Pricing and Reimbursement in the US - Non-LIS Beneficiaries Not Covered by Medicare Coverage Gap to Gain from Reduction in Out-of-Pocket Expenditure for Generic Drugs

GBI Research
February 1, 2012
75 Pages - SKU: XGBR6784724
Countries covered: United States



Pricing and Reimbursement in the US - Non-LIS Beneficiaries Not Covered by Medicare Coverage Gap to Gain from Reduction in Out-of-Pocket Expenditure for Generic Drugs

Summary

GBI Research, the leading business intelligence provider, has released its latest research “Pricing and Reimbursement in the US - Non-LIS Beneficiaries Not Covered by Medicare Coverage Gap to Gain from Reduction in Out-of-Pocket Expenditure for Generic Drugs”. The report provides a comprehensive overview of the healthcare system, and pricing and reimbursement process in the US with key data, information and analysis of pricing and reimbursement decisions across the US. The report closely scrutinizes major changes in pharmaceuticals-related pricing and reimbursement in the US in the recent past and the impact these changes will have in the future. It also describes the efforts taken by the US government and private sector in shaping the pricing and reimbursement policies of brand name and generic drugs. The pricing and reimbursement scenario in some of the major therapy areas of the US has been described with the help of informative case studies.

GBI Research has found that expenditures towards healthcare have increased in the US which has led to an increased life expectancy among the Americans. When compared to the top five countries of Europe (France, Germany, the UK, Italy and Spain), the US has the highest per capita expenditures on healthcare. Out-of-pocket spending is minimal in the US, due to a strong reimbursement system provided by the public and private sector, that covers most age groups and communities. A majority of the US population is under insurance coverage, with private health insurance having a larger share than government health insurance. Most of the states have developed their own insurance plans for the benefit of their residents.

With an increase in the working class and ageing population, chronic diseases, age-related diseases and diseases due to sedentary lifestyle are expected to rise in the future indicating increasing healthcare expenditures. The US President has been implementing a number of changes in the reimbursement system in order to reduce national deficits. The Patient Protection and Affordable Care Act (PPACA) has been introduced to take care of the deficits. The US budget has been designed to reduce deficits and bring about major reforms in the healthcare system of the US.

Scope
  • Detailed study of the healthcare systems in the US.
  • Political, economical, social and technological analysis of the US pharmaceutical industry.
  • Analysis of the pricing and reimbursement mechanisms in the US.
  • Key trends that follow from the recent changes brought about in the pricing and reimbursement system.
  • Build an understanding of the possible major challenges that may arise due to the changes in the pricing and reimbursement scene in the US.
  • Insight into various reimbursement programs in the US with case studies.
  • Particular focus on the pricing and reimbursement in major therapy areas with case studies.
Reasons to buy
  • Build an understanding of the pharmaceuticals-related key pricing and reimbursement mechanisms in the US.
  • Optimize your investment through identification and understanding of the changes in the pharmaceuticals regulatory mechanism in the US.
  • Develop effective business strategies related to new drug launches through the analytical insight gained from key trends in the pricing and reimbursement scene of the US.
  • Improve negotiations with the government agencies to maximize reimbursement of drugs by understanding the mechanisms involved.


Additional Information

Focus Shifting Towards Generic Drugs

The global pharmaceutical market is valued at approximately $850 billion, of which the US market is valued at over $300 billion. Sales of generic drugs totaled $43 billion in 2010, in the US. Of all the prescriptions dispensed, generics constituted a majority share of 75% in 2010, in the US. The US President has recently pledged to accelerate the availability of generic drugs in the market and ban pay-for-delay agreements. The availability of generic drugs will be enhanced by preventing companies to enter anti-competitive agreements. The proposal made by the US government accelerates access to affordable generic drugs by granting brand biologic manufacturers seven years of exclusivity replacing the 12 years, while retaining appropriate incentives for research and development (R&D) for the innovation of breakthrough products.

It has been observed that as more generic manufacturers produce a certain drug, prices of the generic drug falls significantly. This reduction in average price of generic drugs is observed every year. The retail price index for generic drugs decreased at an average annual rate of -1.1% over the past two years. Moreover, discounts on generic drugs will increase from 2011 to 2020 as the generic drug costs paid out-of-pocket by non-Low-Income Subsidy (LIS) beneficiaries in the coverage gap will gradually reduce from 93% in 2011 to 25% in 2020. The majority cost sharing will be undertaken by the Medicare Part D (MPD) plan as it will pay 75% of the generic drug costs by 2020.

Increasing Healthcare Expenditures has Improved Life Expectancy of Americans

Healthcare expenditure has increased gradually from 13.7% of GDP in 1995 to 17.4% of GDP in 2009, according to the Organization for Economic Co-operation and Development (OECD). Per capita spending on healthcare has also improved, from $4,703 in 2000 to $7,410 in 2009, in purchasing power parity (PPP) terms. The increased spending towards healthcare has led to an improved life expectancy. Americans had a life expectancy of 75.7 years at birth in 1995, which has increased to 79 years with the increase in healthcare spending.

Huge Deficits Provoking Cuts in Rebates

The Affordable Care Act (ACA) has been implemented to reduce federal deficits by approximately $230 billion over next decade by delivering better healthcare at lesser costs; provisions to fight waste, fraud and abuse; rewards for high quality care; and innovative healthcare delivery systems. In addition, a proposal to cut $320 billion from US health programs was announced by the US President Barack Obama on September 19, 2011.

Medicare Part B reimburses drugs and biologics medicines indicated for cancer and other serious diseases. In order to reduce the US debt limits, $3 billion in cuts towards payments for Part B drugs has been proposed by the government. Medicare Part B reimbursement had been reformed earlier in 2003 as part of Medicare Modernization Act, in which reimbursement for drugs and biologicals covered under Part B had been reduced significantly. Enacting further cuts in payments to the Medicare Average Sales Price (ASP) system, which includes actual prices paid by physicians and other drug purchasers, may hinder Part B-related healthcare services.

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