美国医疗行业系列研究（三）——美国药品支付体系：拆解：美国高药价的成因？特朗普药价政策的影响？

Investment Rating - The industry investment rating is "Outperform" (maintained) [1] Core Insights - This report is the third in a series on the U.S. healthcare industry, focusing on the complex drug payment system in the U.S. It analyzes the causes of high drug prices and assesses the impact of Trump's drug pricing policies [4][6] - In 2023, the total expenditure on prescription drugs in the U.S. is projected to be $693.4 billion, accounting for 14.2% of overall healthcare costs, with a CAGR of 6.6% from 2018 to 2023 [4][7] - The retail prescription drug expenditure is estimated at $459 billion, representing 66% of total prescription drug spending, while non-retail prescription drug spending is $234.4 billion, accounting for 34% [10][11] - The primary payers for prescription drugs in the U.S. are commercial insurance and Medicare, with commercial insurance spending at $286.5 billion (41%) and Medicare spending at $238.4 billion (34%) [11][14] - The retail prescription drug payment system is dominated by Pharmacy Benefit Managers (PBMs), characterized by high list prices and significant rebates [4][17] - The non-retail prescription drug payment system operates under a "Buy-and-Bill" model, where high prices lead to high profits for providers [4][16] - Trump's drug pricing policies are numerous and include key areas such as Most Favored Nation pricing, PBM transparency reforms, FDA review process reforms, and changes to the 340B program [4][5] Summary by Sections U.S. Prescription Drug Expenditure Breakdown - The overall expenditure is projected at $693.4 billion, with retail and non-retail segments at a ratio of 7:3 [6][7] - Retail prescription drug spending is $459 billion, while non-retail spending is $234.4 billion, with respective CAGRs of 5.1% and 10.1% from 2018 to 2023 [10][11] Payment Sources - In 2023, the breakdown of prescription drug spending by payer is as follows: commercial insurance at $286.5 billion (41%), Medicare at $238.4 billion (34%), Medicaid at $65.4 billion (10%), and out-of-pocket spending at $82.5 billion (12%) [11][14] Retail Prescription Drug Payment System - The retail prescription drug payment system is primarily managed by PBMs, which profit from rebates and price spreads, incentivizing high list prices [4][17][19] - The flow of funds in the retail drug distribution system involves multiple stakeholders, including manufacturers, distributors, pharmacies, and payers, with PBMs playing a central role [19][20] Non-Retail Prescription Drug Payment System - The non-retail system follows a "Buy-and-Bill" model, where providers are reimbursed based on the Average Sales Price (ASP) plus a markup, leading to higher costs and profits [4][16] Impact of Trump's Drug Pricing Policies - The report highlights the need to monitor the implementation of various drug pricing policies introduced during Trump's administration, which could significantly affect the industry landscape [4][5]