布鲁金斯学会-在不断变化的市场中审核处方药消费价格指数

WORKINGPAPER

AUDITINGTHEPRESCRIPTION

DRUGCONSUMERPRICE

INDEXINACHANGING

MARKETPLACE

RICHARDG.FRANK,TheBrookingsInstitutionandNationalBureauofEconomicResearch

ANDREWL.HICKS,HarvardMedicalSchool,DivisionofHealthCarePolicy

ERNSTR.BERNDT,MITSloanSchoolofManagementandNationalBureauofEconomic

Research

ResearchoriginallypresentedattheBatesWhiteLifeSciencesSymposium,Washington,D.C.,May23,2022

ThisresearchwassupportedbyagranttotheDepartmentofHealthCarePolicy,HarvardMedicalSchool,

fromArnoldVentures.ErnstBerndthasreceivedconsultingfeesfromBatesWhiteEconomicConsultants,

workingforOptum,asubsidiaryofUnitedHealthCare,onalitigationmatter,aswellasfromCornerstone

Research,workingforPerrigo,amanufacturerofover-the-counterpharmaceuticalproducts,onalitigation

matter.Otherthantheaforementioned,theauthorsdidnotreceivefinancialsupportfromanyfirmorperson

forthisarticleorfromanyfirmorpersonwithafinancialorpoliticalinterestinthisarticle.Theauthorsare

notcurrentlyanofficer,director,orboardmemberofanyorganizationwithafinancialorpoliticalinterestin

thisarticle.

TheBrookingsInstitutionisfinancedthroughthesupportofadiversearrayoffoundations,corporations,gov-

ernments,individuals,aswellasanendowment.Alistofdonorscanbefoundinourannualreportspublished

online.Thefindings,interpretations,andconclusionsinthisreportaresolelythoseofitsauthor(s)andarenot

influencedbyanydonation.

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I.INTRODUCTIONANDBACKGROUND

Prescriptiondrugspendinganddrugpricesarecentraltoconcernsaboutrapidlyrisinghealthspending.Avarietyoflegislativeproposalshavebeenadvancedaimedatreiningindrugpricesanddrugpricegrowth.Thedebatearoundtheseproposalsisrancorousandfrequentlyfocusesondifferingperceptionsofhowrapidlypricesaregrowing.

OnekeysourceofinformationistheDepartmentofLabor,BureauofLaborStatistics’(BLS’)ConsumerPriceIndex(CPI),whichincludesacomponentthatmeasuresgrowthinprescriptiondrugprices.TheprescriptiondrugcomponentoftheCPIhasrealworldimpactsasitisusedtoconstructpaymentupdatesbyinsurersandregulators,isoftenaconsiderationincontractnegotiationswithinthehealthcareindustry,andisusedtoestimatetrendsinNationalHealthExpendituresanditscomponents.

ButtherearereasonstosuspectthattheCPIhasnotbeenagoodmeasureofactualtrendsinprescriptiondrugprices.Mostimportantly,theCPIalmostsurelymissesalargeshareofspecialtymedicines.Specialtydrugs,suchasthosethattreatcancersandimmunesystemdisorders,carryhighprices,haveexperiencedhighratesofpriceandspendinggrowth,andhaveclaimedarapidlygrowingshareofdrugspending,reaching55%ofU.S.drugspendingin2021,nearlydoublethesharefromtenyearsprior.

1

Intheanalysisthatfollows,weassesshowthetreatmentofspecialtydrugsintheCPIaffectsgrowthinmeasuredprescriptiondrugprices.Weconductthisassessmentusingdatafromlargeinsuredpopulationscoveredbyemployer-sponsoredhealthinsurance.Whilethisisnotafullycomprehensiveanalysisofallpurchasesofprescriptiondrugs,itoffersinformativeinsightsintohowdataonprescriptiondrugpricesarecollectedandusedtounderstand

1IQVIAInstituteforHumanDataScience[2022].

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prescriptiondrugpricechanges.WenotethattheanalysisisgearedtowardstheapproachesusedtocalculatetheprescriptiondrugCPI.Wedonottakeupissuesrelatedtoaccountingforproductqualityinthisanalysis.

TheresultsdemonstratethatconsiderablecautionshouldbetakenininterpretingtheprescriptiondrugcomponentoftheCPIasacomprehensivereflectionofpricegrowthinthosemarkets.Thisisbecausetheshifttospecialtydrugsinvolvesdispensingbyspecialtypharmacies,hospitals,andphysicianoffices–sitesthatarefrequentlynotincludedaspartoftheprescriptiondrugCPIthatisconfinedtosurveysofretailoutlets.Instead,drugpriceshaveincreasinglybecomeacomponentofthepriceindexesforhospitals,physicianoffices,andotherhealthcaresettings.

Theremainderofthismanuscriptisorganizedintothreeadditionalsections.SectionIIprovidesadetailedanalysisoftheroleoftheprescriptiondrugCPIinthelargerconstructionofthenation’sCPI.ThatsectionalsooffersadetaileddescriptionofhowtheprescriptiondrugCPIisconstructedincludingtheapproachtodatacollectionandtheweightingschemesusedtoaggregateacomplexsetofproducts.SectionIIalsoprovidesdetailedevidenceonhowdifferenttypesofprescriptiondrugproductsareincorporatedintothevariouscomponentindexes.ThatevidenceoffersthebasisforahypothesisaboutpotentialdistortionsintheexistingprescriptiondrugCPI.SectionIIIdescribesandconductsanempiricalanalysisthatcomparestheapplicationofthecurrentCPImethodologytoonethatmorecompletelytakesaccountoftheevolutionofprescriptiondrugmarkets.Finally,sectionIVsummarizestheresultsandconsidersimplicationsofthefindingsforongoingpolicydebatesandourunderstandingofprescriptiondrugpricebehavior.

II.THEBLS’CPIMEDICALCAREHIERARCHICALPROGRAMSTRUCTURE

A.OVERVIEWANDRECENTCOMPOSITIONALCHANGES

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MedicalCare

HealthInsurance

MedicalCareServices

22%

1.900

4%

0.371

N/A

N/A

0.210

TheCPIhasahierarchicalstructure.Table1belowdisplaysthehierarchyofthemedicalcare(MC)majorgroup,andrelativeimportanceofthevariouscomponentsofMCasofDecember2010andDecember2021(severalofthedetaileditemsarenotavailablefor2010).AfewsalientfactsemergefromTable1.

Thefirstfacttonoteisthatmedicalcare(MC)costsasashareoftotalconsumerexpenditureshaverisenintheelevenyearsbetweenDecember2010andDecember2021.ThetotalMCrelativeimportancewas6.627percentin2010,andbyDecember2021itincreasedto8.847percent–anincreaseof2.22percentagepoints,oraproportionalincreaseof33.5%(2.22/6.627).

2

Table1.StructureofMedicalCareGroupinMedicalCareCPI,andRelativeImportance,2010and2021

CPIMedicalRelativePercentageof

Importance(%)TotalMC

6.6278.487100%100%

CareItem2010202120102021

MedicinalDrugs

1.422

17%

MedicalCareCommodities1.6331.52425%18%

PrescriptionDrugs

1.044

12%

4%

0.378

MedicalEquipment&Supplies

0.103

1%

4.9946.96275%82%

ProfessionalServices

2.830

3.585

43%

42%

Physicians’Services

DentalServices

0.924

11%

Eyeglasses&EyeCare

Services—OtherMedProfessionals

0.390

5%

Hospital&RelatedServices1.7032.57326%30%

HospitalServices

2.199

26%

InpatientHospital

Services*

OutpatientHospitalServices*

N/A

N/A

NursingHome&AdultDay

CareServices

Elderlyathome

0.164

2%

Non-PrescriptionDrugs

0.461

0.804

7%

9%

2U.S.BureauofLaborStatistics,[2011a],Table1.U.S.BureauofLaborStatistics[2022a],TableA.

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*Substratumindex:Aspecialindexpublishedbelowtypicalitemlevel.Therelativeimportanceweightsisnotavailablefortheseindexes.Source:U.S.BureauofLaborStatistics[2022a],TableA,pp.1-2/7;U.S.BureauofLaborStatistics[2011a],Table1.Note:SeveralofthedetailedCPImedicalcareitemsarenotavailablefor2010intheBLS’[2011a]publication.

AsbackgroundtooursecondmajorobservationinTable1,wenotethereareeightmajorgroupcategoriesinthetoptieroftheCPI–food,housing,apparel,transportation,medicalcare,recreation,educationandcommunication,andothergoodsandservices.InthesecondtieroftheMCCPIhierarchy,theeightmajorgroupsaredividedinto70expenditureclasses.Themedicalcare(MC)groupisdividedintotwomaincomponents:medicalcareservices(MCS)andmedicalcarecommodities(MCC),eachcontainingseveralitemcategories.ThisbringsustothesecondsalientobservationconcerningrecentchangesinMC.WithintotalMC,between2010and2021therehasbeenashifttowardmedicalcareservices(MCS)andawayfrommedicalcarecommodities(MCC).MCSisthelargestitemcomponent,in2010representingabout75%oftheweightwithinMC

3

,increasingto82%in2021.

4

MCCmadeupapproximately25%oftheweightwithinMCin2010,

5

butdecreasedto18%by2021.

6

OurthirdkeyobservationinvolvestheroleofprescriptionpharmaceuticalswithintotalMCintheU.S.WithintheMCCcomponent,prescriptionpharmaceuticaldrugsconstitutethebulkoftheMCCtotalweight.In2010,prescriptionpharmaceuticalsaccountedforroughly75%ofthetotalexpenditureforMCC,

7

butasseeninTable1,in2021theprescriptionpharmaceutical

3AccordingtoU.S.BureauofLaborStatistics[2011a],Table1,asofDecember2010,therelativeimportanceofmedicalcareservicesintotalmedicalcarewas4.994/6.627=0.75358.

4U.S.BureauofLaborStatistics[2022a],TableA.

5InU.S.BureauofLaborStatistics[2011a],Table1,therelativeimportanceofmedicalcarecommoditiesintotalmedicalcarewas1.633/6.627=0.2464.

6InU.S.BureauofLaborStatistics[2022a],TableA,pp.1-2/7,themedicalcareservicesshareis82%ofmedicalcare(6,692/8.487),whilethatformedicalcarecommoditiesis18%(1.524/8.487).

7U.S.BureauofLaborStatistics[2011b],p.6.

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weightfelltoonly68%.

8

Animportantimplicationisthatwhilein2010prescriptionpharmaceuticalsaccountedforabout19%oftotalMCexpenditures(≈75%x25%),by2021theprescriptiondrugshareintotalMCexpendituresfellsubstantiallytoabout12%(≈68%x18%).

9

AlthoughprescriptionpharmaceuticalsbroughtaboutamajorcompositionalchangewithinMCCandwithintotalMCbetween2010and2021,considerablysmallercompositionalchangeshaveoccurredwithinMCS.AsofDecember2010,ProfessionalServicesaccountedfor42.7%ofthetotalMCrelativeimportanceweight(=2.830/6.627).

10

AsofDecember2021,asreportedintheMarch2022CPI,theProfessionalServicesweightintotalMCwasessentiallyunchangedat42.2%(=3.585/8.487).

11

Hospitalandrelatedservicesincreasedslightlyinrelativeimportancebetween2010and2021,accountingfor25.7%(=1.703/6.627)ofthetotalMCweightin2010,

12

butby2021thisweightincreasedto30.3%(=2.573/8.847).

13

Finally,thehealthinsuranceservicescomponentofMCSwas6.94%(=0.461/6.627)ofthetotalMCrelativeimportanceweightin2010,butby2021thisweightincreasedbyabouttwopercentagepointsto9.1%(0.804/8.847).

14

Insummary,themedicalcaremarketplacehaschangedconsiderablyintheelevenyearsbetween2010and2021.ThelargestabsolutepercentagepointscompositionalchangeswithintheBLS’MCCPIinvolvedtheincreaseinMCS(from75%to82%),thedecreaseinMCC(from25%to18%),thedeclineintheprescription

8InU.S.BureauofLaborStatistics[2022a],TableA,p.1/7,therelativeimportanceofprescriptiondrugsinmedicalcarecommoditiesis1.044/.1.524=0.6850.

9InU.S.BureauofLaborStatistics[2022a],pp.1-2/7,prescriptiondrugsaccountforabouttwo-thirdsofthemedicalcarecommoditiesweight(12%of18%),non-prescriptiondrugsaccountfor4%,andmedicalequipmentandsupplies(includingnon-prescriptionmedicinesanddressingsusedexternally,contraceptives,andsupportiveandconvalescentmedicalequipment,e.g.,adhesivestrips,heatingpads,athleticsupporters,andwheelchairs.UsingtheupdatedU.S.BureauofLaborStatistics[2022a]numbers,thisprescriptiondrugsharefallstoabout12%(68%x18%).

10U.S.BureauofLaborStatistics[2011a],Table1.

11U.S.BureauofLaborStatistics[2022a],TableA.

12U.S.BureauofLaborStatistics[2011a],Table1.

13U.S.BureauofLaborStatistics[2022a],TableA.

14NotethatthesumofthesethreerelativeimportanceweightswithinMCSasashareoftotalMCcostswas0.7534in2010,butincreasedto.816in2021,anincreaseofabout3.6percentagepoints.

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pharmaceuticals(from19%to12%),andtheincreaseinhospitalandrelatedservices(from26%to30%).

IninterpretingthesecompositionalchangesinMCspending,webelieveitimportanttorecognizethatthetransactionspricesrecordedarethesumofallpaymentstoahealthcareproviderfromallpayers–cash,commercialinsurers,MedicarePartBinsurance,andMedicarePartDinsurance.Thus,forexample,whenaretailpharmacyorahospitalreceivespaymentforadispensedprescriptionoradeliveredhospitalservice,thetransactionexpenditurepaymentrecordedintheBLS’CPIis,inthecaseofaprescription,thepatient’sout-of-pocketcopaymentorcoinsurancepaymenttotheretailpharmacyplusthereimbursementtothepharmacybytheinsurer;inthecaseofahospitalservice,theCPItransactionexpenditurerecordedisthecashout-of-pocketpaymentbythepatientplustheamountreimbursedthehospitalbytheinsurer.NotethatanypaymentsfromMedicaidorworker’scompensationprogramtotheprovider(e.g.,toapharmacyorhospital)arenotincludedintheCPI,becauseunlikeMedicarePartBorMedicarePartD,therearetypicallynoinsurancepremiumsrequiredtoobtaincoverageasaMedicaidoraworker’scompensationbeneficiary.Incontrast,Medicarebeneficiariesaregenerallyrequiredtomakeregularpremiumpayments.

15

Intheprocessofaggregatingspecifictransactionsitemsintomedicalcarecomponentsandmajorgroups,eachitemindexinTable1isassignedaweight.TheweightofeachitemintheCPIisdeterminedusingtheConsumerExpenditureSurvey(CES),whichcollectsinformationfromthenation’shouseholdsandfamiliesontheirbuyinghabitsorexpenditures,income,andhouseholdcharacteristicseverytwoyears.Goodsandservicesthatconsumersspendthemostonwillbethemostheavilyweighted.TheCEStracksconsumerout-of-pocketspendingonmedicalcare,whichisusedtoweightthe

15U.S.BureauofLaborStatistics[2011b],p.,6.AlsoseeU.S.BureauofLaborStatistics[2022a],p.1/7.NotethislogicimpliesthatthefreeCOVID-19vaccinationsprovidedbytheU.S.federalgovernmentarenottrackedbythemedicalcareCPI.ThatmightchangeifthefederalgovernmentterminatesitssupportforfreeCOVIDvaccinations.

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medicalcareindexes.TheCESdefinesout-of-pocketmedicalspendingasthesumofthreepayments:(i)patientpaymentsmadedirectlytoretailestablishmentsformedicalgoodsandservices;plus(ii)healthinsurancepremiumspaidforbytheconsumer,includingMedicarePartB;plus(iii)healthinsurancepremiumsdeductedfromemployeepaychecks.Notethatemployerpaidportionsofinsurancepremiumsandfullytax-fundedmedicalcare(suchastheexpensespaidbyMedicarePartAandMedicaid)arenotconsideredout-of-pocket,andthereforearenotusedinweightingtheindexes.

16

TheweightusedintheCPIMCrepresentsthesumofpaymentsfromcashandinsurancesources.

II.B.ALLOCATIONAMBIGUITIESINTHEMEDICALCARECPI

TheMCCPIallocatesthetotalpaymentsmadeinatransactiontooneandonlyoneoftheMCcomponents.Thiscreatesambiguities.Considerwhenduringahospitalstayapatienthasapacemakerinstalled–amedicalequipmentitem.IsthisconsideredahospitalandrelatedservicesexpenditureintheCPI,oramedicalequipmentandsuppliesexpenditure?Andwhatifthecardiologistimplantingthedevicebillsthehospitalfortheprocedure–isthatahospitalandrelatedservicesexpenditure,oraphysicianservicewithintheprofessionalservicescategoryofMC?Orconsideranoncologistwhohasinfusionchairsinherofficewherechemotherapydrugsareadministered.ArethechemotherapydrugpaymentstotheoncologistallocatedtoprescriptionpharmaceuticalswithintheBLSCPIMCaccountingsystem,oraretheyassignedtophysicians’professionalservices?Ifintheformercase,thepacemakerbillistreatedaspartofhospitalandrelatedservices,andifinthelattercasethechemotherapyadministrationistreatedaspartofphysicians’professionalservices,thenthepaymentamountsunderlyingtheBLS’CPIMCanditsrelativeimportanceweightswouldlikelyunderstatetheimportanceofpacemakers,orofchemotherapy,inaffectingoverallmedicalcarecosts.Andifchangesinthemedicalcare

16U.S.BureauofLaborStatistics[2022a],p.1/7.

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marketplaceaffectthelocationsandofficeswherecardiacdevicesareimplantedandwheremedicinesareadministered,thencomparisonsofmedicalcarepricesinthemedicalcareCPIovertimecouldbegreatlyaffectedbychangesinthepracticeofmedicine,evenwhennoneofthepricesorpaymentsfortheunderlyingitemsandserviceschange.ThisraisesimportantissuesofhowoneinterpretsthedecreaseintheprescriptionpharmaceuticalweightintheBLS’CPIMCweightbetween2010and2021,andthe2010-2021increaseinthehospitalandrelatedservicesweight?Moregenerally,howdoestheBLSmedicalcareCPIprogramaccountforactivitiesthatsimultaneouslyinvolvedifferentmedicalservicesandinputs?

Ina2011U.S.BureauofLaborStatisticspublicationdescribingpharmaceuticalindustrycoverageinitsConsumerPriceIndex(CPI),ProducerPriceIndex(PPI),andImport/ExportPriceIndex(IPP)programs,theBLSexplicitlystates“TheCPIcollectstransactionspricesreceivedbytheretailpharmacy.”

17

Retailpharmacyincludesbrickandmortarretail,mailorder,andinternet,butexcludesnursinghomeinstitutionalcarefacilities,suchaslongtermcarefacilities.

18

AnaccompanyingtablecomparingthecoverageandscopeoftheCPI,PPIandIPPprogramsdescribesthetypeofpricecollectedbyBLSas“Transactionpricereceivedbythepharmacy”,andthecoverage/scopeas“Physician-prescribedprescriptionandnon-prescriptiondrugsdispensedviaU.S.pharmacies(excludesphysicianandhospitaladministereddrugs).

19

Furthermore,theBLSexplains:“PrescriptiondrugsthatareadministeredinahospitalsettingandbilledbythehospitalasacomponentpartofalargerservicewillnotbepricedintheCPIprescriptiondrugindex,suchpriceswillinsteadbecapturedinthehospitalindexaspartof

17U.S.BureauofLaborStatistics[2011b],p.6.Notably,thisdocumentdoesnotdiscusswhetherspecialtypharmaciesareincludedwithinthedomainofretailpharmacies–weconsiderspecialtypharmacieslaterinthismanuscript.

18U.S.BureauofLaborStatistics[2022a],pp.1-2/7

19U.S.BureauofLaborStatistics[2011b],Table1,p.2.IndiscussionswithBLSpersonnel,wewereinformedthattheCPIcoveragealsoincludesprescriptionsdispensedinretailpharmaciesthatarewrittenbynon-physicianssuchasnursepractitionersandphysicianassistantsthatareauthorizedtoprescribedrugsbystatepharmacyboards.

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apricedhospitalservice.(ThisisoneareainwhichthePPIwouldpickupsomedrugsthattheCPIwouldnot,becausethePPIignoreschannelofdistribution.DrugsthatareusedmostlyinahospitalsettingwillbemissingfromtheCPIsample.)”

20

AlthoughtheBLSdocumentdoesnotexplicitlycommentoncoveragefornurse-andphysician-administereddrugsinphysicianofficesoroutpatientclinics,BLSofficialshaveinformedusthesamelogicapplies,andsuchprescriptiontransactionswouldbecapturedbythephysicians’servicescomponentwithinthephysicians’professionalservicesiteminMCS,notbytheprescriptiondrugsitemintheMCC.

II.C.WHOLESALERS,SPECIALTYDRUGS,ANDSPECIALTYDISTRIBUTORS

Prescriptiondrugsareshippedbymanufacturerstowholesalers,andtoalimitedextent,todispensingpharmacies.Wholesalersandspecialtydistributorsthenshipdrugstodispensingpharmacies,hospitals,andothermedicalcareproviders.In2020,thethreelargestwholesalerswereAmeriSourceBergen,CardinalHealthandMcKesson,whotogetherhada95%marketshare.

21

Itisusefultodistinguishfull-linewholesalersfromspecialtydistributors.Full-linewholesalersgenerallysellamanufacturer’scompletepharmaceuticalproductlinetoretailoutpatientoutlets(e.g.,chaindrugstores,independentpharmacies,mailpharmacies,massmerchandiserswithpharmacies,andsupermarketswithpharmacies),andinstitutionalnon-retailhealthcarefacilitiessuchaslong-termcarepharmacies,hospitals,andphysicianoffices/clinics.In2019retailoutletsaccountedforabout75%offull-linewholesalerrevenues.

22

Specialtydistributorssellspecialtypharmaceuticals(definedbelow)primarilytophysician-owned/operatedclinics,hospitals,andhospital-ownedoutpatientclinics.Specialty

20U.S.BureauofLaborStatistics[2011b],p.7.b

21Fein[2021],p.25.

22Fein[2021],pp.8-9.

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SupportiveCare(e.g.,anemia,bloodmodifiers)7%

Cardiovascular(includespulmonaryarterialhypertension)3%

pharmaceuticalsaredistinguishedfromtraditionalpharmaceuticals.Severalmajorspecialtydistributorsareownedbythelargestwholesalers(e.g.,McKesson).Inothercases,specialtydistributorsarefree-standingdistributors,aformofspecializedwholesaler.Althoughthereisnouniversalorlegislateddefinitionofspecialtypharmaceuticals,theyaretypicallyidentifiedaspharmaceuticalsthattreatchronic,complexillnessessuchascancer,rheumatoidarthritis,multiplesclerosis,andHIV;treatsmallerpatientpopulationsandfrequentlyrequireadministrationbyahealthcareprovider,suchasaphysicianornurse.

23

Inrecentyears,specialtydrugsaccountedforslightlymorethan2%ofallU.S.outpatientprescriptions.In2020,specialtydrugsaccountedforabout1/3offull-linewholesalers’revenues,andfornearlyallofspecialtydistributorrevenues.

24

Specialtydrugsaresubjecttoavarietyofspecialhandlingandpriorauthorizationconditions.Moreover,thereareincreasinglylimiteddistributioncontractsinplace.Thesecircumstancesresultinspecialtydrugsbeinglargelydispensedbyprovidersandspecialtypharmacies.GiventhattheBLSrestrictsitspharmaceuticalsamplingframetoretailpharmacies,itislikelythatfew,ifany,specialtypharmaceuticalsarepricedintheBLS’prescriptionpharmaceuticalpriceindex.

Table2.2019SpecialtyDistributorSalesbyTherapeuticArea

TherapeuticAreaSales(%) Oncology(includesblood,breast,prostateandlungcancers)52%

Inflammatory(includingrheumatoidarthritis,Crohn’sdisease)9%

Ophthalmology7%

Hemophilia,bleedingdisorders(includesrenaldiseases)6%

Centralnervoussystem(includesmultiplesclerosis,Alzheimer’s)4%

Allothers12%

Source:Fein[2021],Exhibit5,p.12

23Fein[2021],p.19.

24Fein[2021],p.270.

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RetailPharmacies

Other

Tohighlightthedifferentdistributionchannelsfortraditionalandspecialtydrugs,Table3belowprovidestheweightedaverageofspecialtydistributorsalesbyprovidersegmentfor2019and2020.Asseenthere,twocustomergroupsdominate–hospitalsandindependentphysician-owned/operatedclinics--eachpurchaseabout40%ofspecialtydistributorsales,inbothyears.Specialtypharmaciesarethethirdlargestpurchaser,atabout10%.ItisveryunlikelythatspecialtypharmaciesaresampledandpricedundertheBLS’retailpharmacycategory.

Table3.2019-20WeightedAverageShareofSpecialtyDistributorSalesbyCustomer

Class

2019

2020

ProviderSegment

Hospitals

37.9%

39.7%

Independentphysician-owned/operatedclinics40.5%37.1%

Specialtypharmacies&mailorder(regardlessofparent8.8%10