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Market Access in the United States: An Uncertain Outlook

Decision Resources
November 1, 2011
SKU: DECR6692977

Abstract Table of Contents Related Reports

Countries covered: United States

The outlook for the U.S. pharmaceutical market is more uncertain than at any other time in recent years. The number of uninsured residents and Medicaid beneficiaries has grown steadily, while the percentage of the nonelderly population covered by employer-sponsored insurance has declined significantly. The quality of benefits is under pressure as payers increase cost sharing and implement policies to restrict the use of high-priced drugs. Healthcare reform promises to boost access to health benefits, but the future for this legislation remains very uncertain.

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Executive Summary: Strategic Considerations; Stakeholder Implications
Introduction
Unequal Access to Health Insurance: Variations in Health Insurance Coverage by Demographic Group; Changing Patterns of Employer-Sponsored Health Insurance; Disturbing Growth in the Ranks of the Uninsured and Underinsured; Prospective Changes in Access to Health Insurance
Close Scrutiny of U.S. Pharmaceutical Prices
Pharmaceutical Market Trends
Employer-Sponsored Health Plans: Growth of Multitier Formularies; Patient Copayments and Coinsurance; Utilization Management Tools; Clinical and Educational Programs; Strategies to Promote Greater Use of Generics; Value-Based Benefit Designs; Management of Specialty Pharmacy Costs
Medicare: Growth of Multitier Formularies; Patient Copayments and Coinsurance; Utilization Management Tools; Potential Changes to Medicare Payment Models
Medicaid: Funding Difficulties; Cost-Containment Strategies; Pricing Reforms
New Initiatives to Improve Public Health and the Quality of Healthcare Provision
Promotion of Comparative Effectiveness Research
Outlook and Implications for the Pharmaceutical Industry: Discord Over How to Tackle the Budget Deficit; Political Deadlock Over Healthcare Reform; Declining Access to Generous Health Benefits; Evolving Cost-Containment Strategies; Increasing Use of Comparative Effectiveness Research; Support for New Healthcare Models
Tables: 1. Key Features of U.S. Healthcare Reform Legislation; 2. Timetable of Key Events for the Pharmaceutical Industry in the U.S. Healthcare Reform Process
Figures: 1. Health Insurance Coverage of the Total U.S. Population, 1999-2010; 2. Health Insurance Coverage of the Nonelderly U.S. Population, 1999-2010; 3. Health Insurance Coverage of the Elderly U.S. Population, 1999-2010; 4. Percentage of U.S. Employers Sponsoring Employee Health Benefits, 1999-2010; 5. Pharmaceutical Pricing Trends in the United States, March 31, 2006, to March 31,2010; 6. Leading PBMs’ Reported Changes in Drug Prices, 2010; 7. Leading PBMs’ Growth Rates for Pharmaceutical Expenditures per Member, 2010; 8. Percentage of U.S. Covered Workers in Formulary Designs of Various Structures,2000-2011; 9. Percentage of U.S. Employers Using Formularies of Various Structures, 2007-2011; 10. Average Copayments in the United States by Formulary Tier, 2000-2011; 11. Evolution of Average Retail Copayments for Generics, Preferred Branded Medicines,and Nonpreferred Branded Medicines, 2000-2011; 12. Evolution of Average Mail-Order Copayments for Generics, Preferred Branded Medicines, and Nonpreferred Branded Medicines, 2002-2011; 13. Percentage of Covered Workers Required to Pay Copayments and/or Coinsurance by Formulary Tier, 2011; 14. Average Coinsurance Rates in the United States by Formulary Tier, 2000-2011; 15. Evolution of Average Retail Coinsurance Rates for Generics, Preferred Branded Medicines, Nonpreferred Branded Medicines, Lifestyle Drugs, and Specialty Drugs,2000-2011; 16. Evolution of Average Mail-Order Coinsurance Rates for Generics, Preferred Branded Medicines, Nonpreferred Branded Medicines, Lifestyle Drugs, and Specialty Drugs, 2000-2011; 17. U.S. Employers’ Use of Common Utilization Management Tools, 2007-2011; 18. U.S. Employers’ Use of Common Clinical and Educational Programs Tools, 2007-2011; 19. Generics’ Share of the U.S. Pharmaceutical Market, 2003-2010; 20. Leading PBMs’ Generics Dispensing Rates, 2006-2010; 21. U.S. Employers’ Use of Value-Based Benefit Design Tools, 2009-2011; 22. U.S. Employers’ Strategies for Managing Specialty Pharmacy Costs, 2010-2011; 23. Percentage of Nonstandard Medicare Plans with Specialty Tiers, 2006-2011; 24. Average Formulary Placement of Select Drug Classes by Medicare Prescription Drug Plans, 2011; 25. Median Medicare Part D Copayments, 2006-2011; 26. Median Medicare Part D Coinsurance Rates for Specialty Drugs, 2006-2011; 27. Percentage of Covered Drugs Subjected to Utilization Management Tools by Medicare Prescription Drug Plans, 2007-2011; 28. Common Approaches to Cost Containment Used by State Medicaid Administrations

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Market Access in the United States: An Uncertain Outlook

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