Cost & Quality Problems

Prescription Drug Costs

Prescription drug costs currently account for 14-15 percent of overall health spending and are once again coming under scrutiny as important drivers of healthcare spending.1

Spurred by blockbuster drugs like Lipitor and Plavix going off patent and increased use of generics, drug spending had moderated in the last decade since the high growth period of over decade ago.2 Two important trends are bringing this period of low drug spending growth to an end: increased spending on prescription drugs, and the diminishing cost-saving  impact of generic drugs. 

High Cost of Specialty Drugs  

Of greatest concern is that the cost of new specialty drugs is truly prohibitive. The term “specialty drug” does not have a uniform definition. The term broadly comprises drugs that are: high priced; often (but not always) made of biological matter; treat complex conditions; require special handling; or require infusion or injection in a doctor’s office.  

Twelve of 13 cancer drugs approved by the FDA in 2012 were priced over $100,000 per course of treatment.3 Specialty drugs are used by fewer than 2 percent of privately insured patients in the United States. However, these drugs currently account for more than 46.5 percent of all drug spending.4

What’s more, specialty drug spending is projected to account for an astounding 50 percent of drug spending by 2020.5

Generics Becoming More Expensive

High rates of generic substitution will continue, but will do less and less to bring down overall spending. In coming years as the market value of products expected to go off patent are significantly less than some of the blockbusters that went off patent in 2012.6

A second reason generics are less likely to moderate future spending is that the costs of many generic drugs are increasing. The reason for these generic cost increases are complex and are due to many factors from raw material shortages to generic competitors leaving the market. But whatever the reason, many drugs that have been historically inexpensive have seen sharp price increases.  One analysis found that half of all retail generic drugs became more expensive over from mid-2013 to mid-2014. Some generic drugs have seen as much as 1,000 percent increase in price.7  Another reason is because more of these alternatives will take the form of biologics, which are high cost and, as the name implies, made of biological matter.

Impact on Consumers

These cost trends mean higher premiums for consumers and plan benefit designs that mean higher cost-sharing and even discriminatory designs.

Another market response to high costs is to limit patient choice. For example, the nation’s largest pharmacy benefits manager, CVS, negotiated an exclusive deal with and AbbVie Inc., a drug maker of an alternative to Sovaldi, in exchange for a discounted price.

Options for Curtailing Rx Costs

Options for curtailing high Rx costs include:

  • Reforming the way monopolies are granted to drug companies to incentivize innovation
  • Greater Government Oversight over pricing
  • Increased use of comparative effectiveness research
  • Generic-Friendly State Substitution Laws

It will take a sustained effort by consumers, payers, purchasers working at both the state and federal level to make headway on these issues and ensure that healthcare costs are to be sustainable and access to life saving drugs is preserved.  In the short-run, advocates may want to consider getting involved in benefit design rules being discussed in state Marketplaces to try to mitigate the impact of high drug costs on sicker enrollees.


1. Yu, Nancy L., Preston Atteberry and Peter B. Bach, “Spending On Prescription Drugs in the US: Where Does All the Money Go?Health Affairs Blog (July 31, 2018)

2. Martin, Anne B, et al., “National Health Spending in 2012: Rate of Health Spending Growth Remained Low for the Fourth Consecutive Year,” Health Affairs, Vol. 22, No. 1 (January 2013).

3. Light, Donald W. and Kantarjian, Hagop, "Market Spiral Pricing of Cancer Drugs," Cancer (November 15, 2014) 

4. IQVIA, Medicine Use and Spending in the U.S.: A Review of 2017 and Outlook to 2022, Durham, N.C. (April 2018).

5. S. Johnson, et al., Specialty Drugs Are Forecasted to be 50 Percent of All Drug Expenditures in 2018,  Prime Therapeutics, University of Minnesota College of Pharmacy, Minneapolis, MN.

6. Purvis, Leigh, A Sense of Déjà vu: The Debate Surrounding State Biosimilar Substitution Laws, AARP, September 2103.

7. Purvis, Leigh, Retail Generic Drug Inflation Reaches New Heights, Drug Channels

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