Maybe surprisingly, the reply is PBMs, not drug producers. That is without doubt one of the conclusions mentioned in a current commentary by Good and Hernandez (2021). They attempt to unravel this query, writing:
Most explanations for growing drug prices begin with drug firms, and certainly they’re a simple goal. Producers within the US are allowed to set their very own worth for brand spanking new merchandise, that are then shielded from competitors by means of patent exclusivity…checklist costs of branded medicine elevated at a yearly common of 9.1% from 2007 to 2018…
Nevertheless, growing checklist costs of medication are partially mediated by ever-increasing reductions. Thus, drug producers level to the web worth of medication (the price of medicine in spite of everything reductions have been utilized) slightly than the checklist worth as representing a extra correct determine of drug prices…earlier analyses point out that reductions on branded merchandise accounted for 60% the rise in drug prices from 2007 to 2018
Extra empirical particulars are offered in a paper by Van Nuys et al. (2021). Utilizing an method much like what was used to trace circulate of funds by means of the drug distribution system total (Sood et al. 2017), they discover that:
Between 2014 and 2018, imply checklist costs of 32 insulin merchandise elevated by 40.1% (from $19.60 to $27.45), whereas imply internet costs acquired by producers decreased by 30.8% (from $10.53 to $7.29). Web expenditures per 100 models of insulin elevated by 3.2% (from $15.11 to $15.59) whereas the share of a hypothetical $100 insulin expenditure accruing to producers decreased by 33.0% (from $69.71 to $46.73) and the share accruing to well being plans decreased by 24.7% (from $13.82 to $10.40). The share of insulin expenditures retained by pharmacy profit managers elevated by 154.6% (from $5.64 to $14.36), the share retained by pharmacies elevated by 228.8% (from $6.21 to $20.42), and the share retained by wholesalers elevated by 74.7% (from $4.63 to $8.09).
In brief, intermediaries (PBMs, pharmacies) are gaining growing share of the insulin worth relative to drug producers. The graphics under are courtesy of JAMA. Do learn all the paper right here.