This analysis of the top drugs by prescriptions dispensed and total sales reveals key trends in today's pharmaceutical market.
Total spending on prescription drugs in the United States rebounded sharply from 2012. Although growth remains at a historically low level, nominal spending rose dramatically due to fewer patent expiries, new drug therapies, and higher utilization of health care services. Out-of-pocket costs have a significant impact on patient behaviors and help to shift the trends in health care spending.
The top 5 therapy classes accounted for more than one-third of spending in 2013. Oncologics continue to be the highest earning class of medications ($27.9 billion), followed by antidiabetics ($24.3 billion), mental health ($23.8 billion), respiratory agents ($20.4 billion) and pain ($18.7 billion). The fastest growth was seen in treatments for multiple sclerosis (20.7%), autoimmune disorders (18%), and nervous system disorders (16%), while 4 of the top 10 earning classes actually had declines in growth of more than 5%. Patent expiries were fewer and less significant in 2013, with Cymbalta being the only $1 billion agent losing patent protection; however, spending declined by over 15% for both anticoagulants and lipid regulators due to patent expiries. Antihypertensives continued to be the highest in prescription volume, with 45.7 million patients receiving therapy and 698 million prescriptions dispensed. Other classes leading in total prescriptions dispensed include mental health, pain, antibacterials, and lipid regulators.
Abilify was the highest earning agent, as nondiscounted spending for the drug increased from $5.7 billion in 2012 to $6.5 billion in 2013. Other top earners included Nexium ($6.2 billion), Humira ($5.6 billion), Crestor ($5.4 billion), and Cymbalta ($5.3 billion). Acetaminophen/ hydrocodone was the most widely dispensed prescription, followed by levothyroxine, lisinopril, metoprolol, and simvastatin.
Health Care Utilization
Health care utilization grew in 2013, reversing the trends of self-rationing and declining spending seen in recent years. The total number of patient office visits in 2013 increased by 2.7%, largely due to increased utilization by seniors and adults visiting specialists. Hospital admissions increased by 2.6% overall. Scheduled inpatient admissions grew by 10.5%, while inpatient admissions via the emergency department (ED) declined by 14.6%. ED day visits grew modestly by 1.8%, down from the 6.2% growth increase seen in 2012.
Prescription demand increased by 1.6% overall in 2013, a 0.9% per capita increase. Utilization among the largest portion of per capita users, patients 65 years and older, declined by 1%, with a per capita decrease of 2% for patients 80 years and older. Antihypertensive agents and mental health therapies grew in volume by 1.1% and 1.7%, respectively. Prescriptions for nervous system disorders grew by 5.9%, largely attributed to the use of gabapentin across a broad range of indications. Hormonal contraceptives grew by 4.6%, as the proportion of patients with a $0 copay rose from 20% to 50%. The utilization of pain medications and lipid regulators declined by 1%, while antibacterial utilization decreased by 1.4%.
Medication Spending and Growth
Medication spending has grown at historically low levels in recent years and has steadily declined since 2009. In 2012, nominal and per capita spending growth shrank by 1% and 3.5%, respectively. Things improved in 2013, as nominal spending grew by 3.2% and per capita spending growth increased by 1%. The increase in nominal spending can be attributed largely to the reduced impact of patent expiries in 2013, which was $10 billion less than in 2012. Additionally, higher per capita utilization of health care services and spending on newer agents contributed to spending growth.
While generics and branded generics represent 86% of the prescriptions dispensed in 2013, they account for on 29% of total spending. Spending on branded drugs accounted for 71% of total spending, or $232 billion. Biologic medications account for 28% of total spending, growing by 9.6%, and spending on specialty medications grew by 9%, to 29% of total spending. Price increases on branded products accounted for $20 billion in growth, and after adjusting for discounts and rebates, net price growth accounted for 5.1% of brand spending growth.
Insurance plans have been shifting to high-deductible health plans (HDHPs), although preferred provider organizations (PPOs) are still the most popular health plan option for employer-based coverage. HDHPs are generally characterized by lower premiums and high deductibles, in which patients pay the full cost of health care until they reach a predetermined threshold. Out-of-pocket spending tends to be significantly less with HDHPs, which may be due to the visible direct costs experienced by patients during the deductible period. Many plans also offer in-network versus out-of-network deductibles to encourage patients to use in-network services.
While out-of-pocket costs for patients have increased overall, more than 75% of prescriptions dispensed in 2013 cost patients $10 or less. More than 50% of prescriptions cost less than $5, and over 20% had no copay. The majority of nocopay prescriptions came from 1 of 5 therapy areas: contraceptives, antihypertensives, respiratory medications, cholesterol medications, and mental health medications. The Affordable Care Act preventive care provisions took effect for most beneficiaries in January 2013, and included a $0 copay for contraceptives. Generic medications accounted for most of the prescriptions under $10, while brands typically cost patients more than $20. Three-fourths of out-of-pocket costs were attributed to prescriptions costing more than $10. The top 2.3% of prescriptions cost patients $70 or more and accounted for 30% of the total out-of-pocket spending in 2013. Most of the top copays came from plans with coinsurance, charging patients a set percentage of high-cost specialty medications, but often plans have a cap on patient out-of-pocket costs. Some manufacturers offer coupons or savings programs for branded products to help offset high out-of-pocket costs, although these programs are often limited to 12 to 24 months.
Trends to Follow
There were 36 New Molecular Entities (NMEs) introduced in 2013, which was the highest number in the past decade and likely marks a trend for the coming years. The number of approvals for orphan drugs, designed to treat rare diseases affecting fewer than 200,000 patients in the United States, more than doubled since 2012 and was the highest of any year since the Orphan Drug Act was passed in 1983. Among these orphan drugs were 7 “ultra-orphan” agents, which target conditions affecting only a few thousand patients each year.
Eight of the NMEs released in 2013 were new dosage forms and additional uses of existing mediations, focusing on improvements in dosing and administration. These included an antipsychotic agent administered via inhalation, oncedaily forms of diabetic mediations, and an epinephrine autoinjector that provides audible administration instructions to the patient.
Oncology and specialty medications accounted for most NMEs launched in 2013. Ten oncology NMEs made available last year, which is the most in the past 10 years. Among the new agents was obinutuzumab, the first FDA Breakthrough Designated Therapy, which targets chronic lymphocytic leukemia, and adotrastuzumab emtansine, dubbed the “smart bomb” for metastatic breast cancer. In the past 5 years, 35 new cancer therapies have been introduced, 30 of which have been targeted therapies. There were 20 specialty medications launched last year, including agents targeting hepatitis C (sofosbuvir, simeprevir), HIV (dolutegravir), type 2 diabetes (canagliflozin), and multiple sclerosis (dimethyl fumarate). Spending on new brand medicines totaled $10.9 billion in 2013, 69% of which was spent on new specialty medications.
Over the next 10 years, drugs gaining the new FDA Breakthrough Therapy Designation will be expedited to serve patients in critical need. Over 30 medications were given Breakthrough designations in 2013, and 3 drugs were granted Breakthrough approval. These innovative new therapies will improve quality of life, focus on unmet needs, and transform treatment areas such as hepatitis C, multiple sclerosis, and cystic fibrosis.
Top 20 Corporations by 2013 Sales
Top 20 Therapies by 2013 Sales
Top 20 Products by 2013 Sales
Top 20 Brand/Generic Products by 2013 Sales
Top 20 Brand/Generic Product
Dr. Bartholow is a clinical pharmacist in the VA Southern Nevada Healthcare System in Las Vegas, Nevada.
Medicine use and shifting costs of healthcare
. IMS Institute for Healthcare Informatics website. www.imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Health%20Institute/Reports/Secure/IIHI_US_Use_of_Meds_for_2013.pdf. Accessed June 2014.