Medicine Use and Spending in the U.S - A Review of 2018 and Outlook to 2023 MAY 2019 - Squarespace
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MAY 2019
Medicine Use and
Spending in the U.S.
A Review of 2018 and Outlook to 2023
$Introduction
The use of medicines in the United States is a critical factor influencing the health
outcomes of millions of Americans and the level and growth of spending among
healthcare stakeholders. The price of new and old drugs and the allocation of costs
among patients, employers, health plans, intermediaries and state and federal
government agencies all command great attention.
This report focuses its attention on drivers changing The goal of this report is to provide objective measures
the use of medicines, including the availability of new of medicine use and their cost to our healthcare system,
branded drugs, generics and biosimilars and efforts to drawing upon the information and expertise of IQVIA.
drive medication adherence in chronic conditions. We hope this report provides the basis for meaningful
discussion among stakeholders with an interest in
To better inform discussions of potential policy reforms,
understanding and improving the functioning of
the report also continues to examine “net spending”
our system.
on medicines in the United States — meaning the
amount received by pharmaceutical manufacturers The study was produced independently by the IQVIA
after rebates, off-invoice discounts and other price Institute as a public service, without industry or
concessions have been made to distributors, health government funding. The contributions to this report
plans and intermediaries. Further, it tracks the overall of Beth Bauer, Allen Campbell, Paul Cariola, Katie
volume of prescription opioids used, even as it declines. Devane, Luke Greenwalt, Brian Hannah, Tim Hughes,
Sarah Keefer, Doug Long, Dave MacDougall, Elyse
In addition, as healthcare costs increase, the report
Muñoz, Bernie Gardocki, Deanna Nass, Alana Simorellis,
examines the level of out-of-pocket costs borne by
Durgesh Soni, Barry Summers, Mason Tenaglia, Marcella
patients filling prescriptions at retail pharmacies.
Vokey, Terri Wallace and dozens of others at IQVIA are
The significant differences between initial prices
gratefully acknowledged.
patients are exposed to and the final amounts they
spend are highlighted and reasons for these differences MURRAY AITKEN
are explored. Executive Director
IQVIA Institute for Human Data Science
Finally, the report provides an outlook through 2023
for the pharmaceuticals market, incorporating key
dynamics around new product launches, patent expiries
and the introduction of generics and biosimilars.
©2019 IQVIA and its affiliates. All reproduction rights, quotations, broadcasting, publications reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without
express written consent of IQVIA and the IQVIA Institute.Table of contents
Executive summary 2
Medicine usage trends 5
Medicine spending and growth dynamics 19
Patient out-of-pocket costs 27
Outlook to 2023 34
Notes on sources 44
Methodology 45
Appendix 48
About the authors 55
About the IQVIA Institute 56
1Executive summary Americans filled 5.8 billion 30-day equivalent prescriptions Prescription opioid volume continued to decline steeply in 2018, up 2.7% over the prior year at a rate of 17.6 in 2018 as changes in regulations and clinical guidelines, prescriptions per person. More than two-thirds of accompanied by high public awareness, drove a 17% prescriptions are for chronic conditions, which are decline in total morphine milligram equivalents (MME) increasingly filled with 90-day prescriptions thought to dispensed. The biggest decline came from the most result in better adherence to prescribed regimens. For potent and dangerous high-dose prescriptions. specialty medicines, which represent 2.2% of volume, Growth in total medicine spending net of rebates, use grew by more than twice the rate of other drugs, and discounts and other price concessions, remained at more than half of the volume in key therapy areas is now historically low levels in 2018, increasing 4.5% and dispensed through retail channels and does not require reaching $344 billion. When adjusted for population and administration in a hospital, clinic or doctor’s office. inflation, net medicine spending in 2018 was $1,044 per In 2018, a growing number of patients were treated with person, up 0.9% or $10 from 2017, and up a total of 4.4% relatively new specialty medicines used across a number or $44 since 2009. Net medicine spending for traditional of disease areas including oncology, migraine, and medicines fell 3.4% on a per capita basis in 2018, while atopic dermatitis. A surge of 6.5 million vaccinations also specialty medicines increased 5.8% and now accounts for occurred due, in part, to the availability of a new shingles $517 out of the $1,044 total per person medicine costs. vaccine. Immuno-oncology checkpoint inhibitors, the Total net spending growth in 2018 of $14.9 billion was first of which launched in 2014, were used to treat over largely driven by more patients receiving existing 200,000 patients in 2018 with a large variety of cancer branded drugs as well as use of newly launched drugs. types, more than double the number treated with these These new drugs contributed $24.2 billion to growth, breakthrough therapies in 2016. Other notable areas mainly from oncology, autoimmune, diabetes and for uptake of new medicines were CGRP modulators for hepatitis C treatments, which together account for over migraine and treatments for atopic dermatitis (eczema). 75% of the total growth. Price increases for branded drugs Use of medicines for autoimmune diseases increased 20% by manufacturers contributed only $800 million to growth in 2018, with newly available treatments for ulcerative in 2018 on a net price basis, at a rate of 0.3% – substantially colitis and psoriasis and related conditions each seeing down from prior years and reflecting lower list price about 30% growth in the number of patients treated. increases and sustained increases in price concessions Lower-cost prescription medicines in the form of generics made by manufacturers across the board, but especially in and biosimilars had modest growth in volume in 2018, diabetes, asthma/COPD and viral hepatitis. as small molecule generics are already dispensed 97% Total patient out-of-pocket costs climbed in 2018 to an of the time they are available, and the generic share of estimated $61 billion, with Medicare patients facing prescriptions reached 90%. Generic approvals increased higher annual out-of-pocket levels than patients in dramatically, with new entrants contributing deflationary commercial plans or on Medicaid. Patients with out- pressure to drug prices, though not all approved generics of-pocket costs over $500 annually represent 8.8% of launched. Three novel biosimilars launched in 2018, total patients, but 20% of Medicare Part D patients. bringing the total to seven molecules. The biosimilar Commercially insured patients increasingly use share of volume exceeded 30% for those medicines, but manufacturer coupons to offset their initial cost exposure, in total these medicines represent less than 1% of biologic and average final out-of-pocket costs remained at $42 volume. Total biologics spending grew by 9.5% in 2018 per brand prescription, similar to 2017 levels. Patient and 13% of the spending in the market is now subject to abandonment of prescriptions at retail pharmacies biosimilar competition, where biosimilars have captured results in patients not receiving medicines prescribed about 12% of total available spend. by their doctors and remains a significant issue when the 2
out-of-pocket costs rise, or when insurance includes a to alternative scenarios based on their impact on payer
deductible. Patients abandon more than 20% of new-to- types, channels and therapy areas and impact invoice
brand prescriptions when the out-of-pocket cost is above spending, net spending and out-of-pocket costs in
$50, and they abandon more than 50% when the cost is very different ways. In one scenario where reforms are
above $125. Final out-of-pocket costs per prescription limited to Medicare programs, patient out-of-pocket
paid by patients when filling retail prescriptions fell slightly costs could decline $14 billion or about 30%, mostly for
in 2018 even as average initial patient cost exposure per Medicare patients but including some dynamics that
prescription rose to record highs. Final out-of-pocket would reduce costs for commercially insured patients
costs paid by patients reflect the use of coupons, and also reduce net spending by as much as 6% to 2023.
discounts or patient assistance and excludes the costs of In another scenario, reforms proposed for Medicare
prescriptions that are abandoned at the pharmacy. The would be extended to the commercial market and
average for the year includes those times when the patient largely remove the existence of off-invoice discounts
is in the deductible period, regular coverage, doughnut and rebates. This would lower patient out-of-pocket
hole or catastrophic care, all of which contribute to costs 30% or $20 billion below projected 2023 levels for
variability in the pharmacy counter cost for the patient. patients of all pay types, and likely drive net spending 9%
lower than base case projections. These net spending
While the full impact on manufacturer net sales of
scenarios embed a large portion of cost reductions
potential policy changes are unclear, the base case
coming from manufacturer net price reductions but
scenario embeds a net market impact of 1–2% below
equally could result in smaller declines for manufacturers
the prior forecast, with the impacts of potential reforms
with different relative splits of impact between health
expected to be phased in gradually. The total net
plans, manufacturers and beneficiary insurance premium
spending growth on pharmaceuticals is forecast to
increases, all of which could vary significantly. Largely due
increase at a compound annual growth rate (CAGR)
to the expected surge in innovative medicines over the
of 3–6% through 2023. The base case scenario for the
next five years, the lower of these scenarios still results in
next five years forecasts net medicine spending in the
net manufacturer revenue growing at a CAGR of 0−3%,
United States will increase from $344 billion in 2018 to
and should that growth fail to materialize, or uptake of
$420 billion in 2023, an aggregate growth of $76 billion
these medicines be less than expected, revenues
compared to aggregate net growth of $84 billion over the
could decline.
past five years.
The largest driver of this growth will be the launch of
new brands that are forecast to contribute $73 billion of
new spending, as clinical development efforts across the
pharmaceutical industry result in new drug approvals and
uptake. Offsetting the impact of new brands will be the
spending on brands losing exclusivity; forecast to total
$78 billion in savings over the next five years. Average
brand net price changes for protected branded
products are forecast to be between a decline of 1% and
increase of 2% per year through 2023 and would result
in about $12 billion in incremental spending over the full
five-year period.
A large number of potential policy changes, with a
particular focus on drug pricing and patient out-of-pocket
costs, are currently under consideration and could lead
3A Note on Nomenclature
In this report, “spending on medicines” and “invoice-price spending” refer to the amounts paid to
distributors by their pharmacy or hospital customers. It does not relate directly to either the out-of-
pocket costs paid by a patient, except where noted, nor does it refer to the amount health plans or
Medicare pay for medicines, and does not include mark-ups and additional costs associated with
dispensing or other services associated with medicines reaching patients.
“Net-price spending” is a proprietary derived estimate of the amount received by pharmaceutical
manufacturers after rebates, off-invoice discounts and other price concessions have been made by
manufacturers to distributors, health plans and intermediaries.
See the Methodology section for more details.
4Medicine Usage Trends
• Nearly 5.8 billion prescriptions were dispensed in 2018, up 2.7% from 2017.
• The top 10 traditional therapy areas, representing nearly two-thirds of traditional prescriptions, grew at
2.4% in 2018.
• Traditional medicines made up 97.8% of prescriptions in 2018 and most large therapy areas grew
faster than the total market, and addressed chronic conditions with increases in prescriptions driven by
adherence improvements.
• Prescription adherence has improved since 2016 across all regions, particularly in Medicare, which ranged
from 78–81% in 2018.
• Adherence is a key driver of better outcomes in chronic therapy areas, but is not uniform regionally and
varies by different factors, such as method of payment; Medicare Part D patients are more adherent on
average.
• Specialty medicines were 2.2% of prescription volume in 2018, but grew at 5.7% in 2018 and at a 4.2%
CAGR since 2013.
• New flu and shingles vaccines are being widely used, leading to 88% of new therapy starts in 2017 and
2018 in vaccines and the remainder in other therapy areas, notably prescription treatments for migraine,
atopic dermatitis, autoimmune disorders and diabetes.
• The number of patients being treated with PD-1 and PD-L1 inhibitors has risen rapidly since their
introduction in 2014, reaching 200,000 patients treated during 2018, more than double the number
treated in 2016.
• The number of autoimmune patients being treated is up 63% since 2013, with six million more patients per
year receiving therapy, largely driven by new treatments for psoriasis and related conditions.
• Generics make up 90% of prescriptions dispensed, up from 75% in 2009, and continue to be dispensed
97% of the time when available.
• Biosimilar ‘efficiency’ has reached 31%, but the accessible market is less than 1% and only seven molecules
have biosimilars available in the market.
• Prescription opioid volume has declined 43% since the peak in 2011, with high-dose prescriptions of
90 MMEs per day or greater declining by 61%, while prescriptions for fewer than 20 MMEs have largely
remained stable.
5MEDICINE USAGE TRENDS
There were 5.8 billion prescriptions dispensed in 2018,
up 2.7% from 2017
Exhibit 1: Prescriptions in Millions and Growth
6,000 5,770 10%
5,522 5,620
5,308 5,394
121 127
112 115
5,000 8%
112
Prescription Growth
4,000 6%
Prescriptions Mn
3,000 4%
2,000 2%
1,000 0%
5,196 5,282 5,407 5,500 5,642
0 -2%
2014 2015 2016 2017 2018
Traditional TRx Specialty TRx Total TRx
Traditional TRx Growth Specialty Growth TRx Growth
Source: IQVIA National Prescription Audit, IQVIA Institute, Jan 2019
• Total prescriptions — adjusted for prescription length based on achieving levels of medicine possession by
— reached nearly 5.8 billion in 2018, up from an patients, called percentage of days covered (PDC),
estimated 5.3 billion in 2014. and that are strongly linked to the rising use of 90-day
prescriptions observed here.
• Chronic prescriptions account for more than two-
thirds of prescriptions, and increasing use of 90-day • Prescriptions for specialty medicines − those that
prescriptions, often with automatic refills is resulting treat chronic, complex or rare diseases, and possess
in significant increases in the amount of medicine additional distribution, care delivery and/or cost
patients have on-hand. characteristics — grew by over 5% for the second
year even as those medicines account for only 2.2%
• The increasing use of 90-day prescriptions is
of prescriptions and have little impact on the overall
particularly notable as the rate of growth without
growth of dispensed prescriptions.
adjusting for prescription length was -0.6% in 2018 but
2.7% after adjusting. • In total, 127 million specialty prescriptions were
dispensed in retail and mail pharmacies in 2018,
• A number of incentives are in place for pharmacies,
up by 15 million since 2014.
providers and Accountable Care Organizations (ACOs)
Chart notes: Chart displays adjusted dispensed prescriptions. Prescription counts are adjusted for length of prescriptions and re-aggregated. Prescriptions referred to as
90-day are calculated based on transactions with 84 days supply or more to include medicines with up to one-week fewer treatment days. Prescriptions for 84 days supply
or more or factored by three, and those under 84 days unchanged. Charted values may not sum due to rounding. IQVIA has restated 2017 and 2018 values to reflect data
collection and methodology changes related to removing abandoned or voided prescription transactions, and in this exhibit prior periods have been estimated based
on back-projection of current values using previously published growth rates. Specialty medicines are those that treat chronic, complex or rare diseases, and which have a
minimum of four out of seven additional characteristics related to the distribution, care delivery and/or cost of the medicines (see Methodology section for more details).
6MEDICINE USAGE TRENDS
Traditional medicines made up 97.8% of prescriptions in 2018
and most large therapy areas grew faster than the total market
Exhibit 2: Traditional Drug Prescriptions and Percentage Growth in 2018 for Top 10 Therapy Areas
Number of Prescriptions Mn
1,190 517 463 447 357 250 243 207 188 141 4,003
5.2% 5.7%
4.0% 4.3% 4.2%
3.5%
2.4% 2.4%
-2.5%
-3.8%
-4.5%
M
O
Li
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Pa
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th
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tic
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la
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ive
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Source: IQVIA National Prescription Audit, IQVIA Institute, Jan 2019
• Dispensed lipid regulator prescriptions saw the • Hypertension drugs, lipid regulators and antidiabetic
greatest growth in 2018, increasing by 5.7%, while pain treatments all increased by more than 4% over 2017
prescriptions dropped by 4.5% driven both by increased disease prevalence and
incentives to improve drug adherence.
• The top 10 traditional therapy areas, representing
nearly two-thirds of traditional prescriptions, grew at • Pain medicines, which in this view include non-narcotic
2.4% in 2018. drugs, declined by 21 million prescriptions, driven
significantly by the declines in prescription opioid use
• Hypertension prescriptions grew by 46 million, with
with little, if any, offsetting use of other types of pain
36 million driven by changes in use related to the
treatment.
aging population and 10 million by population growth.
• Mental health treatments grew by 26 million
prescriptions with only five million tied to population
changes (i.e. growth and aging) and 21 million due to
increased use.
Chart notes: Chart displays adjusted dispensed prescriptions. Prescription counts are adjusted for length of prescriptions (i.e., days supply). Prescriptions referred
to as 90-day are calculated based on transactions with 84 days supply or more to include medicines with up to one-week fewer treatment days. Prescriptions for
84 days supply or more are factored by three, and those under 84 days are unchanged. Other CNS includes behavioral drugs such as tranquillizers, psycholeptic-
psychoanaleptic combinations and drugs for addictive disorders, as well as nootropics, neurotonics and other miscellaneous products, antivertigo preparations and
parasympathomimetics.
7MEDICINE USAGE TRENDS
Prescription adherence has improved since 2016 across all regions,
particularly in Medicare, which ranged from 78–81% in 2018
Exhibit 3: Percentage of Patients Adherent to Dispensed Prescriptions by Region
68.1% 72.2%
75.8% 79.8%
West
65.1% 69.5%
58.0% 60.9%
71.2% 74.9%
Northeast
77.7% 81.2%
69.1% 73.1%
57.6% 60.5%
70.8% 75.0%
Midwest
76.8% 80.8%
69.3% 73.4%
57.5% 60.0%
66.3% 70.8%
73.4% 77.9%
South
64.3% 68.6%
49.8% 51.9%
2016 2018
All Pay Types Medicare Part D Commercial Medicaid
Source: IQVIA Real World Evidence, Longitudinal Prescription Data, Dec 2018
• Across a range of chronic conditions, medication • Clinically complex patients often have lower
adherence is identified as a key contributor to better adherence and may face multiple chronic conditions,
outcomes and has been included in various policies or a severe primary condition (e.g., severe heart failure,
and incentives for health system participants to help metastatic cancer, end-stage renal disease), or have
contribute to better outcomes. concurrent mental and physical health problems.
• Approaches to encourage adherence include the • Patients who are adherent to their mental health drugs
use of health navigators and regular reminder are often more adherent to medications for other
communications via phone, e-mail and mobile apps. chronic diseases as well.
• Perhaps the most common and effective method to • Other reasons for poor adherence can include
encourage greater adherence is the use of 90-day conditions that require treatment by multiple providers
duration prescriptions and automatic refill programs. and resultant high patient burden and/or specialized
sites of care, socioeconomic factors, level of education
• While patients receiving longer prescriptions or
or literacy.
automatic refills may have a higher rate of medicine in
hand, it is unclear whether these contribute to better
outcomes, or offset the root causes of some patients’
non-adherence.
Chart notes: Chart covers patients with cholesterol, diabetes or hypertension prescriptions. Adherence measures the percentage of patients who have medicine
in hand >80% of days of a prescribing period after having started a chronic disease treatment regimen in the three selected therapy areas. Medicaid includes fee
for service and Managed Medicaid. ‘All therapy areas’ includes cash. Adherence ‘period’ is the quarter used to test patient adherence and is Q4 2016 and Q4 2018,
respectively.
8MEDICINE USAGE TRENDS
Adherence is a key driver of better outcomes in chronic therapy
areas, but varies by state and insurance type
Exhibit 4: States with Highest, Lowest and Average Adherence Rates per Pay Type, 2018
Medicare Part D Commercial Medicaid
90% 90% 90%
MN
MN
80% ID 80% 80%
VT
MS OR
70% 70% 70%
MS
60% 60% 60%
IA, NY
50% 50% 50%
AR
40% 40% 40%
30% 30% 30%
Most adherent state
Average adherence
Least adherent state
Source: IQVIA Real World Evidence, Longitudinal Prescription Data, Dec 2018
• Adherence to therapy is not uniform regionally and • The greatest range of variability is within the Medicaid
varies by different factors, such as method of payment. pay type, and could be as a result of socioeconomic
For instance, patients with Medicare Part D are more differences across states as well as whether states have
adherent on average. expanded Medicaid under the ACA.
• Across the country in three large chronic therapy areas • Medicare Part D includes incentives for pharmacies
(Hypertension, Cholesterol and Diabetes), measures and Accountable Care Organizations (ACOs) to
of adherence have varied from as low as 50% in some improve adherence, and many employers and
states among Medicaid recipients, to as high as 85% in commercial plans also target similar goals as improved
others for those covered by Medicare Part D. adherence is associated with better outcomes,
particularly in chronic conditions.
• Vermont and Minnesota and some other states have
generally high adherence across pay types, while • It is possible that some of the approaches used to
others have consistently poor adherence rates, such as improve adherence in Medicare Part D have had
Mississippi and the District of Colombia. spillover effects and have also been applied to the
commercially insured group of patients and even to
• Certain states, such as Iowa are notably near the
Medicaid.
average of each pay type.
Chart notes: Analysis includes the state average adherence across diabetes, cholesterol and hypertension. Adherence measures the extent to which a patient has the
prescribed therapy, and measures the percentage of patients who have medicine for >80% of the prescribing days in a period. An adherence rate in this analysis of
85% indicates that 85% of patients had >80% of prescribing days with medicine in hand. The chart plots the most and least adherent states, median of adherence, and
callouts of average adherent states across payer channels.
9MEDICINE USAGE TRENDS
Specialty medicines were 2.2% of prescription volume in 2018,
but grew at more than double the rate of traditional medicines
Exhibit 5: 2018 Retail Share of Volume for Selected Specialty Therapy Areas and Adjusted Dispensed Prescriptions, Mn
24.0
Oncology 55%
20.2 19%
19.0
Multiple Sclerosis 91%
18.4 3%
11.5
HIV 78%
10.9 5%
8.0
Autoimmune 75%
5.2 55%
1.0
Viral Hepatitis 80%
0.8 18%
Non-Retail Retail 2013 2018
Source: IQVIA National Sales Perspectives, National Prescription Audit, Jan 2019
• Adjusted dispensed prescriptions for specialty • The largest increase in prescription volume is in
medicines grew 5.7% in 2018 and grew at a 4.2% oncology, offering patients a more convenient way to
CAGR since 2013 (see Exhibit 1). receive treatment than prior requirements for infusions
for some tumors.
• Leading therapy areas have had significant prescription
growth in the past five years as a range of new therapies • In oncology in particular, prescription treatments were
have been introduced in oncology, multiple sclerosis once low-cost treatments such as hormonal therapies
(MS), autoimmune, HIV and viral hepatitis. for breast and prostate cancer, but in recent years oral
kinase inhibitors for many solid tumors have driven
• Retail channels, where prescriptions can be dispensed,
much of the volume increases seen here.
represent between 55−91% of volume for these
specialty classes. • In autoimmune diseases, an increasing number of
treatments have launched in the past five years, and
• While each of these therapies employ a mix of
are treating more patients. Some are for specific
prescription medicines and provider-administered
disease areas such as psoriasis, while others have uses
drug therapies, these prescription trends represent a
across multiple conditions.
significant proportion of the volumes used in
these classes.
Chart notes: Prescription counts are adjusted for length of prescriptions and re-aggregated. Prescriptions referred to as 90-day are calculated based on transactions
with 84 days supply or more to include medicines with up to one-week fewer treatment days. Prescriptions for 84 days supply or more or factored by three, and those
under 84 days unchanged. Volumes in retail include retail and mail order and are measured in extended units.
10MEDICINE USAGE TRENDS
New flu and shingles vaccines are being widely used, while there
are fewer new starts in other notable therapy areas
Exhibit 6: New Therapy Starts for Brands Launched Less Than Two Years Prior
Vaccines and All Others, Millions Non-Vaccines
7.5 800,000
700,000
5.4 600,000
500,000
3.6 6.8 400,000
1.4 4.8 300,000
1.8 1.8 200,000
0.7
2.2 100,000
1.8
1.1 0.8
0.6
0
2014 2015 2016 2017 2018 2017 2018
All Other Therapy Areas Vaccines Total Atopic Dermatitis CGRP - Migraine Diabetes
COPD HCV Autoimmune All Others Not Shown
Source: IQVIA National Prescription Audit, Jan 2019
• There were 7.5 million new therapy starts by patients in vaccines, Flucelvax is manufactured from cell cultures
2018, a 40% increase from 2017. rather than eggs, and the FDA noted this technique
helped to provide an improvement in efficacy versus
• Over 88% of new therapy starts in 2017 and 2018
traditional flu vaccines.2
have been in vaccines, with the remainder in more
traditional therapy areas. • Novel mechanisms in established therapy areas
have the potential to rapidly reach patients and
• Approximately 40% of new therapy starts in 2018
change treatment paradigms given the right levels
are due to the launch and rapid uptake of the novel
of accessibility.
shingles vaccine Shingrix. Shingles is a painful disease
that can lead to postherpetic neuralgia, and Shingrix • The continued uptake of crisaborole (Eucrisa) and
has shown to be more than 90% effective and prevent dupilumab (Dupixent) for atopic dermatitis, as well
long-term nerve pain. 1
as the launch of the novel CGRP therapies for chronic
migraine contributed to almost half of all patient starts
• In 2017, almost 60% of new therapy starts were for the
in 2018.
flu vaccine Flucelvax Quadrivalent. Unlike other flu
Chart notes: New Therapy Starts are calculated based on a patient having no previous therapy in the therapy class within the prior year. As these therapies can be
novel classes, the patients could have switched from another therapy or mechanism. Atopic dermatitis includes two medicines, crisaborole and dupilumab which is
also indicated for severe asthma. Totals may not sum due to rounding.
1.
CDC. New Shingles Vaccine Fact Sheet for Adults. Accessed Apr 2019. Available from: https://www.cdc.gov/shingles/fact-sheets/shingles-factsheet-adults.html.
2.
STAT. Flu vaccine grown without eggs provided measurably better protection this season, FDA says. Mar 2018. Available from: https://www.statnews.
com/2018/03/09/cell-culture-flu-vaccine-flucelvax/
11MEDICINE USAGE TRENDS
The number of patients being treated with PD-1 and PD-L1
inhibitors has risen rapidly since their introduction in 2014
Exhibit 7: Unique Patients Treated with PD-1 and PD-L1, 2014−2018
212,473
158,381
96,235
36,191
2,403
2014 2015 2016 2017 2018
Sep 2014
Dec 2014
May 2016
Mar 2017
May 2017
Sep 2018
First indication approval
Cemiplimab
Durvalumab
Avelumab
Atezolizumab
Nivolumab
Pembrolizumab
Source: IQVIA Real World Evidence, Medical Claims, Dec 2018
• The introduction of PD-1 and PD-L1 checkpoint pembrolizumab became the first approved drug of this
inhibitors over the past five years have dramatically type to launch in September 2014.
improved outcomes for patients with a wide range of
• There have been dozens of indications approved for
solid tumors.
these medicines since that time but together they
• These drugs work by using the patient’s own immune represent the some of the most advanced types of
system that is otherwise inhibited or impaired in its treatments available to patients with cancer.
ability to identify and target cancer cells.
• There were more than two hundred thousand patients
treated during 2018, up from 2,403 in 2014 when
Chart notes: Patients are identified as unique patients receiving at least one infusion in that year and do not reflect patients who completed a course of treatment.
PD-1 = Programmed cell death protein 1; PD-L1 = Programmed cell death protein ligand 1.
12MEDICINE USAGE TRENDS
The number of patients with autoimmune diseases being treated
per year is up 63% since 2013, an increase of six million patients
Exhibit 8: Number of Patients Receiving Treatment for Autoimmune Diseases per Year by Indication, Millions
5-Year CAGRs
16.3Mn Overall
Patients 10.2%
16
3% All Other Indications
14
11.4% Ankylosing Spondylitis
Number of Patients Mn
12
10.0Mn
Patients 23.9% Ulcerative Colitis
10
8 14.3% Crohn’s Disease
6 17.1% Psoriatic Arthritis
4 16.6% Psoriasis
2 6.3% Rheumatoid Arthritis
0
2013 2014 2015 2016 2017 2018
Source: IQVIA Real World Evidence, Longitudinal Prescription Data, Jan 2019
• The number of autoimmune patients receiving drug • Rheumatoid arthritis continues to be the most
treatments also grew by 20% alone in 2018. common autoimmune disease treated, with 41% of
all autoimmune patients treated for the condition in
• Ulcerative colitis and psoriasis grew the most in 2018
2018. However, this is a decrease from 2013, when
with 29% and 30% increases, while Crohn’s Disease,
rheumatoid arthritis patients comprised 48% of all
psoriatic arthritis, and ankylosing spondylitis increased
treated patients, indicating the emergence of effective
by 27%, 23%, and 21%, respectively.
therapies for other autoimmune conditions.
• From 2013 to 2018 there has been a 63% increase
• Psoriasis and psoriatic arthritis now comprise 18% and
in patients treated for autoimmune diseases —
11% of patients receiving treatment.
corresponding to a 10.2% CAGR.
• Autoimmune prescriptions increased at a five-year
• Areas of high unmet need, such as Crohn’s disease and
CAGR of 9%, while patient volume has a 10.2% CAGR
ulcerative colitis, saw a doubling (195%) and tripling
over the same timeframe, suggesting new patients
(292%) of patients treated since 2013, respectively.
are being treated but overall rates of adherence are
• Psoriasis and psoriatic arthritis treated patient relatively unchanged during the past five years.
populations have also both more than doubled,
increasing by 120% since 2013, with 16.6% and 17.1%
CAGRs, respectively.
Chart notes: CAGR = Compound Annual Growth Rate. Anonymized patient data used to identify patients receiving at least one claim for prescription or treatment
associated with relevant conditions.
13MEDICINE USAGE TRENDS
Generics make up 90% of prescriptions dispensed, up from 75%
in 2009, and are dispensed 97% of the time when available
Exhibit 9: Generic Shares of Dispensed Prescriptions
Percent of Market Accessible to Generics, % of Total Rx
100%
92% 92% 92%
91%
95% 90%
89%
88%
% Total Rx
Generic (Branded and Unbranded) Market Share, 90% 85%
% of Total Rx 83%
100% 85%
90% 90% 80%
88% 89%
86% 87% 80%
84%
90%
80% 75%
78%
% Total Rx
75% X
80%
Percent Dispensed as Generic When Available
100% (% Generic of Rx Accessible to Generics)
70%
97% 97%
97% 97% 97% 97%
60% % Efficiency 96%
94%
2009 2012 2015 2018 95% 93% 94%
90%
2009 2012 2015 2018
Source: IQVIA National Prescription Audit, Jan 2019
• The overall level of generic dispensing of prescription • There remain several therapy areas where the
medicines has risen from 75% in 2009 to 90% in 2018. interchangeability of small molecule generics is not
considered appropriate by the FDA and individual
• The market accessible to generics, measured as that
doctors, which are often called narrow therapeutic
part of the market where generics have launched, has
index therapy areas.
risen from 80% of prescriptions to 92% over ten years.
• In other cases, patients have preferred the original
• The overall rate of generic dispensing, when it is
brand but usually face higher out-of-pocket costs if a
possible to do so, rose from 93% to 97% by 2013, and
generic is available.
has remained steady for the past six years.
• In many therapy areas, however, the rate of generic
• The high level of generic dispensing is consistent
dispensing is at or near 100%.
with significant financial incentives for patients and
providers to make use of the lowest cost alternatives • This rate includes biosimilars and with a number of
where possible. approvals since 2016, the accessible market, while
remaining small, has increased dramatically.
Chart notes: If a generic or branded generic is available in the market for a medicine (i.e., a molecule, molecule combination, of a specific formulation) it is considered
to be available, whether or not the FDA Orange Book indicates that they are substitutable.
14MEDICINE USAGE TRENDS
Biosimilar use remains small, with under 1% of the market accessible
to biosimilars and biosimilars used less than a third of the time
Exhibit 10: Percent of Biologics Volume Accessible to Biosimilars and Dispensed as Biosimilar When Accessible
erythropoietin alpha
0.9% 35%
infliximab pegfilgrastim
0.8%
% Biologics Accessible to Biosimilars
insulin 30%
% Biosimilar When Accessible
0.7% glargine insulin lispro
25%
0.6%
0.5% 20%
filgrastim
0.4% 15%
0.3%
10%
0.2%
5%
0.1%
0.0% 0%
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2013 2014 2015 2016 2017 2018
% Biologics Accessible to Biosimilars % Biosimilar when Accessible
Source: IQVIA National Sales Perspectives, Jan 2019
• The first biosimilars approved in the United States • The biosimilar share of the accessible market dropped
captured an average 15−30% share of their respective in Q2 2017 and Q2 2018 following the introduction
molecules and averaged 15% from Q2 2013−Q3 2016. of new biosimilars as more of the market became
accessible to biosimilars without those new biosimilars
• In 2016, infliximab and insulin glargine biosimilars were
yet penetrating. It has subsequently risen as those new
approved and the accessible market by volume nearly
biosimilar products have gained market share.
tripled, although the total market remained below
0.3% of overall biologic extended units in the country. • Across multiple therapy areas, the presence of
biosimilars often increases use of the molecule as
• In 2018, another three molecules became available
a whole as well as putting downward pressure on
as biosimilars and the overall volume accessible to
pricing of competing originator brands in the same
biosimilars reached nearly 0.8%.
therapy areas.
• The biosimilar share of the accessible market has
generally been rising, and now averages 31%.
Chart notes: If a biosimilar (or non-original biologic approved through a non-biosimilar pathway) is available in the market for a medicine (i.e., a molecule, molecule
combination, of a specific formulation) it is considered to be available, whether or not the FDA Orange Book indicates that they are substitutable. Volume analysis
conducted using extended unit volume across all channels.
15MEDICINE USAGE TRENDS
Use of prescription opioids in 2018 declined by 17% as clinical
guidelines and public awareness reduced high-dose prescriptions
Exhibit 11: Narcotic Analgesic Dispensed Volumes in Morphine Milligram Equivalents (MME) Bn
250
200
MMEs Dispensed Bn
150
100
50
0
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
19
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
Source: IQVIA National Prescription Audit, Dec 2017; IQVIA Xponent, Feb 2019
• The largest single-year decline in prescription opioid • Decreases in prescription opioid volume have been
volume occurred in 2018, dropping by 29.2 billion driven by changes in clinical use, regulatory and
MMEs. reimbursement policies and legislation, all of which
have increasingly restricted prescription opioid use
• Prescription opioid use in the United States is now
since 2012.
declining rapidly with a 17.1% drop in prescription
opioid volume in 2018 and total declines since 2011 • Prescription drug monitoring programs (PDMPs)
of 43%. are now in place in 49 states and significantly limit
prescribing of high doses of prescription opioids,
• Prescription opioid use was about 22 pills or 134
which according to the Centers for Disease Control
morphine milligram equivalents (MMEs) per adult
and Prevention (CDC) are associated with a higher risk
American in 1992 and rose to a peak of 72 pills or 768
of dependency and overdose.3
MMEs in 2011. Use has since declined to 34 pills and
432 MMEs per adult.
Chart notes: Historic NPA archive data for periods 1992–2005 combined with Xponent analysis for periods 2006–2018. Analysis based on opioid medicines for pain
management and exclude those medicines used for medication-assisted opioid use dependency treatment (MAT) or overdose recovery. Opioid medicines are
categorized and adjusted based on their relative intensity to morphine, see Methodology section for more details.
3.
CDC. Prescription Opioid Data. Accessed Apr 2019. Available from: https://www.cdc.gov/drugoverdose/data/prescribing.html
16MEDICINE USAGE TRENDS
Prescription opioid volume has declined 43% with reduced use of
higher doses, while medication-assisted treatments have risen
Exhibit 12: Narcotic Analgesic Dispensed MMEs Bn, Prescriptions and Medication-Assisted Treatments (MAT) Mn
250 70 4.5
Percent
Total Dispensed Opioid Prescriptions Mn
Total Dispensed MAT Prescriptions Mn
Change 4.0
since 2011 60
200 3.5
Overall 50
MMEs Dispensed Bn
-43% 3.0
150 40 2.5
-61%
30 2.0
100
-22% 1.5
20
50 1.0
-28%
10
0.5
-4%
0 0 0.0
Q1Q2Q3Q4 Q1Q2 Q3Q4 Q1Q2Q3Q4 Q1Q2Q3Q4 Q1Q2Q3Q4
2011
2012
2013
2014
2015
2016
2017
2018
2014 2015 2016 2017 2018MEDICINE USAGE TRENDS
The relative per capita rates of prescription opioids and
medication-assisted treatment use vary widely by state
Exhibit 13: Retail Dispensed Prescriptions for Opioids and Medication-Assisted Treatments per Capita By State
State per Capita Use Rates
AK ME Relative to Mean
VT NH
Prescription Opioid per Capita
High Opioid High Opioid
WA MT ND MN WI MI NY MA RI
Low MAT High MAT
ID WY SD IA IL IN OH PA NJ CT
OR NV CO NE MO KY WV MD DE
CA AZ UT KS AR TN VA NC DC Low Opioid Low Opioid
Low MAT High MAT
NM OK LA MS AL SC
TX GA Medication-Assisted Treatment
(MAT) per Capita
HI FL
Source: IQVIA Xponent, US Census Bureau, Feb 2019
• The national averages for opioids per capita and MATs • States shaded in dark blue indicate high per capita
per capita are 516.1 (per 1,000) and 49.4 (per 1,000), use of both opioids and MAT relative to the mean.
respectively, but states differ significantly in their per Notably, this includes states hit hardest by the opioid
capita use of opioids and MATs. crisis, such as Alabama, Tennessee, Kentucky and West
Virginia, each with 958, 852, 780, and 657 opioids per
• States shaded in light green have opioids per capita
capita, respectively.
above the national mean but have MATs per capita below
the mean. Arkansas and Oklahoma have among the • States shaded in light blue have lower than average
highest prescription opioid-to-MAT per capita ratios. opioids per capita but higher MAT per capita
Arkansas’ opioid per capita use is 906, while their MAT compared to the mean, and include all of the New
per capita is 34, followed by Oklahoma with 797 opioid England states, which have enacted new controls
prescriptions and the second lowest MAT per capita at 47. on opioid prescribing and support for opioid
dependency in the past three years.
• States shaded in dark green have both opioids and MAT
per capita below the national average. These include • Among these, the state with the highest MAT per
states with the lowest opioid use, such as Minnesota capita is Vermont, with 247 and opioid per capita use
(341), Hawaii (343), and California (354). Of note, these of 415. Maine has the second highest MAT per capita,
states have low MAT use with 21, 20, and 15, respectively. with 175 and opioids per capita of 483.
Chart notes: Per capita figures expressed per 1,000 population. Analysis based on opioid medicines for pain management and exclude those medicines used for
medication-assisted opioid use dependency treatment (MAT) or overdose recovery. Opioid medicines are categorized and adjusted based on their relative intensity
to morphine, see Methodology section for more details. High denotes above the mean. Low denotes below the mean.
18Medicine spending and growth dynamics
• Medicines spending growth in the United States rebounded to 4.5% on a net basis, while growth at the
invoice-level was 5.7%.
• Discounts, rebates and other price concessions on brands reduced absolute invoice spending by an
estimated 28% to $344 billion.
• Real net per capita spend in 2018 is $1,044, nearly the same as in 2009 when it was $1,000.
• In 2018, net spending growth rebounded to $14.9 billion due to new and protected brand volume and
despite lower price growth.
• In the past five years a total of 219 NASs were launched with 136 in specialty classes and 57 in oncology.
• Protected brand net prices moderated to 0.3% on average in 2018, continuing below invoice price growth
and now lower than inflation.
• Net price growth was 0.3% in 2018, a drop of 1.6% below the Consumer Price Index in that year, while
price increases for protected brands averaged 5.5% on an invoice-price basis.
• The number of new generic approvals has increased dramatically, with 3,446 ANDAs for 677 distinct
molecules approved since 2013, contributing to price deflation, but not all approvals have launched.
• Biologics growth continues, and three new molecules had their first biosimilar competitors in 2018;
overall biosimilars now compete for market share among medicines with $15.9 billion in spending.
19MEDICINE SPENDING AND GROWTH DYNAMICS
Medicines spending growth in the United States rebounded to
4.5% on a net price basis
Exhibit 14: Total Spending on Medicines and Growth US$Bn
600 20%
500
15%
400
Spending US$Bn
10%
Growth
300
5%
200
0%
100
0 -5%
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Net Spending Net Spending Growth Invoice to Net Difference Invoice Spending Growth
Source: IQVIA, National Sales Perspectives, Jan 2019; IQVIA Institute, Apr 2019
• In 2018, spending grew 4.5% net of off-invoice • On an invoice basis, spending has risen 57% since
discounts and rebates, while growth at the invoice- 2009, from $290 to $479 billion in 2018, but only 36%
level was 5.7%. on a net basis, from $252 to $344 billion in 2018.
• Discounts, rebates and other price concessions on • The past decade has included both the most impactful
brands reduced absolute invoice spending by an concentration of patent expiries in 2011 and 2012, as
estimated 28% to $344 billion. well as the largest impact from new brand launches
from late 2013 through 2015, while periods since have
• Spending grew in 2018 due, in part, to the launch of
shown more modest growth dynamics.
new branded products as well as an increase in the
volume of current branded products.
Chart notes: Measures total value of spending on medicines, including generics, branded products, biologics, small-molecules, retail and non-retail channels. Invoice
spending is based on IQVIA reported values from wholesaler transactions measured at trade/invoice prices and exclude off-invoice discounts and rebates that reduce
net revenue received by manufacturers. Net spending reflects company recognized revenue after off-invoice discounts, rebates and price concessions are applied.
Includes all medicines in both pharmacy and institutional settings. Pricing is at the manufacturer level.
20MEDICINE SPENDING AND GROWTH DYNAMICS
Real net per capita spending per year grew by only $44 since
2009 as specialty nearly doubled and traditional drugs declined
Exhibit 15: Real Net per Capita Medicine Spending and Growth by Product Type US$
25%
1,200
1,043 1,064 1,034 1,044 20%
1,000 1,006 988 981
1,000 931 922
Real 2018 US$ Net per Capita
15%
262 279 289 438 471
Medicine Spending
800 300 385 489 517 10%
318
600 5%
Growth
0%
400
–5%
200
–10%
738 727 699 631 603 595 605 592 546 527
0 –15%
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Traditional Spending Specialty Spending Total Spending
Traditional Growth % Specialty Growth Total Spending Growth
Source: IQVIA, National Sales Perspectives, IQVIA Institute, Jan 2019; U.S. Census Bureau; U.S. Bureau of Economic Analysis (BEA), Dec 2018
• Medicine spending per capita, adjusted for population • The largest proportion of new medicines launched
growth and shown in current dollars, grew only $44 in the past five years have been specialty drugs, and
since 2009. specialty spending per person has risen $255 per
person since 2009, while traditional net medicine
• Real net per capita spending grew by 0.9% from
spending has declined by more than $210 per person
$1,034 per person in 2017 to $1,044 in 2018 in current
over the same period.
dollars, and 1.1% 10-year CAGR to 2018.
• Across all settings, specialty medicines treat relatively
• Specialty share of net spending across institutional and
fewer patients and have costs far higher per patient
retail settings rose from 26.2% in 2009 to 49.5% in 2018.
than traditional medicines.
• Specialty medicines are rapidly approaching half of
• Spending on traditional medicines has declined
medicine spending, driven by innovation, and the
primarily due to patent expiries and associated brand
declining share for traditional medicines as growth has
losses of exclusivity, as well as a general shift in the
slowed due to patent expiries.
focus of innovation.
• Growth in real net per capita spending for specialty
medicines peaked in 2014, when it grew by 21% with
the introduction of several breakthrough therapies for
hepatitis C virus, cancer and autoimmune diseases.
Chart notes: Real medicine spending reflected in 2018 US$. Specialty and Traditional medicines are defined by IQVIA, see Appendix. Includes all medicines in both
pharmacy and institutional settings. Totals may not sum due to rounding. Pricing is at the manufacturer level.
21MEDICINE SPENDING AND GROWTH DYNAMICS
Growth rebounded to $14.9 billion in 2018 due to new and protected
brand volume increases and despite lower price growth
Exhibit 16: Net Spending Growth by Product Type US$Bn
26.6 27.1
1.8 3.1
5.1 2.6
2.1 14.9
12.2
9.9
6.7 1.6
3.6 0.8
3.7 1.4 13.2
5.7
5.4
20.9 0.8
17.3
13.4 12.0 11.0
-9.8 -9.4 -8.2
-11.3 -12.3
-0.7
-0.8 -1.4
-5.1
-0.5
2014 2015 2016 2017 2018
New Brands Protected Brands Price Protected Brands Volume Generics Volume Generics Price LOE Total Growth
Source: IQVIA National Sales Perspectives, Jan 2019; IQVIA Institute, Apr 2019
• In 2018, net spending growth amounted to $14.9 billion, • Loss of exclusivity (LOE) had the lowest impact of the
much higher than the 800 million increase in 2017, past five years, at $8.2 billion. LOE was a significant
driven by new brand spending and growing volume downward pressure on net spending growth from
use of protected brands. 2015−2017, but in 2018 fewer branded products lost
market exclusivity, and thus LOE had less impact on
• Protected brand volume growth on a net basis
net spending growth.
expanded to $13.2 billion from $1.4 billion the year
before. This trend is, in part, due to earlier-launched • From 2013—2015 generics had been a positive driver
innovative brands seeing increased uptake as of spending growth as the combination of fewer
standards of care gradually shift. expiries and price increases lifted generics spending.
However, starting in 2016, generics volume and price
• Protected brand price growth is lower than
growth declined as greater competition in a number of
experienced in 2017, at only $800 million, suggesting
markets drove down prices. In 2018, the volume use of
that price increases have slowed or have been offset
generics shrank, decreasing spend by $1.4 billion.
by coupons and discounts.
• New brand net spending growth added $11 billion to
spending in 2018 reflecting the launch and uptake of
almost 60 new active substances (NAS) in 2018.
Chart notes: New brands are protected branded products on the market less than 24 months during the year reported. Protected brands are products that are no
longer “new” and have yet to reach patent expiry. Loss of Exclusivity (LOE) are brands that were once protected and have since lost patent protection. Generics
include both unbranded and branded generics. All segments are mutually exclusive in each time period. Includes all medicines in both pharmacy and institutional
settings. Charted values may not sum due to rounding.
22MEDICINE SPENDING AND GROWTH DYNAMICS
Use of new brands and volume growth of existing brands
totaled $24 billion in 2018, up from $13 billion in 2017
Exhibit 17: New Brand & Existing Protected Brand Volume Net Spending Growth by Therapy Area US$Bn
30 27.1
24.2
Other Specialty
23.0
25 Other Traditional
17.0 MS
20 Respiratory
13.4
HIV
15 Cardiovascular
HCV
10 Diabetes
Autoimmunue
5
Oncology
Total
0
-5
2014 2015 2016 2017 2018
Source: IQVIA National Sales Perspectives, Jan 2019; IQVIA Institute, Apr 2019
• New medicines launched in the past two years • Autoimmune treatments added $3.9 billion in 2018 as
contributed $11 billion to net growth in 2018, which a range of newer treatments options became available
along with $13.2 billion from volume growth for for patients with psoriasis and other conditions.
existing protected brands, accounted for $24.2 billion
• Diabetes treatments with newer mechanisms of action
in spending growth.
continue to be adopted more widely and added
• The new medicines first launched in 2018 included $3.8 billion in 2018.
59 New Active Substances (NAS), 39 of which are in
• Treatments for hepatitis C added $3.1 billion in 2018
specialty therapy areas.
as new treatment options have gained wider adoption
• In the past five years a total of 219 NASs were launched and have offset the significant net price concessions
with 136 in specialty classes and 57 in oncology. made by most manufacturers.
• Oncology spending growth derived from use of new
medicines and an increased volume use of existing
patent-protected medicines — driven by expansion
to new indications or earlier lines of therapy — totaled
$7.7 billion in 2018.
Chart notes: New brands are defined as brands launched in the last twenty-four months and defined separately for each year. Specialty and traditional medicines are
proprietary definitions by IQVIA, see Methodology section for more details. Traditional in the chart includes diabetes and other traditional. Charted values may not
sum due to rounding. Includes all medicines in both pharmacy and institutional settings. MS = multiple sclerosis; HCV = hepatitis C.
23MEDICINE SPENDING AND GROWTH DYNAMICS
Protected brand net price increases moderated to 0.3% on
average in 2018 as invoice price growth continued to fall
Exhibit 18: Protected Brand Invoice and Net Price Growth %
13.5%
11.2%
8.7%
7.1%
5.5%
4.3%
2.9%
1.6% 2.1%
1.9%
1.6% 2.1%
1.3%
0.1%
0.3%
2014 2015 2016 2017 2018
Estimated Brand Net Price Growth % Brand Invoice Price Growth % Consumer Price Index
Source: IQVIA National Sales Perspectives, Jan 2019; IQVIA Institute, Apr 2019
• Net price growth was 0.3% in 2018, 1.6% below inflation • Increasing competition across multiple therapy areas
in that year based on the Consumer Price Index, while including diabetes, asthma/COPD, viral hepatitis
invoice price increases for protected brands averaged products and autoimmune biologic treatments, is
5.5%, both historically low growth rates. contributing to net price growth slowing to near zero.
• Most of the top ten pharmaceutical companies have • In addition to negotiated rebates, other discounts, fees
announced commitments to both lower levels of list under the affordable care act and the value of patient
price growth and net price transparency, including the coupons have contributed to lower net price growth.
regular release of more sensitive information around
net price growth.
Chart notes: “Invoice” values are IQVIA reported values from wholesaler transactions measured at trade/invoice prices and exclude off-invoice discounts and rebates
that reduce net revenue received by manufacturers. “Net” values denote company recognized revenue after discounts, rebates and other price concessions. Results
are based on a comparative analysis of company reported net sales and IQVIA reported sales and prices at product level for branded products representing 75—93%
of brand spending in the period displayed. All growth is calculated over same cohort of products in the prior year. See Methodology section for more details. Includes
all medicines in both pharmacy and institutional settings.
24MEDICINE SPENDING AND GROWTH DYNAMICS
The number of new generic approvals has increased dramatically,
contributing to price deflation, but not all approved drugs launched
Exhibit 19: Generics Approvals and Launches and Generics Net Price Growth
2018 551 178 729 53 18 71
10.1%
7.4%
7.4%
2017 515 299 814 70 22 92
3.5% 3.8% 3.5%
6.1%
2016 446 147 593 64 18 82 -1.1% -0.1%
-0.9%
1.3%
2015 99 12 111 -6.5%
388 158 546
-3.7% -3.8%
2014 330 60 390 115 7 122
-10.2%
2013 190 184 374 185 14 199
2014 2015 2016 2017 2018
Generics Molecules Without New ANDAs 2013-2018
ANDAs Launched Molecules Launched Total Generics Total
ANDAs Not Launched Molecules Not Launched Generics Molecules with New ANDAs Approved 2013-2018
Source: FDA Orange Book, Feb 2019; IQVIA National Sales Perspectives, IQVIA Institute, Jan 2019
• Since 2013, 3,446 ANDAs received FDA approval, • The period from 2014 to 2015 was marked by high-
relating to 677 distinct molecules or molecule generic net price growth driven by older generic
combinations. medicines, many of which were not facing competition
at the time.
• Of the 677 distinct generic molecules, 87% had a
subsequent generic launch over the same time period. • Generic net price growth has declined since 2016,
impacted more heavily by generic molecules where
• The number of ANDA approvals increased
ANDAs were approved, as these molecules face
dramatically between 2014 and 2018 to 729 approvals,
increased competition and downward price pressure.
up from 390 — an increase of 87%.
• Generic molecules without ANDAs approved between
• On average in 2018 there were 10 ANDAs per
2013 and 2018 saw positive growth in 2018, in part
launched generic molecule compared to 2013 where
due to the ability to increase prices in the absence of
on average there was one ANDA per launched generic
competition, but price growth was modest at 3.5%.
molecule, suggesting that there is greater generic
competition at the molecule level in 2018 than in 2013.
Chart notes: ANDA = abbreviated new drug approval. ANDAs approved correspond to all ANDAs approved by the FDA, including multiple ANDA filed by a company
for a single molecule. Generics include unbranded and branded generics if approved through the abbreviated pathway. ANDAs approved since January 2013 were
identified and compared to launches in IQVIA data. Analyses at ANDA level aggregate to the molecule and company level, while analyses at the molecule level show if
any company was approved or launched generics for that molecule.
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