为什么美国药品价格越来越高?（一）
Why are US drug prices getting much higher?
译文简介
网友：为什么美国让制药商自行制定药品价格？这会导致美国药品价格上涨吗？
我们让制药商自行定价，因为这是自由市场经济......
正文翻译
Why are US drug prices getting much higher?
为什么美国药品价格越来越高?
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
评论翻译
很赞 ( 1 )
收藏
Why does the US let drug makers set their own drug prices? Does this lead to higher drug prices here in the US?
We let drug makers set their own prices because this is a free market economy.
Tonight you will be hungry. There are three restaurants close to your house: Morton’s of Chicago steakhouse, Outback Steakhouse, and McDonald’s.
At Morton’s you will get a prime cut of meat, aged for 30 days, cooked to order by a highly trained cook, paired with a fine wine, and served with delicious side dishes by highly attentive wait staff. You will also pay over $100 for your meal.
At Outback, you will get a distinctly lower quality cut of meat, aged since this morning, served with Coors Light . You will pay around $30.
At McDonald’s, you will get the world’s most generic hamburger, fries, and a Coke, served by a teenager who’d rather be checking his phone than listening to you. You will pay $5, maybe less if you order from the value menu.
Not that in each case, when you walk away, you will not be hungry and your body will have obtained nourishment. But the experience was vastly better when you spent more.
为什么美国让制药商自行制定药品价格？这会导致美国药品价格上涨吗？
我们让制药商自行定价，因为这是自由市场经济。
今晚你会饿的。你家附近有三家餐厅：芝加哥莫顿牛排馆、澳洲乡村牛排馆和麦当劳。
在芝加哥莫顿牛排店，你会得到一块上等的肉，陈化30天，由训练有素的厨师烹制，配以美酒，并由细心的服务员提供美味的配菜。你还将支付超过100美元的餐费。
在澳洲乡村牛排馆，你会得到一块质量明显较低的肉，从今天早上开始陈化，配上银子弹啤酒。你将支付大约30美元。
在麦当劳，你会得到世界上最普通的汉堡、薯条和一杯可乐，由一个宁愿看手机也不愿听你说话的青少年提供。你将支付5美元，如果你点超值菜单，可能还会少点。
并非每个案例都是如此，当你离开时，你都不会饿，你的身体也会得到营养。但如果你花的钱越多，体验就会好得多。
Guess what happens? You no longer get a 24 oz cut of aged prime New York strip, because that is too expensive. The steak you do get is no longer cooked to order, the wait staff is less attentive, and the wine list consists of Two Buck Chuck. It isn’t a great experience, and you might not go back. Or you might not get the chance to, as they are likely to go out of business, because they can no longer afford their rent.
You try Outback instead, but even their food is worse. The steak is smaller and the Bloomin’ Onion is gone.
McDonald’s is unaffected, because their meal never did cost more than $20.
也许你没钱去高级牛排馆吃饭，或者你想经常去，你认为这么贵是不公平的。你让当地的国会议员同意，然后通过一项法律，将餐馆一顿饭的价格限制在20美元。你得意洋洋地出现在莫顿餐厅，手里拿着20美元，准备迎接幸福。
猜猜会发生什么？在纽约黄金地带，你再也买不到一份24盎司的陈年干酪，因为那太贵了。你吃到的牛排不再是随叫随到的，服务员也不那么细心了，酒单上只有廉价红酒“两元恰克”。这不是一次很好的经历，你可能再也不会去了。或者你可能没有机会了，因为他们很可能会破产，因为他们再也付不起房租了。
你可以试试澳洲乡村牛排馆，但就连他们的食物也更糟糕。牛排变小了，洋葱也没了。
麦当劳没有受到影响，因为他们的餐费一直就没有超过20美元。
However, we like medical progress. There are things I can treat better and more effectively now than I could 20 years ago. Innovation is expensive. Developing a new drug can cost hundreds of millions of dollars and take 10 years. Sometimes that time and money go to waste because the drug is rejected by the FDA over safety concerns (most new drugs do not make it through this process). Drug companies are not going to take the risk of making new drugs unless there is a reward at the end of the tunnel, and that reward is the profits from the initially very high prices. They get those profits primarily from the US market. Congratulations America, you fund drug development for the whole world.
But if you limit those profits with price controls, there is less risk taking, less development, and less progress. A diabetic that I treat with nothing but generic drugs is going to do much worse and die sooner than one I treat with the fancy new stuff.
Yes, it sucks if you are the one spending $$$ on meds. The meal at Morton’s was expensive, but you wanted to go there, enjoyed the meal, and will remember it fondly. Absolutely no one wants to spend $100 on medications. But not dying or losing your vision or having crippling arthritis is good too.
这就是药品市场。那里总是有麦当劳。我可以用便宜的仿制药有效地治疗许多疾病。我有很多病人同时服用六种药物，每个月的药费都不超过10美元。这些大多是老药，但仍然有效。如果有效，那就太好了。
然而，我们喜欢医学的进步。与20年前相比，我现在可以更有效地治疗一些疾病。创新是昂贵的，开发一种新药可能要花费数亿美元，耗时10年。有时，这些时间和金钱会被浪费，因为该药物因安全问题被美国食品药品监督管理局拒绝（大多数新药都无法通过这一过程）。制药公司是不会冒险研发新药的，除非在研发过程的尽头有回报，而这个回报就是从最初的高价格中获得的利润。他们的利润主要来自美国市场。祝贺美国，你们资助了全世界的药物研发。
但是，如果你用价格控制来限制这些利润，就不会承担那么多的风险，就会减少发展，也会减少进步。我只用非专利药物治疗的糖尿病患者会比我用新奇的药物治疗的糖尿病患者更糟糕，死得更快。
是的，如果你是那个花钱买药的人，那就太糟糕了。这就像在莫顿餐厅吃的饭很贵，但你想去那里吃，吃得很好，会留下美好的回忆。绝对没有人愿意在药物上花费100美元，但不死亡、不失明、不患致残性关节炎也是好事不是。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
Why are prescxtion drug prices so high in the U.S. compared to the rest of the world?
Because we let them.
Read that again.
Because WE let them.
Medicare Part D specifically PROHIBITS the negotiation of drug prices.
(Some Big Pharma lobbyist, somewhere, broke out the champagne and got a huge bonus for that one.)
Just about every other country in the world, where universal health care exists, negotiates their drug costs. Those countries know that saying that the system pays only X dollars for Y drug means that effectively, that drug won’t go anyone in that country, unless Big Pharma plays ball.
The same cancer drugs that cost thousands here can be purchased in Europe for one hundred dollars.
为什么美国的处方药价格比世界其他地方高?
因为我们让他们这样的。
再读一遍。
因为“我们”让他们这样的。
医疗保险D部分特别禁止就药品价格进行谈判。
(在某个地方，一些大型制药公司的说客打开了香槟，并因此获得了巨额奖金。)
世界上几乎所有其他存在全民医疗保健的国家都在协商药品成本。这些国家知道，说系统为Y种药物只支付X美元的话，实际上意味着，除非大型制药公司合作，否则这种药物不会进入该国的任何人手中。
同样的抗癌药物在美国要花几千美元，在欧洲只要100美元就能买到。
I have another that can no longer pay for the rheumatoid arthritis drug, that keeps her functional, because her insurance company won’t pay the four thousand dollars a month for Enbril. It is an older drug. It used to cost seven hundred a month.
My son has severe allergies. He used to carry an Epi-pen with him everywhere. Again, a very old drug. Used to cost ninety buck for two. It went up to around eight hundred each.
Why?
Because WE let them.
Who is WE?
It’s YOU and ME.
If we don’t take action, we will continue to be like sheep going to the slaughter house.
The sheep aren’t doing anything about because, well, they’re sheep.
Don't be a sheep.
我有一个患有1型糖尿病的朋友，她需要定量使用胰岛素，因为她负担不起每月500美元的费用。没有胰岛素，她会死的。
我还有一个无法再支付治疗类风湿性关节炎药物的费用，因为她的保险公司不会支付每月4000美元的Enbril费用。它是一种较老的药物。过去一个月要花700美元。
我儿子有严重的过敏症。他以前到哪都带着肾上腺素注射器，这又是一种非常古老的药物。以前两支要90美元，如今每支价格涨到了800美元左右。
为什么？
因为我们让他们这样干的。
我们是谁？
是你和我。
如果我们不采取行动，我们将继续像羊一样走向屠宰场。
绵羊什么也不做，因为，它们是绵羊。
不要做绵羊了。
There is currently drugs cost legislation being considered, in Washington.
If you are interested, and it’s cool if you are not (bah), go to FightPharma.org/senate.
There you can send a letter to the senators involved in this decision.
Tell your story. Add personal comments.
Let them know that this is an issue that will determine your vote, when they come up for re-election.
你有投票的权力、你有抗议的权力。
目前，华盛顿正在考虑就药品成本立法。
如果你感兴趣，如果你不感兴趣也没关系，请访问FightPharma.org/senate。
在那里你可以写信给参与这个决定的参议员。
讲述你的故事，添加个人评论。
让他们知道，当他们竞选连任时，这个问题将决定是否获得选票。
As I uncover more practical steps that you can take, I’ll let all my wonderful Quora followers know.
Peace.
Edit——
Anyone that wants to throw blame around in the comments can stop right here.
The point of this answer was to empower and inform, not to bash each other’s political points of view or to throw blame around.
The house is burning down, arguing about who should put it out is a waste of time.
我只用了不到五分钟的时间。
当我发现更多你可以采取的实际步骤时，我会让我所有优秀的Quora粉丝知道。
和平
编辑----
任何想在评论中指责别人的人都可以在这里停下来。
这个回答的重点是赋予权力和信息，而不是抨击彼此的政治观点或相互指责。
房子着火了，争论谁来灭火是浪费时间的行为。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
Why are pharmaceuticals less expensive everywhere outside the U.S.?
There are two main drivers: strict enforcement of liberal intellectual property laws, and political restriction of bargaining power.
The grant of a patent on a drug compound gives its owner a monopoly for the lifetime of the patent, which is now 20 years. During this time the patent holder is free to charge as much as they believe the market will bear without the threat of being undercut by competition.
This is not quite as bad as it sounds - drugs are patented before they receive FDA clearance for marketing, so the effective life of the monopoly is usually on the order of 10–16 years, not 20.
Some countries - India and South Africa are prime examples - are not particularly respectful of intellectual property rights. They have refused to enforce patents when homegrown competitors make generic versions of on-patent drugs, or they threaten to do so in exchange for country-specific reduced pricing.
But pharma companies have gotten very creative about extending their monopolies. One strategy is to pay generic drug manufacturers not to compete[1] . Another is to make very minor - and in my opinion, obvious - changes in formulation that result in new patents and a brand-new patent clock.
The most notorious example of this practice is Prilosec/Nexium for acid reflux disease[2] . The active ingredient in both drugs is precisely the same. However in the original formulation (Prilosec), the drug is a 50:50 mixture of two mirror-image versions of the same molecule. One version is active, the other is inactive.
为什么美国以外的地方的药品都便宜。
主要有两个驱动因素：严格执行自由的知识产权法，以及政治上对议价能力的限制。
一种药物化合物的专利被授予后，其所有者在专利有效期内拥有垄断权，现在是20年。在此期间，专利持有人可以自由地收取他们认为市场可以承受的价格，而不会受到竞争削弱的威胁。
这并不像听起来那么糟糕——药物在获得FDA批准上市之前就获得了专利，所以垄断的有效期限通常是10-16年，而不是20年。
一些国家——印度和南非就是最好的例子——并不特别尊重知识产权。当本土竞争对手生产专利期内的仿制药时，他们拒绝强制执行专利，或者他们就此要挟对在特定国家的药品降价销售。
但制药公司在扩大垄断方面变得非常有创意。一种策略付钱给非专利药制造商，让他们不要竞争。另一种是在配方上做出非常微小的（这很显然是我的观点）改变，从而产生新的专利和全新的专利有效期。
这种做法最臭名昭著的例子是用于胃酸反流疾病的奥美拉唑/埃索美拉唑。这两种药的有效成分完全相同。然而，在原始配方(奥美拉唑)中，该药物是同一分子的两个镜像版本的50:50混合物。一个版本是有化学活性的，另一个是无化学活性的。
Nexium’s clinical benefits over Prilosec are very modest, and mostly result from comparing the two drugs at equal doses, even though Prilosec is only 50% active. But AZ has marketed the hell out of Nexium, and global sales are around $4B[3] .
The other driver of high US drug prices is a lack of bargaining power. Other countries have centralized/universal health care organizations that can and do negotiate with pharma companies on price.
Except that they are specifically prohibited by law from bargaining. Medicare and Medicaid must pay for nearly all FDA-approved drugs prescribed by a physician. But the Republican Congress, when it set up Medicare Part D in 2003, forbade Medicare from negotiating drug prices. Since Medicare must cover all drugs, and cannot bargain, pharma companies are free to charge as much as they like, knowing that Medicare simply has to pay up. This is a legally mandated transfer of funds from taxpayers to pharma companies.
And don’t expect this to change with a Republican Congress and President. US taxpayers will continue to be raped in this way for the foreseeable future.
奥美拉唑的所有者阿斯利康（AstraZeneca）想出了如何从不具备化学活性的分子中分离出化学活性分子的方法。这很有挑战性，但并不是什么突破。这样做是一个非常明显的步骤——当然，你希望配方由其活性成分组成。专利应该只授予那些非显而易见的发明，但专利局对非显而易见性设定的标准很低，并授予阿斯利康一项纯化形式的专利，该专利被称为埃索美拉唑。
埃索美拉唑相对于奥美拉唑，增加的临床益处非常小，主要是在同等剂量下比较两种药物的结果，尽管奥美拉唑只有50%的活性。但AZ已经将埃索美拉唑推向了市场，全球销售额约为40亿美元。
美国药品价格高企的另一个驱动因素是缺乏议价能力。其他国家有集中/普遍的医疗保健组织，可以而且确实可以与制药公司就价格进行谈判。
除非法律明确禁止他们讨价还价。医疗保险和医疗补助必须为医生开出的几乎所有fda批准的药物买单。但是，共和党控制的国会在2003年设立医疗保险D部分时，禁止医疗保险参与药品价格谈判。由于医疗保险必须覆盖所有药品，而且不能讨价还价，制药公司可以随心所欲地收取费用，因为他们知道医疗保险必须支付全部费用，这是法律强制将资金从纳税人向制药公司进行转移。
不要指望共和党国会和总统会改变这种情况，在可预见的未来，美国纳税人将继续被这种方式蹂躏。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
Why are drug prices so much higher in the US than in France?
I’m no expert on this one but the explanation I’ve been given in the past is that it comes from a difference in bargaining power between the different actors in the two markets.
As you may be aware of, France has a very socialized health system and, among other things, most drugs prescribed by a doctor will be paid for by our public health insurance system and not by the patient himself.
Now, if you are a pharmaceutical company willing to commercialize a new drug in France, you have two options :
you simply go through the process of getting your product approved for the French market. In this case, if you do get the authorization from the French authorities, you will be allowed to sell your drug in France at the price you wish but it won’t be part of our insurance system either (meaning that your customers will actually have to pay for the drug themselves)
in addition of having your product approved, you make an application to the French administration for it to be registered by our insurance system. In addition of checking that your molecule is in line with all the regular medical requirements, this process will involve a negotiation with the French administration on a fixed commercialization price… but it also means that your prospective customers will not have to pay themself for your product if it is accepted
为什么美国的药品价格比法国高得多？
我不是这方面的专家，但我过去得到的解释是，这源于两个市场中不同参与者之间议价能力的差异。
正如你可能知道的，法国有一个非常社会化的卫生系统，除其他外，医生开的大多数药物都将由我们的公共医疗保险系统支付，而不是由患者自己支付。
现在，如果你是一家愿意在法国将新药商业化的制药公司，你有两个选择：
你只需通过让你的产品进入法国市场的程序。在这种情况下，如果你确实获得了法国当局的授权，你将被允许以你希望的价格在法国销售你的药物，但它也不会成为我们保险系统的一部分(这意味着你的客户实际上必须自己支付药物费用)。
除了让你的产品获得批准，你向法国行政部门提出申请，在我们的保险系统中登记。除了检查你的药品分子是否符合所有常规医疗要求外，这个过程还包括与法国政府就固定的商业化价格进行谈判，但这也意味着，如果你的产品被接受，你的潜在客户将不必为你的产品付钱。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处
On the other hand, in the US, where my understanding is that the whole health care system is privatized pharmaceutical companies enjoy much more bargaining power and do get to set higher prices.
I believe (though not 100% sure) that most of Western Europe works with more or less socialized health systems and that the price gap mentionned in the question is not limited to France.
At the end of the day, one thing that is sure is that, in this organization, the American customer probably ends up subsidizing the R&D programs (whose costs are massive in drug development) the French (and possibly European) one is ultimately enjoying the benefits of.
实际上，任何药物都必须成为这一保险体系的一部分，才能在法国获得显著的市场渗透（可能会有一些非常吸引人的对冲措施，他们仍然可以承担不参与其中的后果，但这真的不是主流）。最终，这意味着制药公司必须与一个控制其进入整个法国市场的单一机构进行谈判。这意味着法国政府在谈判中处于非常有利的地位，从而使其能够确保低药价。
另一方面，在美国，我的理解是，整个医疗保健系统都是私有化，制药公司拥有更大的议价能力，可以设定更高的价格。
我相信（尽管不是100%确定）大多数西欧国家或多或少都有社会化的医疗体系，问题中提到的价格差距不仅限于法国。
归根结底，有一点是肯定的，在这个组织中，美国客户可能最终会资助研发项目（其在药物开发方面的成本巨大），而法国（可能还有欧洲）客户最终会享受到这些项目的好处。
How has the "big pharmafia" impacted drug prices?
They game the patent system. For example they reformulate a medication in a more desirable package (like a longer acting version, or one with less side effects) and repatent it for another decade. I’m not sure why they can get away with this, it seems like a stupid loophole, but it apparently works.
They buy off potential generic makers. If you were a small company thinking of cloning say Ozempic in a few years. You could invest in a production line, buy raw materials, start advertising, fight against the “generics aren’t as good” thought process. Or you could just accept the $3 billion dollars that were offered to just bow out. Which is better for your stock holders? Interesting that Mark Cuban, of all people is trying to disrupt this. He’s buying and eventually going to be making, his own generics and selling them at 15% over his cost, with $5 shipping per order.
They do the absolute minimum research to get something approved. For example, they might use a surrogate endpoint, like blood sugar for diabetes or drop in blood pressure rather than the decrease in cardiac deaths we’re really concerned about. They leave the “does this stuff actually help people live longer or healthier” for the patients to sort out!
“大型制药公司”是如何影响药品价格的?
他们玩弄专利制度。例如，他们将一种药物重新配制成更理想的包装（如长效或副作用较小的版本），然后再使用十年。我不知道他们为什么能逃脱惩罚，这似乎是一个愚蠢的漏洞，但它显然有效。
他们收购潜在的仿制药商。如果你是一家考虑几年后克隆的小公司，比如Ozempic。你可以投资一条生产线，购买原材料，开始做广告，对抗“仿制药没有那么好”的思维过程。或者你可以接受30亿美元的报价，然后退出。哪一种对你的股票持有者更有利？有趣的是，在所有人中，马克·库班（马克·库班，是现任美国职业篮球联赛达拉斯独行侠的拥有者。库班还拥有两架波音商务喷射机）正试图破坏这一局面。他购买并最终生产自己的仿制药，并以比成本高出15%的价格出售，每笔订单的运费为5美元。
他们只做最少的研究就能获得批准。例如，他们可能会使用一个替代终点，比如糖尿病的血糖或血压下降，而不是我们真正关心的心脏病死亡人数的减少。他们把“这些东西真的能帮助人们活得更长或更健康吗”留给病人来解决！
They market directly to consumers (you) and provide lecturers to sell their claims. Back in the 00s I treated a lot of diabetes, and I’d started using a fair amount of Avandia, because it was one way to reduce blood sugars when everything else didn’t work. Turn out that it doesn’t help diabetics health (surrogate marker) but we didn’t know that yet. The drug company offered to pay me $100s a night to lecture people on how wonderful Avandia was.
为了上述利益，他们经常会用统计数据对FDA/CDC和医生撒谎。他们会带着一个明确的目标(药物X是否能减少问题Y)开始临床试验，结果失败了，但X减少了与问题Y相关的某些东西，所以他们会重写研究来强调这一点。或者他们会启动一个项目，发现它似乎只对特定的亚群体有帮助，所以他们会找到一种方法来排除所有帮助不到的人群。或者他们会谈论趋势，而不是谈论重要的结果。做足假账，你几乎可以证明任何事情，几乎可以证明能帮助所有人。治疗阿尔茨海默氏症的新药就是一个很好的例子——每一种药物都被大张旗鼓地推出，尽管几乎没有任何积极作用，而且每月要花费数千美元。
他们直接向消费者（你）推销，并准备好讲师来推销他们的主张。早在00年代，我就治疗了很多糖尿病，我开始使用大量的文迪雅，因为当其他一切都不起作用时，这是降低血糖的一种方法。事实证明，它对糖尿病患者的健康没有帮助（替代标记），但我们还不知道。制药公司愿意每晚付给我100美元，让我向人们宣传文迪雅有多棒。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处