αi r sJ a n u a r y / c h a n g e s, h o s p i t a lP&Tc o r n r n i t t e e sw i l lhavea F e b r u a r y reasont od i s c u s sp h a r r n a c o e c o n o r n i c swhen 2 )OECD( 2 0 0 1 )“ H e a l t h a tαG l a n c e " c h o o s i n gnewd r u g s .官 邸 w i l lc r e a t eal a r g e rr o l e 3 )h t t p : / / w w w . c r n s . h h s . g o v / s t a t i s t i c s / n h e / f o rp h a r r n a c i s t sont h e s ec o r n r n i t t e e s . The 紅. t 部 P h i s t o r i c a l l c h p h a r r n a c yp r o f e s s i o nw i l lh a v et oi n t r o d u c enew 4)C e n t e r sf o rM e d i c a r eandM e d i c a i dS e r v i c e s: e d u c a t i o n a lp r o g r a m sf o ri t sr n e r n b e r sa n dp r o r n o t e eF a c t sa b o u tU p c o r n i n g M e d i c a r ew e b s i t e .官 l news t a n d a r d sf o rd a t aa n a l y s i sa n de v a l u a t i o n . NewB e n e f i t si nM e d i c a r e .Downloadedf r o r n I n s u r a n c eb e n e f i t si nJ a p a na r ep a i donaf e e f o r s e r v i c eb a s i s , g i v i n gi n d i v i d u a lr n e d i c a li n s t i t u t i o n s 紅e . g o v /M e d i c a r e R e f o ロ n I h t ゆ : / / w w w . r n e d i c 5)Mayer,Gregg L . and Tanaka,S h i g e r u, l i t t l ei n c e n t i v et oreducer n e d i c a le x p e n s e s . “ ManagedC a r eD e v e l o p r n e n ta n dI n n o v a t i o ni n C o n t r o l l i n gh e a l t he } 申e n d i t u r e so v e r a l lt h e r e f o r e t h eUS, andT h e i rP o l i c yI r n p l i c a t i o n sf o r r e q u i r e st h a te c o n o r n i ce v a l u a t i o n sber n a d eo f J a p a n ", Journ αlo fHe αl t hG α仰 仰dS o c i e t y 6 8 医療経済研究 v o 1 . 14 2 0 0 4 7 ( 1 ) :1 0 9 1 2 7 , May , 1 9 9 7 6)Departmento fH e a l t handHumanS e r v i c e s . ,August, 2 8 )ASHPPharmacoeconomicS u r v e y 1 9 9 8 .The FoodandDrugA d m i n i s t r a t i o n2001 2 9 )i b i d P r e s c r i p t i o nDrugM a r k e t i n gActR e p o r tt o 3 0 )I n t e r v i e wwi 出 AMCP2 / 1 3 / 0 3 町: / / w w w . f d a . g o v C o n g r e s s . D o w n l o a d e df r o mh 1 )i b i d 3 a / r e p o 此2 0 0 1 / /odpsm 3 2 )I n t e r v i e ww i t hK a i s e rP e r m a n e n t e2 / 1 0 / 0 3 7 )i b i d t . al . “ GIScore: A Simple S e l f 3 3 )Singh,e 8)i b i d e n tt oQuan 時r 血eR i s ko f a s s e s s m e n tIns蜘n 9)i b i d S e r i o u sNSAID-RelatedGIC o m p l i c a t i o n s " e r v i c e s, 1 0 )Departmento fH e a l t h& HumanS A r t h r i t i sRheum1 9 9 8S e p ;4 1 ( 9s u p p l ) :S 7 5 ( 2 0 0 0 )R e p o r tt ot h eP r e s i d e n t :P r e s c r i p t i o n 3 4 )I n t e r v i e ww i t hK a i s e rP e r m a n e n t e2 / 1 0 / 0 3 DrugCoverage, Spending, U t i l i z a t i o n, and t . al . , “ Improving Appropriate 3 5 )Hyatt,e P r i c e s P r e s c r i p t i o nDrugUset oBestP r a c t i c e : 1 1 )i b i d S u p p o r t i n gE v i d e n c e B a s e dd r u gU s e ", The 1 2 )i b i d Perm α . n mteJournal7(2), Sp 血1 9 2 0 0 3 1 3 )i b i d 1 4 )i b i d 3 6 )I n t e r v i e ww i t hVHAM e d i c a lC e n t e rP h a r m a c y S 阻宜"S anF r a n c 民c o 1 5 )i b i d 3 7 )i b i d 1 6 )i b i d e t .a , . l 2002 “ ,C l i n i c a landEconomic 3 8 )Boro, , Ph αrmaceutica 1PricingUpd αt e , 1 7 )IMSH e a l t h 2 0 0 1 1 8 )G e n e r i cP h a r m a c e u t i c a lA s s o c i a t i o nwebs i 蛇: h t ゆ: / / w w w . g p h a o 凶卸e . o r g Outcomeso fP h a r m a c i s t sr e c o m m e n d a t i o n si n aV e t e r a n sA f f a i r sMedicalC e n t e r "A mJ He a 1 t hS y s tPh α , rm1 ;5 9 ( 2 1 ) :2 0 7 0 7 3 9 )S h i n y a M a t s u d a :I n f l u e n c e sont h eu t i l i z a t i o n 1 9 )i b i d andd i s t r i b u t i o no fd r u g sandm e d i c a ld e v i c e s 2 0 )Fruedenheim, M i l t “ ,AsDrugsPatentsEnd, aM a t s u d ae d .M e d i c a lc a r ei n byDPC.S h i n y Costf o rGenericsSurge, "TheNewYor・ k 2 1 由C e n t u r yandDPC.p 5 76 6J i h o2 0 0 3 , Tokyo Times, 2 7December2 0 0 2 ( i nJ a p a n e s e ) 2 1 )i b i d s o c i a t i o nwebs i t e : 2 2 )G e n e r i cP h a r m a c e u t i c a lAs h t 中: / / w w w . g p h a o 叫i n e . o r g 2 3 )I n t e r v i e ww i t hPhR MA , 2 1 1 4 / 0 3 2 4 )I n“ TheValueofMedicines", p u b l i s h e dby PhRMA2003 2 5 )i b i d n t e r v i e ww i t hPhRMA, 2 / 1 4 / 0 3 2 6 )I 2 7 )I n t e r v i e ww i t hASHP , 2 / 1 3 / 0 3 “ TheU s eo fP h a r m a c o e c o n o m i c si ntheUSH e a l t h e a r eS y s t e m Addressco 町e spondencet o : 6 9 H i r o y u k i , S 必叩n a k i I n s t i t u t ef o rH e a l 血E c o n o r n i c sa n dP o l i c y G r e g g1 .M a y e r H紘 u g iK i y o n o G r e g gL .M a y e r&Company , I n c . 7 0 1 9S t o c k t o nA v e n u e , E lC e n i t o , C a l 江o r n i a9 4 5 3 0 USA TEL+1 5 1 0 5 5 9 3 2 0 0 F A X + 1 5 1 0 ・ 5 5 9 4 0 4 4 E m a i l :g r e g g @ g l m c o . c o m 157 , N a g a t a c h o, C h i y o d a k u, Tokyo, 1 0 0 0 0 1 4, J a p a n T E L + 8 1 3 ・ 3 5 0 6 8 5 2 9 FAX+ 8 1 3 3 5 0 6 8 5 2 8 E m a i l :s a k a m a k i @ i h e p . j p ・ ・ Glossary e r i c a nM e d i c a lAs s o c i a t i o n AMA Am AMP a v e r a g em a n u f a c t u r e rp r i c e IDN i n t e g r a t e dd e l i v e r yn e t w o r k ISPOR I n t e m a t i o n a lS o c i e t yf o r AMCP Academyo f M a n a g e dC a r eP h a r m a c y P h a r m a c o e c o n o r n i c sa n dO u t c o m e s e r i c a nS o c i e t yo fH e a l 出S y s t e m ASHP Am R e s e a r c h AWP 紅m a c i s t s Ph KP K a i s e rP e r m a n e n t 疋 a v e r a g ew h o l e s a l ep r i c e 垣muma l l o w a b l ec o s t MAC ma CME c o n t i n u i n gm e d i c a le d u c a t i o n a n a g e dc a r eo r g a n i z a t i o n MCO m CMoP C l i n i c a lM a n a g e m e n to fP h a r m a c e u t i c a l s NCQA N a t i o n a lC o m r n i t t e ef o rQ u a l i t y COX-2 c y c l o o x y g e n a s e 2 CRO c o n t r a c tr e s e a r c ho r g a n i z a t i o n s 加l e n t o f H e a l t h a n d H u m a nS e r v i c e s e p a r S D DmI DIS n f o r m a t i o nS e r v i c e s D r u gI DPC D i a g n o s i sP r o c e d u r eC o m b i n a t i o n DRUG D r u gU t i l i z a t i o nG r o u p As s u r a n c e NSAID nons t e r o i d a lanti~加盟ammatory 世ug OECD O r g a n i s a t i o nf o rE c o n o r n i cC o o p e r a t i o n a n dD e v e l o p m e n t P&T P h a r m a c ya n dTh e r a p e u t i c sC o m r n i t t e e Committee DTC ・ c o n s u m e r d i r e c t t o PBM DUR d r u gu t i l i z a t i o nr e v i e w MAP h a r m a c e u t i c a lR e s e a r c ha n d PhR FDA i n i s t r a t i o n F o oda n dD r u gA也n FSS F e d e r a lS u p p l yS c h e d u l e PORG P h a r τ n a c yO u t c o m e sR e s e a r c hG r o u p GDP r o d u c t G r o s sD o m e s t i cP PPO P r e f e r r e dP r o v i d e rO r g a n i z a t i o n GERD g a s t r o e s o p h a g e a lr e f l u xd i s e a s e R&D r e s e a r c ha n dd e v e l o p m e n t a n u f a c t u r i n gP r a c t i c e GMP GoodM SSRI s e l e c t i v es e r o t o n i nr e u p t a k ei n h i b i t o r GPO g r o u pp u r c h a s i n go r g 担u z a t i o n E 百 ¥ 1 : 0 h e a l t hm a i n t e n a n c eo r g a n i z a t i o n P h a r m a c e u t i c a lB e n e f i t sM a n a g e m e n t 加r e r so fAme r i c a M a n u f a c VHA V e t e r a n sH e a l t hA d r n i n i s t r a t i o n 7 0 医療経済研究 v o J . 14 2 0 0 4 米国ヘルスケアシステムにおげる 薬剤経済学の利用状況 G r e g gL .Mayer1 申 H a k u g iKi y o n o*1 坂巻弘之申 2 米国の医療費は、毎年10% 近い伸びを示しており、 2001 年には約1~~3000億ドルが支出された。そのうちの薬剤費の割 合は約 10%であるが、処方薬の市場の伸びは 15.7%であり、ここ数年、全体の医療費の伸びに比べ大きな数値を示してい る。一方、 1990年代以降のマネジドケアの拡大 ! i、さまざまな手段で医療費コントロールを行っている。マネジドケアに とどまらず、 PBM、病院、医師グループは、フォーミュラリーへの新薬の収載、更新のために P&T 委員会を組織しており、 近年、フォーミュラリーコントロールに薬剤経済学の利用が進んでいる。また、病院など医療現場では、薬剤師が自らの 業務を経済的に評価するなどの形でも薬剤経済学の考え方が浸透しつつあり、マネジドケアに関連する学会や薬剤師団体 では、薬剤経済学データの利用の標準化のためにガイドラインや関係者への教育プログラムを提供している。米国におけ る薬剤経済学の利用方法は、日本においても医療の現場で薬剤経済学を用いる際の参考になると考えられる。 キーワード:薬剤経済学、米園、医薬品流通、フォーミュラリー r e g g1 .M a y e r&C o m p a n y .I n c . *1 G 医療経済研究機構 *2
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