A.3 The Mechanism of Stock Buybacks and Executive Incentive

A substantial portion of these shareholder distributions, approximately 60%, was executed through stock buybacks. In a stock buyback, a company repurchases its own shares, which reduces the total number of outstanding shares and mathematically increases the value of the remaining stock. This practice disproportionately benefits high-level corporate executives whose compensation packages are heavily weighted toward stock options. The pressure on corporate management to execute buybacks and other short-term maneuvers to boost stock prices reinforces a fundamental misalignment of incentives. The goal of executive compensation is maximized by actions that increase stock value, which directly fuels organizational decisions, such as aggressive cost minimization and minimization of benefit payouts, that bolster financial performance but may simultaneously degrade the quality or affordability of healthcare services.   

B. Market Consolidation and the Exercise of Monopsony Power

Market concentration, driven by aggressive horizontal and vertical consolidation, allows commercial insurers to exert significant market power, resulting in financial capture that benefits the corporation rather than the consumer.

B.1 Horizontal Consolidation and Premium Inflation

Insurers frequently argue that mergers and acquisitions lead to greater efficiencies, allowing them to negotiate better rates with providers and ultimately reduce costs for members. However, empirical evidence strongly suggests the opposite outcome for consumers. Analyses exploring insurer consolidation activity, particularly between 2007 and 2010, found a measurable correlation between insurer mergers and subsequent premium increases in specific markets. This occurs because market concentration reduces competition, lessening the pressure on consolidated insurers to maintain low premiums or risk losing substantial market share. The financial gains derived from consolidation are thus retained by the insurer.   

B.2 Retention of Provider Price Savings (The Monopsony Power Trap)

Consolidation also grants large insurers immense monopsony power—the ability of a large buyer to demand and secure lower prices from sellers (i.e., healthcare providers). Research confirms a correlation between high insurer market concentration and the reduction of provider prices below competitive levels.   

A critical finding in market analysis is that evidence does not support the assumption that these negotiated provider price savings are passed through to consumers in the form of lower premiums or reduced out-of-pocket costs. Instead, these savings are largely retained by the insurance carriers themselves. This mechanism demonstrates a crucial structural dynamic: the consolidated entity gains leverage over both input markets (providers) and output markets (consumers). By suppressing provider reimbursement while increasing or maintaining high premiums, insurers maximize the financial spread between the premiums collected and the benefits paid. This captured revenue is then diverted into the flow of shareholder funds identified in Section I.A, reinforcing the system’s reliance on financial extraction.   

B.3 Vertical Integration: The Case of PBMs

The healthcare market is increasingly dominated by vertically integrated conglomerates that merge large insurers with Pharmacy Benefit Managers (PBMs). The concentration of this market is profound: the three largest PBMs (CVS Caremark, Express Scripts, and OptumRx) control an estimated 80% of U.S. prescription drug claims. As of 2023, 77% of commercial and Medicare Part D beneficiaries were enrolled in a plan where the insurer and the PBM were owned by the same parent company.   

This market structure has demonstrably negative competitive effects. An analysis of the Medicare Part D market, a concentrated environment, showed that the 2015 merger between UnitedHealth and Catamaran, which eliminated the last significant standalone PBM option, led to negative consequences for rival insurers. Non-vertically integrated insurers experienced premium increases that were 36% higher compared to the premiums of vertically-integrated insurers. This outcome is consistent with a pattern known as input foreclosure, where vertically integrated PBMs raise the costs of rival insurers by leveraging their control over essential drug supply chain services. The integration thus serves as a primary tool for market entrenchment, creating a closed ecosystem that financially incentivizes patients to stay “in house” , simultaneously reducing transparency and competition in the critical drug benefit space.   

C. Mechanisms of Profit Extraction through Administrative Friction

Commercial insurers operationalize cost minimization through a sophisticated system of administrative friction, leveraging complex processes to deter claims, shift financial burdens onto providers, and ultimately minimize benefit payouts.

C.1 Utilization Review and Claims Denial as a Profit Strategy

Insurers heavily rely on utilization review (UR), including prospective review (prior authorization) and retrospective claims review, to challenge the medical necessity of services and reduce benefit expenditures. The volume of denied claims is substantial: insurers offering Qualified Health Plans (QHPs) on HealthCare.gov denied an average of 20% of all claims in 2023 (19% in-network), with denial rates reaching as high as 54% for certain plans. Similarly, Medicare Advantage (MA) plans, operated by private insurers, showed claim denial rates around 17% of initial submissions.   

C.2 The Economic Cost of Friction and Improper Denials

For healthcare providers, managing this administrative friction incurs a significant financial and labor burden. Reworking or appealing denied claims costs an average of $181 per claim for hospitals and $25 per claim for medical practices. This deliberate creation of administrative overhead strains provider resources and, for community providers, can threaten financial viability and restrict the ability to reinvest in infrastructure.   

Crucially, the high volume of denials does not indicate legitimate cost control. In the MA market, a staggering 57% of all claim denials were ultimately overturned. This high overturn rate provides quantitative evidence that initial denials are often improper, based on overly restrictive interpretations of medical necessity, or outright erroneous. However, the system is designed to capitalize on procedural deterrence: consumers rarely challenge these decisions, appealing fewer than 1% of denied claims. When internal appeals are filed, insurers usually uphold their original denial 56% of the time.   

This system reveals a structural pattern: the primary financial utility of denial is not to permanently save the full value of the claim, but to save the large percentage of claim values successfully deterred by the cost, time, and administrative hassle of the appeal process. Denial, therefore, functions as a highly profitable filtering mechanism that shifts financial risk and labor burden onto patients and providers.

C.3 Incentivizing Denial Through System Design

While some state regulations and internal policies prohibit offering direct financial or nonfinancial incentives to utilization management (UM) decision-makers for denying care , the structure of administrative denial suggests institutionalized incentives persist.   

Federal transparency data for ACA plans show that only 6% of denials were explicitly based on “lack of medical necessity”; the majority were due to administrative reasons (18%), excluded services (16%), or the vague catch-all category of “Other” (34%). This profile suggests that the denial process is often friction-based rather than medically justified.   

Furthermore, investigative reports and whistleblower accounts allege the use of internal “denial quotas” and advanced algorithmic decision systems (such as Cigna’s PXDX system, reported to allow review of 50 charts in 10 seconds) to flag and rapidly deny claims based on cost thresholds, effectively bypassing thorough clinical review. This evidence suggests that rather than violating prohibitions against explicit individual monetary incentives, large insurers have implemented systemic, high-volume, automated processes and internal performance metrics that maintain the functional financial incentive for denial. This effectively moves the mechanism of profit extraction from individual malpractice to organizational design.   

D. Regulatory Gaps and Enforcement Weakness

The structural failures on the payer side are enabled by significant gaps in the regulatory framework, particularly concerning federal preemption and the insufficient scale of enforcement penalties.

D.1 The Employee Retirement Income Security Act (ERISA) Preemption

The Employee Retirement Income Security Act (ERISA) of 1974 regulates employer-sponsored health coverage, the predominant form of coverage for Americans under 65. ERISA includes a broad preemption provision that shields self-insured employer plans—which cover a majority of privately insured Americans—from state laws that “relate to” employee benefit plans.   

This preemption critically limits state authority to impose robust consumer protections, benefit mandates, and administrative reform requirements (such as specific utilization review criteria or comprehensive network adequacy standards) on the self-insured market. As states are traditionally the primary regulators of insurance , this preemption creates an enforcement vacuum. It mandates a “single uniform national scheme” that, in practice, lacks sufficiently robust federal oversight to counterbalance the financial pressures exerted by large, consolidated insurers.   

D.2 Insufficient Deterrence via Penalties

Federal enforcement bodies, including the Department of Labor (DOL) and the Centers for Medicare & Medicaid Services (CMS), levy penalties for violations of ERISA and other federal health statutes. However, the financial scale of these penalties is often insufficient to deter systemic non-compliance by multi-billion-dollar entities.

Penalties for prohibited transactions under ERISA Section 502(i) start at 5% of the amount involved. Fines for administrative violations, such as failure to provide required notices, are often capped at amounts like $190 per day. Even high-profile HIPAA civil monetary penalties, while reaching up to $2.1 million per violation, fail to register as a genuine financial threat when weighed against the multi-billion-dollar scale of annual administrative savings achieved through widespread, systematic denial and friction.   

The result is that the cost of regulatory non-compliance, even when proven, is vastly outweighed by the profit derived from minimizing benefit payouts. This low financial deterrent transforms statutory fines into a marginal “cost of doing business,” contributing to the perpetuation of practices that harm consumers and providers.

D.3 PBM Transparency Failures

Compounding the regulatory gaps in the Payer market is the failure to mandate sufficient financial transparency within the Pharmacy Benefit Manager (PBM) structure. The opaque nature of rebate negotiation between PBMs and manufacturers, discussed further in Section II.C, hinders external oversight. This opacity prevents sophisticated payers (such as large employers or plan sponsors) from accurately evaluating the true net cost of drugs, thereby limiting their ability to select plans that genuinely offer the best value and contributing to systemic cost escalation.   

II. The Pharmaceutical Industry: Pricing Monopoly and Investment Allocation

A. Pricing Model vs. Global Peers

The pharmaceutical industry’s contribution to unaffordability stems from its unique pricing model, which is structurally protected from competition and regulation, resulting in massive price disparities relative to the rest of the developed world.

A.1 Extreme U.S. Price Disparity

The single greatest driver of high pharmaceutical costs in the United States is the price of brand-name originator drugs. Quantitative comparison confirms a significant and growing price divergence:   

• Overall Drug Prices: In 2022, U.S. prices across all drugs (brands and generics combined) were 2.78 times as high as prices in a comparison basket of 33 Organisation for Economic Co-operation and Development (OECD) countries.   
• Brand-Name Drugs: The disparity is most severe for protected brand-name originator drugs. U.S. gross prices for these medications were 422% (over four times) the prices found in comparison countries. Even after accounting for estimated rebates and discounts paid by manufacturers in the U.S., net prices for brand drugs remained at least 322% higher than in comparable nations.   

This price profile demonstrates a fundamental failure in market regulation for patent-protected products. By contrast, U.S. prices for unbranded generics were found to be lower than those in most comparison countries, underscoring that where robust competition exists, the U.S. market is efficient at lowering costs. The high costs are a direct result of government-granted market monopolies that prevent price competition for key products.   

Table II.A.1 summarizes the price disparity.

A.2 The Historical Absence of Price Negotiation

Unlike other wealthy nations, which utilize collective bargaining, health technology assessments, and price regulation to ensure cost-effectiveness, the U.S. has historically prohibited direct federal price negotiation for pharmaceuticals. This prohibition, particularly concerning large government programs like Medicare, allowed manufacturers to set initial list prices unilaterally for patent-protected drugs.   

A.3 Impact of the Inflation Reduction Act (IRA)

The Inflation Reduction Act (IRA) of 2022 introduced the first mechanism allowing Medicare to negotiate prices for a limited list of high-cost, long-marketed drugs. This change is anticipated to save the Medicare program an estimated $98.5 billion over ten years.   

However, initial analysis of the negotiated prices (to be implemented in 2026) demonstrates that Medicare’s new prices are still substantially disconnected from global market value. On average, the Medicare negotiated prices are 2.8 times the average of drug prices achieved in 11 comparable wealthy nations. This outcome occurs because the IRA negotiation process is statutorily bound by a ceiling derived from existing U.S. non-federal average manufacturer prices. The lack of prior pricing regulation means the high, artificially inflated list price acts as a “high anchor,” ensuring that even deep discounts still result in globally excessive prices.   

B. Patents, Evergreening, and Market Exclusivity

The high prices for brand-name drugs are sustained by robust intellectual property (IP) rights, which manufacturers strategically extend to preserve market monopoly well beyond the initial therapeutic innovation.

B.1 Intellectual Property as a Monopoly Tool

Patents and regulatory exclusivities (such as 20-year patents, 7 years for Orphan Drug designation, or 3 years for new clinical studies) grant manufacturers a protected monopoly intended to allow them to recoup substantial R&D costs. However, pharmaceutical manufacturers routinely employ tactics to prolong this monopoly period, a strategy commonly referred to as “evergreening”.   

B.2 The Mechanics of “Evergreening”

Evergreening involves filing secondary patents on minor product changes—such as new delivery systems, extended-release formulations, or new dosages—late in a drug’s life cycle. These secondary patents, which are often less innovative than the original discovery, function as anti-competitive barriers designed to delay or block the entry of lower-cost generic and biosimilar alternatives.   

This practice has had a measurable effect on market duration: the average period of market exclusivity for top-selling drugs increased by more than 20%, rising from 10.3 years to 12.5 years between 1995 and 2004. Manufacturers actively encourage patient switching to these new, reformulated versions just before the original drug loses exclusivity, maximizing market share retention and profit margins.   

While some industry reports and analyses from the U.S. Patent and Trademark Office (USPTO) suggest that claims of widespread “evergreening” and “patent thickets” are overstated, arguing that multiple patents are normal for complex technologies , the measurable economic cost of these practices demonstrates their powerful anti-competitive effect.   

B.3 Quantified Cost of Delayed Competition

The delay in competition resulting from patent extension strategies imposes a significant and quantifiable cost on the healthcare system. Policy modeling indicates that implementing reforms to limit evergreening could generate substantial savings, including reducing federal deficits by at least $10 billion and lowering private sector drug costs by $9 billion over a single decade (2021–2030). The sheer volume of savings created when generic competition is permitted highlights the financial burden of market exclusivity: generic and biosimilar medicines saved the U.S. healthcare system $408 billion in 2022 alone. This confirms that the marginal utility of subsequent patents often shifts from incentivizing new development to maximizing the price-setting power of the existing monopoly, transforming IP protection into a financial rather than a purely innovation-driven tool.   

C. PBM and Supply Chain Opacity

The pharmaceutical pricing failure is deeply intertwined with the structure of the PBM industry, whose opacity creates perverse financial incentives that contribute to list price inflation and higher consumer costs.

C.1 PBM Market Concentration and Function

PBMs manage prescription drug benefits, negotiate rebates, and maintain formularies. The concentration of this market (80% controlled by the top three integrated entities) grants them immense leverage over both manufacturers and payers.   

C.2 The Perverse Incentive of Opaque Rebates

PBMs demand rebates from manufacturers in exchange for preferential placement on drug formularies. Research provides evidence that the demand for these large rebates is at least partly responsible for incentivizing manufacturers to inflate the initial list price of the drug.   

This financial arrangement benefits the PBM, which profits from receiving a portion of the rebate and from the “spread”—the difference between the amount the insurer pays and the amount the pharmacy is reimbursed. Critically, this structure harms patients with high cost-sharing responsibilities (such as deductibles or coinsurance) that are tied to the inflated list price, meaning they pay significantly more out-of-pocket before the rebate is factored in.   

PBMs, influenced by rebate potential, have been found to regularly place higher-cost medications in favorable formulary positions, even when lower-priced, clinically comparable options exist. This rebate-driven formulary management can lead to treatment choices that result in “adverse financial or medical outcomes” for patients.   

C.3 The Cost of Opacity and Proposed Reform

Vertical integration—where the insurer owns the PBM—exacerbates this issue by internalizing the opaque financial flows, hiding the true net cost from external scrutiny.   

The economic impact of this system has been quantified: research suggests that moving PBM compensation away from the rebate model to a transparent, fixed administrative fee structure could potentially reduce annual net drug spending by an estimated $95.4 billion (nearly 15% savings). This potential savings figure highlights the extent to which the current opaque supply chain generates economic rent rather than efficiency.   

D. Research & Development (R&D) Justification vs. Financial Priorities

The pharmaceutical industry justifies its extraordinary prices by citing the high, necessary costs and risks associated with funding R&D for innovative new drugs. However, corporate financial allocation patterns demonstrate a significant deviation from this stated justification.

D.1 The Shareholder Priority

The pharmaceutical industry accounted for the largest aggregate share of shareholder payouts across the entire healthcare sector, collectively returning $1.2 trillion to shareholders between 2001 and 2022. This concentration of profit distribution directly contradicts the narrative that high profits are primarily channeled back into R&D.   

D.2 Shareholder Payouts vs. R&D Investment

An analysis of leading pharmaceutical companies found that spending on payments to shareholders frequently outpaced investment in R&D. For the top 10 pharmaceutical companies in 2017–2018, aggregate shareholder payouts (including buybacks and dividends) totaled $115 billion, significantly outpacing the total R&D expenditure of approximately $71.7 billion.   

Specific financial behavior among these leading companies further highlights the structural prioritization of finance over innovation. Seven out of these ten companies spent over 100% of their net income rewarding shareholders, with figures such as AbbVie at 318% and Merck at 232%. This demonstrates that capital is routinely diverted from potential long-term R&D investment or price stabilization toward immediate financial engineering.   

D.3 Marketing, Administration, and Line Extensions

Furthermore, detailed financial breakdowns reveal that large pharmaceutical companies often prioritize Sales and Marketing (S&M) and General and Administrative (G&A) expenses over R&D.   

Historical data indicates that marketing and administration consumed 31% of revenues for major drug makers in 1999, which was nearly three times the 11% dedicated to R&D. Contemporary analysis confirms that many of the largest firms continue to spend more on sales and marketing than on R&D.   

Moreover, the quality of R&D spending is critical. A significant portion of reported R&D expenditure is directed toward low-risk, incremental improvements, such as “line extension” drugs (new dosages or delivery systems) , which primarily function to support the “evergreening” strategy (Section II.B) rather than funding high-risk research for New Molecular Entities (NMEs). This structural allocation confirms that the high prices consumers pay are predominantly funding financialization (shareholder payouts) and product defense/promotion (marketing), structurally decoupling price from genuine, groundbreaking therapeutic innovation.   

Conclusion and Policy Imperatives

3.0 Synthesis: The Confluence of Payer Friction and Pharma Monopoly

The analysis demonstrates that the unaffordability of American healthcare is the result of a coordinated, structural failure driven by the synergistic operation of the two most powerful financialized segments of the system: the commercial payers and the pharmaceutical industry.

1. Payer Side: Commercial insurers utilize consolidation to achieve market power (monopsony over providers, monopoly over consumers), enabling them to retain negotiated savings rather than passing them to consumers. They institutionalize profit extraction through administrative friction—high-volume, improper denial quotas and complex claims processes—which shifts financial burden onto providers and patients. The resulting profits are prioritized for shareholder payouts (95% of net income diverted), a practice largely shielded by the regulatory gaps created by ERISA preemption and insufficient federal penalty scales.
2. Pharma Side: Pharmaceutical manufacturers leverage government-granted intellectual property monopolies and anti-competitive “evergreening” tactics to establish and defend globally anomalous list prices (422% higher than OECD peers for brand-name drugs). These inflated prices are structurally maintained by the opaque, rebate-driven PBM system, which prioritizes the maximization of spread and rebate capture. The financial returns generated by these price monopolies are disproportionately directed toward financial markets (buybacks and dividends) and marketing, rather than fulfilling the core public justification of high-risk R&D funding.

The system operates as a zero-sum game regarding affordability. Any potential savings generated within the system—whether lower provider prices negotiated by insurers or significant rebates negotiated by PBMs—are captured internally by the vertically integrated conglomerates or distributed externally to investors. These gains are structurally prevented from being passed through to patients, employers, or taxpayers in the form of lower premiums or reduced out-of-pocket costs, thus ensuring the perpetuation of the affordability crisis.

4.0 Recommendations for Policy and Structural Reform

Based on the evidence that current corporate structure and financial priorities drive unaffordability, the following structural and policy reforms are imperative:

4.1 Strengthening the Social Utility Mandate (Payer Reform)

1. Enhance Antitrust Enforcement: Aggressively enforce antitrust law against both horizontal mergers (insurer-insurer) and vertical integration (insurer-PBM, insurer-provider) to dismantle the market power that facilitates price retention and input foreclosure.
2. Mandate Administrative Transparency and Standardization: Implement federal mandates requiring standardized utilization review protocols and publicly transparent performance metrics to eliminate the potential for internal denial quotas and rapidly automate review processes. The goal should be to eliminate the functional financial profit derived from procedural friction, directly addressing the documented 57% improper denial rate in Medicare Advantage.
3. Reform ERISA Preemption: Amend the Employee Retirement Income Security Act to narrow the scope of preemption, allowing state-level consumer protection laws and affordability mandates (e.g., related to network adequacy and utilization review standards) to apply to self-insured employer health plans, thereby closing the existing enforcement vacuum.

4.2 Curbing Price Monopoly and Directing Investment (Pharma Reform)

1. Implement PBM Delinking and Transparency: Implement legislative changes to separate PBM compensation from the list price of drugs, transitioning to a transparent, fixed administrative fee model. Analysis suggests this change could reduce annual net drug spending by approximately $95.4 billion, eliminating the perverse incentive for list price inflation.
2. Curb Patent Evergreening: Reform patent and regulatory exclusivity laws to significantly limit the ability of manufacturers to extend market monopolies through secondary patents on minor changes. Accelerating generic and biosimilar market entry is proven to yield billions in savings for consumers and payers.
3. Establish Investment Accountability: Institute a mechanism to ensure that the profits generated from patent-protected, high-cost drugs are genuinely reinvested in innovation. This could involve corporate tax policies or price regulation that mandates price adjustments if shareholder payouts, marketing, and general administrative expenditures consistently and significantly outpace high-risk R&D investment, thereby reinforcing the public good justification for temporary monopolies.

Shareholder Primacy, Healthcare Consolidation, and Drug Pricing

1. Legal Foundations of Shareholder Primacy

• A Legal Theory of Shareholder Primacy – UF Law Scholarship Repository
• A Legal Theory of Shareholder Primacy – Minnesota Law Review
• Shareholder Primacy and the Moral Obligation of Directors – Colorado Law Scholarly Commons

2. Corporate Profit Priorities in Healthcare

• Health Care Company Payouts Favor Shareholders – Yale Medicine
• Healthcare Companies Are Redistributing Most of Their Profits to Shareholders – HealthCare Dive
• Health Care Profits Increasingly Support Shareholder Payouts – Penn LDI
• Healthcare Corporations Spent Trillions on Shareholder Payouts – Lown Institute
• Health Care Profits Flow to Shareholders, Not Patient Care – Medical Economics

3. Market Consolidation and Administrative Burden

• Trends and Consequences in Health Insurer Consolidation – Center for American Progress
• Evaluating the Impact of Health Insurance Industry Consolidation – Commonwealth Fund
• Skyrocketing Hospital Administrative Costs and Burdensome Insurer Policies – AHA

4. PBMs, Vertical Integration, and Market Power

• The PBM Effect: Regulatory and Market Implications – Buchanan Ingersoll & Rooney
• Unchecked Power in PBM Industry Puts Patients at Risk – AMA
• Disadvantaging Rivals: Vertical Integration in the Pharmaceutical Market – USC Schaeffer Center
• Competition in PBM Markets and Vertical Integration (2025 Update) – AMA
• The Role of Pharmacy Benefit Managers and Rising Medication Costs – PMC

5. Claim Denials and Utilization Review

• Legal Implications of Utilization Review – NCBI
• Claims Denials: A Step-by-Step Approach – AHIMA
• Claims Denials and Appeals in ACA Marketplace Plans (2023) – KFF
• Medicare Advantage Denies 17% of Initial Claims – Health Affairs
• Prohibiting Financial Incentives in Medical Necessity Determinations – Anthem
• Insurance Claim Denials – Connecticut General Assembly
• The AI Revolution Against Insurance Denials – Counterforce Health
• Health Insurance Claim Denials Are on the Rise – PBS
• UnitedHealthcare Whistleblower: Claim Denial “Quotas” Exist – YouTube

6. ERISA, Penalties, and Federal Oversight

• The Regulation of Private Health Insurance – KFF
• ERISA: Legal Framework and Recent Supreme Court Litigation – Congress.gov
• Enforcement Manual – Civil Penalties – U.S. Department of Labor
• 2024 Adjusted Penalties for ERISA Violations – Groom Law Group
• Penalties for HIPAA Violations (2024 Update) – HIPAA Journal
• Top HIPAA Violation Settlements (2024) – ThinkSecureNet

7. Drug Pricing, Patents, and Pharmaceutical Policy

• Hospital and Physician Consolidation: Impact on Federal Budget – CBO
• International Prescription Drug Price Comparisons (2022 Data) – RAND
• Prescription Drug Costs: U.S. vs. Other Countries – Health System Tracker
• Comparing Prescription Drugs: Prices and Availability – NCBI
• Prescription Drug Prices in the U.S. Are 2.78x Higher Than Other Countries – RAND
• Pharmaceutical Policy and Pricing – KFF
• Negotiating Medicare Drug Prices – PMC
• Medicare Price Negotiation: A Paradigm Shift – Milliman
• How Medicare Negotiated Drug Prices Compare Internationally – Health System Tracker
• Patents and Regulatory Exclusivities in Drug Pricing – Congress.gov
• May Your Drug Price Be Evergreen – Journal of Law & Biosciences
• Limiting Evergreening for Name-Brand Drugs – CRFB
• Debunking Myths Around Patent “Evergreening” – PhRMA
• Congress Must Consider Accurate Data About Patent Thickets – C4IP
• Fact Check: Debunking Myths About Patents – C4IP
• Turning Pharmaceutical Patent Expirations into Competitive Advantage – DrugPatentWatch

8. PBMs, Rebates, and Pharmaceutical Economics

• The Role of PBMs in Prescription Drug Markets – House Oversight
• Pharmacy Benefit Tactics Drive Up Prices and Limit Access – PBGH
• New Evidence Shows Prescription Drug Rebates Increase List Prices – USC Schaeffer
• Delinking PBM Compensation From Drug Prices Could Save Billions – USC Schaeffer
• The High Cost of Shareholder Power in Big Pharma – Roosevelt Institute

9. Pharmaceutical R&D vs. Marketing Spend

Five Things to Understand About Pharmaceutical R&D – Brookings Institution

Pharmaceutical Marketing and Research Spending – Boston University

Big Pharma R&D vs. Marketing – National Nurses United

Big Pharma Spent More on Marketing Than R&D – AHIP

Do Biopharma Companies Really Spend More on Marketing Than R&D? – RAPS

Research and Development in the Pharmaceutical Industry – CBO