Subject: Re: OT: Highest Life Expectancy Countries
The industry is becoming integrated where the largest pharmacies have their own PBMs. This leads to odd effects for example, your co-pay for a particular drug with insurance costs you more at say, CVS, than than paying 100% out of pocket at an independent pharmacy.

The US PBM's are definitely a head-shaking phenomenon. It's an interesting thought experiment: what would happen if there were a law requiring every drug to be sold at a single price to all, without volume discounts or rebates? (other than knocking the stuffing out of the budgets non-US drug buyers)

But all the middlemen, in aggregate, could probably use a rethink (not that I expect anyone can or will). Insurers, drug distributors and pharmacies take their pound of flesh too. They probably deserve more ire than the drug companies who seem to take all the heat.

The four gatekeeper industries combined had revenues equal to 25% of total US health care spending in 2013, and 45% in 2022. In aggregate their "rent", estimated return on invested capital above estimated WACC (not my fave), is 2.3%/year higher than the rest of the SP 500, 5.9% vs 3.6%.

Jim