Estimation of the Share of Net Expenditures on Insulin Captured by US Manufacturers, Wholesalers, Pharmacy Benefit Managers, Pharmacies, and Health Plans From 2014 to 2018.

Importance: Recent US media and policy attention on insulin affordability has focused on the role of manufacturers in setting prices; however, the role of other drug distribution intermediaries in determining prices has received less attention. Objective: To estimate the share of net expenditures on insulin captured by manufacturers, wholesalers, pharmacy benefit managers, pharmacies, and health plans from 2014 to 2018. Design Setting and Participants: This cross-sectional study of the US insulin market was conducted in 2020 using 2014-2018 data from multiple sources, including list and estimated net prices from SSR Health for 32 insulin products, mean use weights from a commercial pharmacy claims database, mean acquisition costs and reimbursements from the Centers for Medicare & Medicaid Services, mean spread and share of rebates retained by pharmacy benefit managers from state Medicaid and drug transparency reports, and profit margins from the public filings of distribution system participant companies. Participants were insulin manufacturers, drug wholesalers, pharmacies, pharmacy benefit managers, and health plans. Main Outcomes and Measures: Mean list and net insulin prices, mean net expenditures on insulin, share of expenditures retained by each distribution system participant. Results: Between 2014 and 2018, mean list prices of 32 insulin products increased by 40.1% (from $19.60 to $27.45), while mean net prices received by manufacturers decreased by 30.8% (from $10.53 to $7.29). Net expenditures per 100 units of insulin increased by 3.2% (from $15.11 to $15.59) while the share of a hypothetical $100 insulin expenditure accruing to manufacturers decreased by 33.0% (from $69.71 to $46.73) and the share accruing to health plans decreased by 24.7% (from $13.82 to $10.40). The share of insulin expenditures retained by pharmacy benefit managers increased by 154.6% (from $5.64 to $14.36), the share retained by pharmacies increased by 228.8% (from $6.21 to $20.42), and the share retained by wholesalers increased by 74.7% (from $4.63 to $8.09). Conclusions and Relevance: Results of this cross-sectional study of the distribution of insulin expenditures suggest that policies to control insulin costs should consider all entities throughout the insulin distribution system. Manufacturers represented a decreasing share of insulin expenditures, and pharmacies, pharmacy benefit managers, and wholesalers accounted for a growing share; all entities play a role in increasing insulin costs.

Provider differences in biosimilar uptake in the filgrastim market.

OBJECTIVES: To identify differences in biosimilar uptake across providers and to examine the association between provider biosimilar uptake and observable practice-level characteristics. STUDY DESIGN: A retrospective analysis of 100% of a commercial medical claims database from June 2015 to June 2018. METHODS: We focused on providers of biologic (Neupogen) and biosimilar (Zarxio) filgrastim. We compared trends in biosimilar uptake across 2 dimensions: provider's place of service and provider's prescribing exclusivity. We then used multivariate regression analysis to estimate the association between any biosimilar uptake and practice-level characteristics, controlling for geography and time fixed effects. RESULTS: Relative to hospital-based providers, office-based providers were earlier and quicker adopters of the biosimilar filgrastim. Across all places of service, providers predominantly prescribed either the biosimilar or biologic, exclusively, for all their patients. Any biosimilar uptake was more common among providers in office-based settings, providers with larger practice sizes, and providers with a higher share of health maintenance organization patients, nonwhite patients, and younger patients. CONCLUSIONS: This study uncovers important associations between provider practice characteristics and biosimilar uptake. Our findings suggest that provider awareness and incentives can be important levers to strengthen US biosimilar market penetration and competition.

El trabajo infantil y juvenil en Colombia y algunas de sus consecuencias claves / Child and juvenile work in Colombia and some key consequences

Este documento busca responder el interrogante sobre cuáles son los efectos del trabajo infanto-juvenil en la educación y salud de las niñas y niños colombianos. Haciendo uso de la Encuesta Nacional de Calidad de Vida de 2003, se concluye que la vinculación temprana al mercado laboral de las y los niños con edades entre 12 y 17 años afecta negativamente su asistencia escolar, aumenta sus niveles de extraedad educativa y deteriora la percepción de su estado de salud. Para los menores entre 7 y 11 años, la relación entre trabajo infantil y la educación no es tan clara, debido posiblemente al bajo número de niños trabajadores en este rango etáreo y a la gran cobertura escolar en básica primaria que tiene Colombia. La no influencia inmediata en la salud de los oficios realizados, y la ejecución de labores más suaves respecto a las hechas por los niños de mayor edad, podrían ser algunas de las causantes de que el perjuicio en la salud de las y los niños trabajadores no sea evidente en la población de 7 a 11 años. Las pruebas empíricas contenidas en este artículo predicen que los programas encaminados a aumentar la cobertura y calidad educativa y, máxime, a impulsar y facilitar la asistencia escolar, principalmente en niveles superiores a la básica primaria, serán grandes aliados en la erradicación del trabajo infanto-juvenil en Colombia. Palabras clave: Trabajo de menores, niñez, juventud, educación, salud, Colombia.