Pharmaceutical Pricing and Reimbursement in the United States : Market Research Report

Pharmaceutical Pricing and Reimbursement in the United States

Published: Dec. 15, 2006 - 48 Pages

Executive Summary: Strategic Considerations; Stakeholder Implications
Overview: Organization and Funding of the U.S. Health Care System; Private Insurance; Medicare; Medicaid; Military and Other Federal Health Care Programs
Pharmaceutical Prices in the United States: Prices Relative to Other Major Markets; Pricing in the Public Sector; Pricing in the Private Sector; Generics Pricing
Provider Reimbursement: Medicare; Hospital Inpatient Treatment; Hospital Outpatient Treatment; Office-Based Physicians; Commercial Insurers; Coverage Decision Making; Public Sector; Private Sector; Cost-Containment Measures; Multitier Formularies; Patient Copayments and Coinsurance; Use of Generics; Therapeutic Substitution; Prior Authorization and Step Therapy; Mail-Order Pharmacy; Specialty Pharmacy
Outlook for the U.S. Pharmaceutical Market

Abstract

Introduction

One of the most attractive features of the U.S. pharmaceutical market for manufacturers is the unrivaled freedom of its pricing and reimbursement environment. However, after many years of vigorous expansion, the U.S. pharmaceutical market has recently shown signs of a slowdown in its growth rate. Companies will need to give considerable thought to future pricing strategies in the United States.

Questions Answered in This Spectrum Report

On average, pharmaceutical prices in the United States are much higher than in Europe. How are pharmaceutical prices determined in the public and private sectors in the United States?

Drugs administered by medical professionals require reimbursement for the costs of both the medicines themselves and the service of administering them. In an attempt to curb the inexorable growth in spending on these medications, third-party payers have developed complex systems for provider reimbursement. How are providers reimbursed for the costs of these drugs?

Managed care organizations employ a wide range of demand-side cost-containment measures to curb pharmaceutical spending in the United States. What are the most widely used cost containment measures?

Pharmacy benefit management companies (PBMs) play a pivotal role in the U.S. pharmaceutical market. PBMs administer the drug benefits of approximately 200 million U.S. residents. How do PBMs negotiate drug prices with pharmaceutical companies? How do PBMs impact prescription drug costs?

Scope

Organization and funding of the U.S. health care system: private insurance, Medicare,
Medicaid, military and other federal health care programs.
Pharmaceutical prices in the United States: prices relative to other major markets, pricing in the public and private sector, and generics pricing.
Provider reimbursement: reimbursement procedures set by Medicare and commercial insurers.
Coverage decision making: drug coverage decisions in the public and private sector.
Cost-containment measures: multitier formularies, patient copayments and coinsurance, use of generics, therapeutic substitution, prior authorization and step therapy, mail-order pharmacy, and specialty pharmacy.
Outlook: effect of pricing and reimbursement trends on the U.S. pharmaceutical market.

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Pharmaceutical Pricing and Reimbursement in the United States

Table of Contents

Abstract