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A country that spends Are we en route to What does this mean for a lot of resources on a "socialised" health the sector, and what are its health, but lacks PANORAMA
US pharmaceuticals have enjoyed their time in
the sun, but is it time to get out the umbrellas?

espite having the highest igned to correct these shortcomings, in prices would certainly affect the bot- healthcare expenditure of particular by increasing health insu- tom line of the companies working in all industrialised nations rance coverage. Yet beyond this ques- this sector, especially the laboratories D(17.1% of GDP in 2013), tion of coverage, cost has become a who would be forced to review their
the US public health out- crucial issue. Households are finding operations and cut back on research comes are being outper- that the high price of medicines is and development (R&D) spending.
formed by other advanced nations.
becoming prohibitive. This has led to a Back in 2010, the introduction of the rising call for reform (especially during (1) Dubbed "Obamacare", the ACA is discussed in Affordable Care Act (ACA) (1) was des- the presidential campaign). A drop in greater detail below.

US pharmaceuticals have enjoyed their time in
the sun, but is it time to get out the umbrellas?


1.1. Medicines even more expensive
But it's not just the cost of drugs that is an issue, than in Europe
and one study conducted by the InternationalFederation of Health Plans in 2013 showed that The price of medicines has risen sharply in the the cost of hospital services is also high. The USA in recent years. Gleevec (leukaemia) cost authors in fact found that the USA charged more 270% more in 2015 ($118,000/year) than in 2011 than every one of the comparator countries (2).
($31,930/year). The cost of Januvia (diabetes) The cost of an angioplasty or bypass is nearly rose from $146/month in October 2006 to $213 twice as much as in New Zealand or Australia.
in December 2013 (+46%), and $331 in January The same applies to diagnostic imaging tech- 2015 (+55%). One good example was the deci- niques (e.g. scans). The average cost of a hospi- sion taken by Pfizer Inc. in January 2016 to tal stay in America is $18,000, whereas in implement a massive 20% price hike for 100 of Canada, the Netherlands and Japan, it ranges between $4,000 and $6,000.
Contrary to other advanced nations, the law pro- Graph n°1
hibits the country's biggest buyers, such as Difference between US discounted drug prices and the average price in five Medicare (3), from negotiating prices directly with advanced nations* the drug companies. In the USA, it is the phar- maceuticals that set the price, as opposed to theEuropean States where the price is set by the healthcare system. Prices are generally higher inAmerica than in advanced countries, despite the fact that US insurance companies give discountsfor a large number of drugs. According to Lan- greth et al. (2015) (4), of the eight top-sellingmedicines in advanced countries, seven were more expensive in the USA, even after discounts(graph n°1). The drug companies justify these high prices by high R&D spending ($50 billion in 2014, 0.3% of American GDP) and a relatively short-lived global patent protection (12 years before genericversions can be produced). * Gerrmany, Canada, France, Japan, United Kingdom Source: Bloomberg (2) With the exception of cataract surgery (3) A federal programme initially aimed at the over 65s subject to certain income requirements.
(4) Langreth et al., 2015, "The U.S pays a lot more for top drugs than other countries", Bloomberg.
Drugs have become more effective, as sugges- 1.2. Public health falling well behind
ted by the fall in potential years of life lost (6) since the 1960s. However, there are still diffe-rences between countries in terms of cost-effec- Patients are suffering from the high cost of their tiveness. For every dollar spent, Japan generates medicines: 90% of seniors and half the total a sevenfold greater health gain than the USA.
population take prescription drugs each month.
This ratio is fivefold in France, threefold in the A 2013 study (5) found that three out of every five UK and twofold in Sweden. The USA therefore personal bankruptcies in the USA was due to spends relatively more than other countries for exorbitant medical expenses.
poorer health outcomes. This has been confir-med by a survey of quality of life indicators in Graph n°2
the USA. The country scored significantly worse Health indicators in the USA and 12 advanced countries*, 2013 than other advanced economies, apart from thecategory of daily smokers aged 15 years and over (graph n°2).
Life exp. at birth Whilst it is true that these figures have improved % of pop. age 65+ with two or in the long-term, the same also applies to the more chronic conditions** other OECD countries. On the other hand, obe-sity is the only indicator studied to have deterio- rated over the long-term in each one of the 13 countries, due to changing lifestyles. The USAis particularly prone to this problem, with two Infant mortatlity thirds of the population overweight, of which per 1,000 live births one third are obese. As well as the obviousimpact on health, obesity carries a high econo- Practising physicians (per 1,000 population) Advanced economies mic cost. One study that came out in 2009 (7) put it at between $147-$210 billion a year (0.8-1.2%GDP). As well as the quality of life statistics, per- % of pop. (15+) who are ceived quality of life has also fallen, according to the Kaiser Institute. The proportion of adults believing themselves to be in poor health rosefrom 13% to 18% between 1993 and 2013.
* Average indicator of 12 advanced economies (Austalia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, UK, Sweden, Switzerland) ** Excluding Denmark and Japan 1.3. Uneven coverage
Source: OECD, The Commonwealth Fund, Coface The inefficiencies of the American health caresystem are hitting the most vulnerable popula-tions the hardest. People who are divorced orseparated, those with a lower level of education Graph n°3
and the younger populations are the most likely Percentage of people without health insurance coverage to not have medical insurance (graph n°3). Thisproblem is exacerbated by the fact that, accor- ding to the latest report from the US Census Bureau (8), the uninsured rate remains high, at10.4% of the population in 2014 (33 million peo- ple), despite a recent improvement (41.8 million in 2013); the OECD average is less than 3%. Since the introduction of the ACA, the number ofpeople without health insurance fell by 8.8 million in just one year, despite the fact that 17 States have yet put in place the coverage offered by thescheme. In fact, there are marked differences bet- ween the States in terms of coverage. Northern States have on average a higher rate of coverage than the Southern States. According to a Gallup survey, Massachusetts recorded the lowest num- ber of uninsured (3.5%) and not only was Texas the highest (22.3%), but it was the only one to come in at over 20%. Ethnic origin
Source: US Census Bureau (5) NerdWallet, 2013, "NerdWallet health finds medical bankruptcy accounts for majority of personal bankruptcies". (6) OECD statistic that measures the number of years remaining that would have been lived were it not for premature death.
(7) Finkelstein et al., 2009, "Annual Medical Spending Attributable to Obesity". Health Affairs (8) US Census Bureau, 2015, "Health insurance coverage in the United States: 2014" ARE WE EN ROUTE TO A "SOCIALISED"

2.1 Using the ACA to redress the
balance between insured
patients and the insurers and
care providers

The enactment of the ACA was intended to give The case of hepatitis C drugs gives us a good idea uninsured Americans a more accessible, higher of the impact of the ACA. Again according to the quality and affordable health care system. This IMS, only 18,000 people were receiving treatment aim went hand in hand with the desire to reduce for this condition in 2013. That number rose to the number of uninsured people, in particular by 170,000 in 2014, and 249,000 in 2015, most of forcing them to take out health insurance or which were patients insured under federal pro- accepting them onto Federal programmes (9).
grammes (69%). Nevertheless, although 28% of Since 1 October 2013, nearly 12.7 million Ameri- these patients were able to receive treatment cans have taken out health insurance via one of under their insurance without the need for a fede- the digital marketplaces (10). The CMS (11) says that ral programme, some of them took out their these gains resulted in a 5.3% increase in health policy using the marketplaces organised by the expenditure in 2014, compared to 2.9% in 2013.
The other factor that has been highlighted is thearrival of expensive drugs onto the market.
Beyond health insurance coverage, one of the Again according to the CMS, Americans spent salient features of this reform is cost manage- nearly $11 billion in 2014 on hepatitis C drugs, out ment, because not only does the Government of a total of $151 billion in new health spending.
grant tax relief to the lowest income households In turn, the IMS estimates that the American who take out insurance via one of its market- drug market grew by 14.2% in 2014, but adds places, but it has also widened the scope of that it experienced slower growth in 2015 some of its federal programmes (Medicare and Medicaid). Nevertheless, the Federal State iscurrently finding it hard to control drug prices,unlike the European States. 2.2 Bring on the presidential
Graph n°4
Annual prescription market, in billions of dollars and as a percentage change Most of the people questioned for a KFF survey (12)in October 2015 wanted the Federal Govern- ment to regulate the prices of drugs used to treat chronic conditions (diabetes, cancer,cardiovascular disease etc.). A total of 77% of those surveyed supported this proposal, regardless of their political affiliation (Table n°1 page 5).
Source: IMS Health (9) Mainly Medicaid: a programme designed to grant health insurance coverage to the most disadvantaged groups.
(10) This percentage differs from the Census Bureau figures because it comes from a survey conducted by Gallup for its Healthways Well-Being Index. We wanted to include it because it is a recent figure. (11) Federal agency that administers the Federal social insurance programmes, including the ACA.
(12) Kaiser Family Foundation: a non-profit organisation that aims to focus the debate on national health issues.
Table n°1
Priorities for the new US President according to a KFF survey Making sure that high-cost drugs Making sure that high-cost drugs Making sure that high-cost drugs Making sure that high-cost drugs for chronic conditions, such as HIV, for chronic conditions, such as for chronic conditions, such as for chronic conditions, such as hepatitis, mental illness and cancer, HIV, hepatitis, mental illness and HIV, hepatitis, mental illness and HIV, hepatitis, mental illness and are affordable to those who need cancer, are affordable to those cancer, are affordable to those cancer, are affordable to those who need them (85%) who need them (75%) who need them (73%) Government action to lower Government action to lower Government action to lower Repealing the entire prescription drug prices (63%) prescription drug prices (74%) prescription drug prices (60%) health care law (58%) Making sure health plans have sufficient provider networks of doctors and hospitals (63%) Making sure health plans have Making information comparing Government action to lower sufficient provider networks of Protecting people from being the quality of health care prescription drug prices (56%) doctors and hospitals(58%) charged high prices when they provided by doctors and visit hospitals or outpatient clinics hospitals more available to covered by their health plan but are seen by a doctor not covered by their plan (63%) Source: Kaiser Family Foundation The drastic rise in the price of certain drugs in In turn, before he stepped down the CEO of 2015 easily explains the results of this survey. For Valeant was called before the United States example, the 5,000% increase in the price of Senate to explain his company's price strategy for Daraprim (13), which went from $13.5 to $750 after the newly-acquired Nitropress and Isuprel. These Turing Pharmaceuticals (14) purchased the marke- numerous examples angered the public, and moti- ting rights (graph n°5). vated each party's candidates for the Presidentialprimaries to suggest ways of lowering the price ofprescription drugs. Donald J. Trump, the Republi-can presumptive nominee, announced plans to Graph n°5
allow the Federal authorities to negotiate drug Sharper rises in the price of medicines prices directly with the laboratories. He estimatedthat this would save the taxpayers $300 billion,but stopped short of explaining how he intended to achieve this goal. However, that $300 billionaccounts for nearly 80% of the spending on pres-cription medicines recorded by IMS Health in Trump also suggested allowing the importation ofdrugs. A number of analysts jumped on this pro- posal, pointing out that some of the cheapestdrugs would come from countries with low ornon-existent quality controls. This is precisely whythe FDA has banned the import of drugs and active ingredients from any one of 38 Chinese factories, after inspections raised concerns aboutthe integrity of their quality control data. In 2008,the import of a counterfeit ingredient (16) led to the death of nearly 243 Americans. A similar approach has been used in India, where generics manufac-turers (17) have been banned from exporting to the USA after failing FDA inspections. (13) An antiparasitic drug whose patent expired several decades ago (14) Drug company founded by Martin Shkreli, a controversial figure who is facing several federal charges.
(15) Medicines use and spending in the U.S., A review of 2015 and outlook to 2020, IMS Institute for Healthcare Informatics.
(16) Used to make the blood thinner heparin.
(17) Producers of generic drugs.
Over on the Democrat side, Hillary Clinton is an Woolhandler and Himmelstein (20) believe that avid supporter of universal coverage. Back when switching to a single-payer system would mean her husband, Bill Clinton, was serving his first Pre- greater bargaining power, especially for the price sidential term, the First Lady headed up a task of prescription drugs. These two professors also force for granting health insurance coverage to think that, when it comes to prescription drugs, every US citizen and permanent resident, by the system would allow savings of $1 trillion over making it compulsory for them to enrol in a health the next decade.
plan (with the poorest being exempt from payingthe premium). The proposal also included a limit onspending at the discretion of patients. However, the 2.3 Ever-increasing drug costs,
plans came to nothing due to disagreement within or the development of specialty
the Democrat camp and pressure from the health insurance sector. According to IMS Health, drug spending in the For the 2016 campaign, one of her proposals is to USA rose by 12.2% between 2014 and 2015. The encourage enrolment in a health plan via the Medi- most buoyant segment of this market is spe- care programme. She plans to limit rises in pre- cialty medicines (21). Again according to IMS, this miums in order to combat the unwarranted profits segment now accounts for 36% of total spen- generated by the pharmaceutical industry. As we ding, and rose by 21.5% in 2015. Sales of this have seen, Americans pay much more for their type of drug contributed 70% of total spending medicines than people in other developed countries, growth between 2010 and 2015. Their market especially in Europe. In addition, this proposal would share in 2010 was only 24% (22).
allow the US Secretary of Health to negotiate thecost of prescription medicines (as do the European These drugs cover the full range of treatment agencies when they determine the reimbursement areas, but in particular they target patient micro- level), with a monthly cap on out-of-pocket (18) drug populations with hard-to-treat conditions. Some costs of $250 per person. see them as innovative, whilst others have com-mented that their benefits are only marginal and Bernie Sanders, the other candidate for the do not justify the price, which is particularly high.
Democratic nomination, has also taken the plunge The price of Sovaldi from Gilead Sciences comes and suggested a single-payer health care plan, an to $84,000 per course of treatment, or $1,000 idea inspired by Western Europe. His proposal per pill. According to the AARP Public Policy Ins- involves developing the Medicare system for all US titute, the average price of specialty medicines citizens and residents and introducing a single- rose above the median US household income payer model, whilst doing away with deductibles in 2013. On average, a person insured through and "copays" (19). According to his sponsor, a family his employer will be responsible for a copay of of four would save $6,000 a year under this nearly 2% of the price of the medicine, but scheme. According to his detractors, however, the also has to cope with annual increases in his pre- plan would not only result in a fall in health spen- mium. In fact, according to a survey by the ding, but it would well and truly worsen public KFF (23), the yearly premium for a family rose by debt by adding the exorbitant and far-fetched 203% between 1999 and 2015, whereas the ave- sum of $18 trillion over 10 years. Nevertheless, rage nominal income went up by only 56%. Thissame survey found that the number of house-holds covered by a company health plan with a Graph n°6
general annual deductible increased from 55% in PPI comparison for pharmaceutical products and manufactured goods 2006 to 70% in 2010, to 81% in 2015. The average deductible was $303 in 2006, $646 in 2010 and$1,077 in 2015. PPI for pharmaceutical goods This rise in health care costs cannot be attribu- PPI for manufactured goods ted solely to the rise in the cost of drugs. Spen-ding on hospital stays and other services has also contributed to the situation. Nevertheless, astudy by the Federal Reserve Bank of San Fran- cisco (24) concluded that core inflation had beenheld back by health-care services due to thelegislative measures taken by Government to restrict public insurance payments to the Medi-care and Medicaid programmes (by nearly half).
For the time being, however, there are no figuresto corroborate this view, since the production price index for pharmaceutical products has been growing faster than for manufactured goods (graph 6).
(18) « out-of-pocket drug spendings » (19) Amounts paid by the patient towards the healthcare services received. A system put in place by the insurance companies to avoid part of the risk, and also intended to avoid drastic increases in premiums.
(21) Defined by the IMS as medicines for complex diseases and if injected can only be administered by a specialist. (22) This represents considerable growth, especially given the sharp rise in generics following the recent Patent Cliff.
(23) Kaiser Family Foundation/HRET Survey of Employer-Sponsored Health Benefits, 1999-2015. (24) Clemens, Gottlieb, and Shapiro, Mai 2016, Medicare Payment Cuts Continue to Restrain Inflation, Federal Reserve Bank of San Francisco Economic Letters. Largely spared by the financial crisis, production Price controls are easier to implement if there is prices in the pharmaceutical sector have been ris- a public healthcare systems, such as in Europe, ing steadily, contrary to the manufacturing sector compared to the USA, with its fragmented as a whole. Drug prices have gone up sharply, financing system and the lesser weight of the without any signs of a slowdown, despite the payers (compared to their European counter- upset to the American economy in 2008 and parts). However, attempts have been made to promote such practices. For example, we notethe rise in power of medico-economic review We predict (25) a rise in the pharmaceutical PPI of agencies such as ICER (26), whose work reflects 9.3% by the end of 2016, compared to 7.2% in 2015 the debate surrounding certain diseases. At the and 8.5% in 2014.
same time, certain PBMs (27) and health careinsurers use the results published by these various institutes to demand price cuts (if thelaboratory does not have a monopoly). AETNA, The most suitable method is an ARIMA model (5, 1, 2), whereby
one of the country's biggest insurers, projects a future value can be predicted based on its past values and
that its value-based spending will rise to 70% a series of random shocks.
by 2020, compared to its current rate of 30%.
Others are already following in its footsteps (the (𝟏−𝜽 𝑩−𝜽 𝑩𝟐−𝜽 𝑩𝟑−𝜽 𝑩𝟒−𝜽 𝑩𝟓)(𝟏−𝑩)𝒀 Blue Cross and Blue Shield plans, Humana).

3.1 A fall in profits?
Price being a fundamental part of the equation Let us suppose that the US drug companies for the cost of the American health care system, bring their prices down to the level seen in reducing it would be a positive move for Europe. France is a good example, because for patients, but would reduce the appetite for risk reimbursable drugs the country sits at the lower among the laboratories and biotechs.
end of the prices charged. According to IMS Health, Harvoni (28) from Gilead Graph n°7
Sciences was America's top-selling drug in 2015, Sales of the top five drugs in 2015 in the USA, in billions of dollars generating revenues of $14.3 billion (graph n°7). Itmade only $1.6 the previous year, when it was first marketed. A 12-week course of treatment costs $94,500. In France, the negotiated price secured by the CEPS (Economic Committee for Health- care Products) and the Ministry of Health (29) isaround ¤46,000 or $51,865. Approximately 151,323 patients were treated this year. If theFrench price was applicable in the US (and assu- ming there was no competition from anotherdrug), Harvoni's turnover would plummet by $7.84billion, a fall of nearly 45%. Sovaldi, made by the same company, has had its reimbursement pricefixed in France at ¤41,000 ($46,227).
Source: IMS Health (25) These figures were calculated using ARIMA forecasting.
(26) Institute for Clinical and Economic Review.
(27) Pharmacy Benefit Managers, who process prescriptions on behalf of insurers but negotiate the cost of the drugs directly with the laboratories and pharmacy (28) A drug that according to the laboratory cures over 90% of Hepatitis C sufferers.
(29) Which issued a release on this topic.
In the absence of accurate information about the Two practices employed by private insurers (not laboratories' price structure, it is hard to predict involved in government schemes such as Medi- the effects of a fall in prices on a financial indi- care, Medicaid, marketplaces, CHIPS) are also cator such as EBITDA. Nevertheless, according worth a mention: the exclusion of certain drugs to the Census Bureau, drug manufacturers loca- from the coverage lists, and rationing. They nor- ted on American soil saw a 8% year-on-year rise mally go hand in hand, whenever an expensive in profits for the third quarter 2015 (30), after a 6% drug provides therapeutic benefits to patients.
rise in Q3 2014 and a fall of 4% in Q3 2013 Some laboratories cite them as a risk factor that (mainly due to the patent cliff). can affect their bottom line. Nevertheless, it ishard to determine their actual effects on profita-bility using just public data. The arrival on the American market of expensive treatments, as well as the development of health
insurance coverage for millions of citizens, have led us to revise our risk assessment for this zone. It has
been reduced to a low risk.

Table n°2
Global pharmacy sector assessments Emerging
Middle East
Ï The risk has improved The risk has deteriorated 3.2 Effects on R&D.
The American drug industry often points out ceuticals. They have pointed to a correlation bet- that by charging high prices, it can generate suf- ween the degree of regulation in Europe and the ficient profit to be able to invest in R&D. Given intensity of R&D. This effect is less marked if the that the cost of bringing a molecule (31) to market company has a strong presence in the USA, is between $1-1.5 billion, it makes sense that where companies are free to set their own cheaper prices would mean less R&D spending.
prices. Likewise, a stronger presence in Europe, Numerous econometric studies have highlighted where there is strict regulation, brings a lesser the existence of a causal link between the cost inclination to invest in R&D (34). Arbitration is at of drugs already on the market, and the fall in play, because company well-being requires price the number of molecules in the pipeline. Accor- control in order to ensure access to care is uni- ding to a study (32) by Abbott and Vernon, a 40- versal, but they need to receive fair remunera- 50% fall in the cost of drugs in the USA would tion for the risks they undertake.
lead to a 60% drop in the number of preclinicaltrials. This study is based on simulations to indi- These two authors identify expected profits as a cate the effects of price reductions, because few key determinant of investment. This explains molecules developed in the laboratory are ever why therapeutic areas that closely match the tested on humans: according to the Californian needs of the Americans are those which are Biomedical Research Association, 0.1% of these given research priority, and why laboratories first molecules get to clinical trials. seek approval from the FDA, before any otheragency. According to IMS Health, nearly half of European researchers (33) have tried to predict the new molecules approved by the FDA bet- the impact of European price regulation (i.e.
ween 2006 and 2015 were for oncology, infec- price reduction) on R&D spending by pharma- tions and neurological conditions. (30) Figures for Q4 are available but are likely to be revised in the coming months.
(31) Estimated at $1-1.5 billion according to Prof. DeMasi.
(32) Abbott & Vernon, 2005, The Cost of US Pharmaceutical Price Reductions: A Financial Simulation Model of R&D Decisions, NBER Working Paper.
(33) Eger et Mahlich, 2014, Pharmaceutical regulation in Europe and its impact on corporate R&D, Health Economics Review.
(34) R&D is becoming ever more expensive, according to the sector, and is hindered by the various stages involved in bringing a drug to market.

3.3 Relief for households?
Nearly three out of every five personal bankrupt- A mismatch between the needs of the patients and cies are due to the debts accumulated by an indi- their insurance coverage has been put forward to vidual for health care needs. An older study (35), explain this outcome. In fact, like the ACA, the aim but whose conclusions are still relevant, tells us of this reform was to grant health coverage for all.
that nearly 62.1% of all personal bankruptcies in But with the patient still required to pay high costs the USA were caused by medical bills. For 92% of (out of pocket, deductibles, copays, and uninsured those, the bill came to at least $5,000 - 10% of the services), the likelihood of going bankrupt only patient's gross annual income. It would be easy to increased. The authors calculated that one in every assume that these indebted households belong to two households with an annual income of nearly the most disadvantaged swathes of American $44,000 could be out of pocket by $20,512 every society, but the opposite is in fact true, with the year i.e. nearly half its annual income.
typical patient profile being an educated, middle-class property-owner. Three quarters of the peo- So, with the price of drugs rising constantly over ple who went bankrupt had health insurance the past few years, and based on our forecasts of (about 77.4%). Having been declared bankrupt, a further increase of around 9.3% (driven mainly the out-of-pocket costs for the patient were on we believe by the arrival of particularly expensive average $17,943. The leading cause cited for these specialty medicines), this trend looks set to con- personal bankruptcies, mentioned by nearly 48% tinue in the coming years. of those surveyed, was hospital stays. However,this was followed by prescription costs (18.4%).
The ACA does not provide for a reduction in the This cause was given by one third of cases when price of drugs. However, this is a major issue, as the patient suffered from a cardiovascular, pul- we have seen above, with the KFF survey. A recent monary or psychological condition. We note how- study by Prof. Y. Zafar from Duke University in the ever that "hospital costs" can include the price of USA, the results of which were presented at the drugs dispensed via the hospital.
ASCO Conference (36), demonstrates that patientswith a form of leukaemia requiring the expensive Two years later, the same team studied medical- drug imatinib (Gleevec (37)) but only able to get related personal bankruptcies in relation to the coverage under the bronze plan (38), would reach introduction of Romneycare in the State of Mas- the insurer's annual limit of cover in just three sachusetts, a particularly interesting case since months. And that is just for treating this condition.
the ACA drew inspiration from this law designed The ACA only partially resolves this problem, and to give health coverage to all. Bankruptcies rose does not limit the impact of innovative and expen- in this State by 51% between 2007 and 2009. sive treatments.
(35) Himmelstein et al., 2009, Medical Bankruptcy in the United States, 2007: Results of a National Study, The American Journal of Medicine.
(36) American Society of Clinical Oncology. (37) Its price ranged between $90,000 and $118,000 in the USA before its patent expired. Even in this case, an Indian generics manufacturer announced it could cut the price to $60,000.
(38) The cheapest plan if using the marketplaces set up by the ACA.
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Looking to the future article from the garden march 2016

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