《【妖舞魔亂】自由沙漏-013》

 

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【十年內，全球洗腎人口加倍 飛快成長的洗腎市場】
作者：經濟學人 出處：天下雜誌 445 期  2010/04

 

全球各地的洗腎人口快速增加，讓洗腎成為飛快成長的龐大市場，然而，控制成本也變成了政府與業者的當務之急。

俗稱洗腎的血液透析，做起來麻煩又痛苦，是醫學上最不受人歡迎的治療之一，但洗腎卻是個成長快速、獲利可觀的龐大市場。

以產業來說，這是個寡佔的行業。全球有超過一半的洗腎（血液透析）機，都是由德國的費森尤斯醫療集團（Fresenius Medical Care）所生產，瑞典大廠金寶（Gambro）緊追其後。

另方面，洗腎市場最有利可圖的業務，就是經營洗腎中心。美國最大的兩家連鎖洗腎集團分別是費森尤斯與達維它（DaVita），在全美各自擁有一千多家診所。

目前，全球的洗腎病患約有兩百萬人，其中有四分之一在美國。而美國也是全球最大的洗腎市場，政府每年支出二四○億美元（每個病人每年平均七萬多美元）在洗腎上，保險公司支付的更多。

控制成本，看緊每一分錢

不只美國，全球各地的洗腎人口、治療成本也都在快速增加。以英國為例，近幾年有三％的醫療支出是用在腎衰竭治療上，比往年增加了近五成。估計未來十年，全球洗腎人口還可能加倍，而且大部份都會是開發中國家的病人，因為新興國家在所得增加後，醫療體系也開始治療那些原本被放棄醫治、只能等死的腎臟病人。

洗腎支出快速增加下，無論政府或業者，控制成本都變成了當務之急。費森尤斯集團的成功經驗，提供了兩個啟示，一是要軟硬通吃，做機器也做服務，「業界最佩服費森尤斯的，就是這種一次購足（one-stop shopping）的模式，」羅蘭貝格顧問公司的丹納指出。

另外，則是要看緊每一分錢。出差習慣搭經濟艙的費森尤斯執行長施耐德就批評製藥業，因為營運費用太高，讓藥品價格降不下來。

未來美國的健保改革，可望改善部份的浮濫支出。例如，目前美國洗腎中心的用藥是以「成本加利潤」方式計價；將來引進固定費率的「套餐價」，分析師估計，藥品成本至少可以省下一○％。（吳怡靜譯）

 

【The dialysis business】
By The Economist print edition
From The Economist  Published: April 22, 2010

 

The battle over one of medicine's fastest-growing and least loved markets

DIALYSIS—the use of machinery to make up for malfunctioning kidneys—is among medicine's least loved treatments, both to endure and to administer. Patients have to be hooked to machines for hours at a time every few days. Those providing care often find it difficult, too: as many as a fifth of their patients die each year, many of them after choosing to stop their treatment. But it is also a fast-growing and lucrative market, and one that provides valuable lessons about making health care affordable.

Dialysis is dominated by an oligopoly. Fresenius Medical Care, the dialysis business of Germany's Fresenius, makes more than half of the dialysis machines sold in the world, followed by Gambro, a Swedish firm. Ulf Mark Schneider, the chief executive of Fresenius, attributes his company's success to the fact that it plays to traditional German strengths. "A dialysis machine has the same number of parts as a car," he says. "Making one brings together electronics and mechanical engineering, which Germany is good at."

The real money, however, is in running dialysis clinics and administering drugs, which account for 80% of the cost of dialysis. The two biggest operators of dialysis clinics are Fresenius and DaVita, which bought Gambro's American clinics in 2004. Each of them runs almost a third of America's dialysis clinics.

Some 2m people receive regular dialysis to clean their blood of impurities that build up as a result of kidney failure. About a quarter of them are in America, which has one of the highest rates of dialysis in the world. This is less because Americans are especially unhealthy (although high rates of obesity and diabetes do play a role) and more because American health policy is to provide dialysis to anyone who needs it, regardless of their ability to pay or their chances of surviving much more than a few months. It is also the world's most lucrative dialysis market, with the government spending $24 billion a year, or $71,000 a year per patient, on dialysis, and private insurers paying yet more.

But the number of patients is growing fast all over the place (see chart), as is the cost of treatment. In Britain around 3% of health spending is devoted to treating kidney failure, a proportion that has increased by about 50% in recent years. Globally, the number of patients on dialysis is likely to double over the coming decade. Most of them will be in developing countries, where numbers are growing by 10% or more a year. Worsening diets are playing a part but so are rising incomes, as a result of which health systems treat people who would previously have been left to die.

With spending rising rapidly, attention is now focused on to trying to control costs. Fresenius's experience offers two lessons. First, combining the manufacture of machines with the running of clinics has helped it dominate both markets. "The thing that other people in the industry admire about Fresenius is this one-stop shopping model," says Stephan Danner of Roland Berger, a consulting firm. By the same token, Gambro is the preferred supplier for DaVita's clinics. Second, Fresenius is ruthless about spending. Mr Schneider, who often flies economy on business trips, is outspoken in his criticism of the pharmaceutical industry's "corptocracies", which have high overheads that need to be supported by profit margins of as much as 80% on expensive blockbuster drugs.

Fresenius stands to become a big beneficiary as America's health-care reforms take on some of the more bloated parts of the business. At present American dialysis clinics are paid on a "cost-plus" basis for the drugs they use. That, naturally, has encouraged them to use lots of expensive ones, which now account for almost a quarter of the total cost of treatment. Analysts at Bernstein, a research firm, note that American clinics used to favour an injected drug costing $4,100 a year over an identical oral one which was introduced to the market at a cost of $450 a year. After languishing unused, the oral drug now costs more than the injected one. "There is negative price elasticity here: the higher the price, the more competitive the product," Bernstein's analysts observe.

The reforms will introduce a "bundled price", whereby clinics receive a set rate for providing treatment. Analysts expect drug costs to fall by at least 10% soon after the change, as clinics use fewer or cheaper drugs. A huge share of the savings will go straight to Fresenius's bottom line.

 

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