Prescription drug spending in the USA has soared, fueled by rising drug prices. A critical mechanism for restraining drug prices is the formulary tiering system. Although tiering should reflect the cost of a drug—and reward patients who choose less-expensive drugs—something is seriously amiss. Using Medicare claims data from roughly one million patients between 2010 and 2017, this article finds troubling amounts of distorted tiering and wasted cost. Increasingly, generics are shifted to more expensive—and therefore less accessible—tiers. The percentage of generics on the least-expensive tier drops from 73% to 28%; the percentage of drugs on inappropriate tiers rises from 47% to 74%. Considering only costs paid by patients and the federal Low-Income Subsidy Program, tier misplacement cumulatively costs society $13.25 billion over the time period. An unruly problem demands a disruptive solution. This article advances the counterintuitive regulatory reform that tiering should be based on a drug’s list price. Yes, list price—that roundly dismissed figure—should become the touchstone. This would deter incentive-distorting rebate schemes while recognizing that many people already pay list price. It is a remarkably streamlined approach for cutting through a wide swath of perverse incentives and manipulations.

中文翻译：

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层级中的魔鬼^1个

在美国，由于药品价格上涨，处方药支出猛增。限制药品价格的关键机制是配方分级系统。尽管分层应该反映药物的成本，并奖励选择较便宜药物的患者，但某些事情严重不对。使用2010年至2017年间的大约100万患者的Medicare索赔数据，本文发现了令人费解的分层失真和成本浪费。泛型已越来越多地转移到更昂贵的层，因此也越来越难以访问。最便宜的一级仿制药的比例从73％下降到28％；不适当等级的毒品所占比例从47％增加到74％。仅考虑患者支付的费用和联邦低收入补贴计划，在一段时间内，错位累计给社会造成了132.5亿美元的损失。一个不守规矩的问题需要一个破坏性的解决方案。本文提出了违反直觉的监管改革，即分层应该基于药品的标价。是的，标价（被舍弃的数字）应该成为试金石。在认识到许多人已经支付了标价的同时，这将阻止激励扭曲的回扣计划。这是消除大量不正当奖励措施和操纵手段的一种非常简化的方法。