The 2017-18 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors

By Adam J. Fein, Ph.D.
(downloadable PDF file; Released October 2017)

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In 2017, pharmaceutical wholesalers confronted a deteriorating business environment. Many of the trends that we identified in previous editions of this report culminated in significant profit declines and loss of stock market value.

The 2017–18 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors—our eighth edition—remains the most comprehensive tool for analyzing the economic and business realities of U.S. pharmaceutical distribution. Click here to download a free overview of the 2017-18 report.

The report is researched and written by Adam. J. Fein, Ph.D., one of the world’s leading experts on the drug distribution industry and the author of the influential Drug Channels website. Dr. Fein has synthesized a wealth of statistical data (including 117 data-packed exhibits), research studies, financial information, and his own unique business consulting experience into a definitive, nonpartisan resource.

That’s what makes this report essential reading for pharmaceutical manufacturers, wholesalers, pharmacists, pharmacy owners, hospital executives, buyers, benefit managers, managed care executives, healthcare policy analysts, investors, consultants—anyone who wants to understand and benefit from this ever-changing industry.

This year’s report has been updated, revised, and expanded. This 2017-18 edition contains the most current market and industry and data available. It also includes the latest financial data and market positions of the largest public companies: AmerisourceBergen, Cardinal Health, and McKesson. It updates our analysis of each wholesaler’s business segments and underlying business profitability, based upon our proprietary economic models. This information allows you to assess differences among the public wholesalers’ business organizations, strategies, and financial performance.

No other report on the market today offers the depth, insight and analysis of the 2017–18 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors.

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TABLE OF CONTENTS

Introduction and Guide to This Report

PREFACE: INDUSTRY TRENDS AND KEY REPORT THEMES

SECTION I: WHOLESALER AND CUSTOMER INDUSTRY ANALYSIS

Chapter 1: Industry Overview

  • 1.1. Wholesale Industry Fundamentals
    • 1.1.1. Defining Drug Wholesale Distribution
    • 1.1.2. Full-Line Wholesalers
    • 1.1.3. Specialty Distributors
    • 1.1.4. Regulation and Supply Chain Security
  • 1.2. The Products That Wholesalers Sell
    • 1.2.1. Brand vs. Generic Drugs
    • 1.2.2. Route of Administration
    • 1.2.3. Specialty vs. Traditional Drugs
    • 1.2.4. Specialty Product Distribution
  • 1.3. Overview of Wholesalers’ Channel Roles
    • 1.3.1. Physical Distribution
    • 1.3.2. Financial Intermediation
    • 1.3.3. Services for Pharmacies, Providers, and Manufacturers
    • 1.3.4. Impact on Pharmacy and Provider Reimbursement
  • 1.4. Industry Participants
    • 1.4.1. Big Three Wholesalers: Revenue and Growth Trends
    • 1.4.2. Other Wholesale Market Participants

Chapter 2: Channel Role for Retail, Mail, and Specialty Pharmacies

  • 2.1. The Pharmacy Market
    • 2.1.1. Outpatient Dispensing Formats
    • 2.1.2. Pharmacy Market Size and Structure
    • 2.1.3. Differences Among Outpatient Dispensing Formats
  • 2.2. Independent Pharmacies
    • 2.2.1. Industry Position and Wholesaler Market Shares
    • 2.2.2. Wholesaler Services for Independent Pharmacies
    • 2.2.3. Franchise Programs and Marketing Groups
    • 2.2.4. PSAOs and the Wholesalers’ Role in the Pharmacy-Payer Relationship
    • 2.2.5. Wholesaler Relationships with Pharmacy Group Purchasing Organizations
    • 2.2.6. Wholesaler Generic Source Programs for Smaller Pharmacies
  • 2.3. Retail Chains and Mail Pharmacies
    • 2.3.1. Wholesale Suppliers to Largest U.S. Pharmacies
    • 2.3.2. Physical Distribution Relationships Between Wholesalers and Retail Chains
    • 2.3.3. Generic Sourcing Relationships Between Wholesalers and Large Pharmacies
  • 2.4 Specialty Pharmacies
    • 2.4.1. Specialty Pharmacy Market Participants
    • 2.4.2. Wholesalers’ Specialty Pharmacies
    • 2.4.3. Wholesalers’ Role in Manufacturer-Defined Limited Specialty Networks

Chapter 3: Channel Role for Physician Offices/Clinics and Hospitals

  • 3.1. The Provider-Administered Drug Market
    • 3.1.1. Spending and Sites of Care
    • 3.1.2. The Buy-and-Bill System
    • 3.1.3. Provider Reimbursement in the Buy-and-Bill System
    • 3.1.4. Group Purchasing Organizations (GPOs)
    • 3.1.5. Contract Management and Chargebacks
  • 3.2. Physician Offices
    • 3.2.1. Pharmaceutical Purchasing and Distributors’ Services
    • 3.2.2. GPOs for Physician Practices
    • 3.2.3. Specialty Drug Dispensing By Physician Practices
  • 3.3. Hospitals
    • 3.3.1. Pharmaceutical Purchasing and Wholesalers’ Services for Hospitals
    • 3.3.2. Hospital GPOs
    • 3.3.3. Specialty Pharmacies at Hospitals and Health Systems
    • 3.3.4. Wholesalers and the 340B Drug Pricing Program

SECTION II: BUSINESS ECONOMICS AND INDUSTRY TRENDS

Chapter 4: Wholesaler Profitability

  • 4.1. Sources of Wholesaler Gross Profits and Gross Margin
  • 4.2. Components of Buy-Side Gross Margin
    • 4.2.1. Distribution Service Agreements
    • 4.2.2. Payment Discounts
    • 4.2.3. Specialty Distribution Service Agreements
    • 4.2.4. Generic Sourcing Formularies
    • 4.2.5. Wholesaler Compensation and Bona Fide Service Fees
  • 4.3. Sell-Side Gross Margins and Cost-Minus Discounts
  • 4.4. Estimates of Overall Buy-Side and Sell-Side Gross Margins
  • 4.5. Gross Profits of Brand vs. Generic Drugs
    • 4.5.1. Lifecycle Profits for Traditional Generic Drugs
    • 4.5.2. Lifecycle Profits for Provider-Administered Generic Drugs
    • 4.5.3. Private Label Generic Drugs
  • 4.6. The Profit Impact of Brand-Name Drug Price Inflation
    • 4.6.1. Brand-Name Drug Inflation and Wholesaler Fees
    • 4.6.2. Inventory Appreciation and Revaluation
  • 4.7. Operating Expenses and Operating Profit

Chapter 5: Financial Stability and Cash Management

  • 5.1. Debt, Coverage, and Liquidity Ratios
  • 5.2. Balance Sheet Assets
  • 5.3. Cash Conversion Cycle
    • 5.3.1. Inventory Levels and Days Inventory Outstanding
    • 5.3.2. Accounts Receivable and Days Sales Outstanding
    • 5.3.3. Accounts Payable and Days Payable Outstanding
  • 5.4. Uses of Cash
  • 5.5. Return on Invested Capital
  • 5.6. Stock Market Performance

Chapter 6: Forces of Change for Drug Distribution

  • 6.1. The Outlook for U.S. Pharmaceutical Spending and Brand-Name Drug Prices
  • 6.2. Deflation of Generic Drug Prices
  • 6.3. Evolution of Traditional and Specialty Dispensing Channels
    • 6.3.1. Pharmacy Market Evolution
    • 6.3.2. Retail Pharmacies
    • 6.3.3. Specialty Pharmacies
    • 6.3.4. Provider-Operated Specialty Pharmacies
  • 6.4. Challenges to Physician Buy-and-Bill
    • 6.4.1. Hospital Acquisition of Physician Practices and Shifting Sites of Drug Administration
    • 6.4.2. Specialty Pharmacy Displacement of Buy-and-Bill Channels
  • 6.5. The Impact of Biosimilars
    • 6.5.1. Update on the Biosimilar Market
    • 6.5.2. Biosimilars Under the Pharmacy Benefit
    • 6.5.3. Biosimilars Under the Medical Benefit

SECTION III: BIG THREE WHOLESALER PROFILES

Chapter 7: AmerisourceBergen Corporation

  • 7.1. Business Overview
    • 7.1.1. Company Information
    • 7.1.2. Company History
    • 7.1.3. Acquisitions and Divestitures
    • 7.1.4. Business Segments
  • 7.2. Profitability
    • 7.2.1. Overall Pharmaceutical Distribution
    • 7.2.2. Profitability by Business Sub-Segment
  • 7.3. Customers
    • 7.3.1. Top 10 Largest Customers
    • 7.3.2. Walgreens Boots Alliance
    • 7.3.3. Express Scripts
  • 7.4. Growth Trends
    • 7.4.1. Distribution Company Growth Trends
    • 7.4.2. Specialty Group Trends
    • 7.4.3. MWI Animal Health

Chapter 8: Cardinal Health

  • 8.1. Business Overview
    • 8.1.1. Company Information
    • 8.1.2. Company History
    • 8.1.3. Recent Acquisitions
    • 8.1.4. Business Segments
  • 8.2. Profitability
    • 8.2.1. Overall Pharmaceutical Distribution
    • 8.2.2. Profitability by Business Sub-Segment
  • 8.3. Customers
    • 8.3.1. Top 10 Largest Customers
    • 8.3.2. CVS Health
  • 8.4. Growth Trends
    • 8.4.1. U.S. Distribution Growth Trends
    • 8.4.2. Specialty Solutions
    • 8.4.3. Cardinal Health China and Chinese Pharmaceutical Distribution

Chapter 9: McKesson Corporation

  • 9.1. Business Overview
    • 9.1.1. Company Information
    • 9.1.2. Company History
    • 9.1.3. Acquisitions and Divestitures
    • 9.1.4. Business Segments
  • 9.2 Profitability
    • 9.2.1. Overall Distribution
    • 9.2.2. Profitability by Business Sub-Segment
  • 9.3. Customers
    • 9.3.1. Top 10 Largest Customers
    • 9.3.2. CVS Health
    • 9.3.3. Rite Aid
  • 9.4. Growth Trends
    • 9.4.1. U.S. Drug Distribution Growth Trends
    • 9.4.2. McKesson Specialty Health
    • 9.4.3. McKesson Europe

Acronyms and Abbreviations

Endnotes

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LIST OF EXHIBITS

Exhibit 1: Full-Line Wholesale Revenues, by Type of Customer, 2015
Exhibit 2: Full-Line Wholesalers, Inventory Levels vs. Product Sales, by Product Type, 2015
Exhibit 3: Full-Line Wholesalers, Inventory Levels vs. Product Sales, by Product Type, 2011 vs. 2015
Exhibit 4: Specialty Distributor Revenues, by Type of Customer, 2015
Exhibit 5: Specialty Distributor Sales, by Therapeutic Area, 2015
Exhibit 6: Timeline of DSCSA Requirements for Wholesale Distributors, 2013-2023
Exhibit 7: Unbranded and Branded Generics, Share of U.S. Prescriptions, 2003-2021F
Exhibit 8: Allowance for Doubtful Accounts, by Company, 2017
Exhibit 9: U.S. Drug Distribution and Related Revenues at Big Three Wholesalers, Calendar Year 2016
Exhibit 10: U.S. Drug Distribution and Related Revenues, Big Three Wholesalers, 2012-2017E
Exhibit 11: The U.S. Pharmacy Distribution and Reimbursement System for Patient-Administered, Outpatient Brand-Name Drugs
Exhibit 12: Total U.S. Pharmacy Industry Revenues, Prescriptions, and Locations, by Dispensing Format, 2016
Exhibit 13: Average Annual Number of Prescriptions per Pharmacy, by Retail Dispensing Format, 2016
Exhibit 14: Average Annual Prescription Revenue per Pharmacy Outlet, by Retail Dispensing Format, 2016
Exhibit 15: Number of Independent Pharmacies, 1991-2016
Exhibit 16: Estimated Drug Sales and Market Share with Independent Pharmacies, by Wholesaler, 2016
Exhibit 17: U.S. Pharmacy Franchise and Marketing Programs, 2016
Exhibit 18: Consumer Satisfaction with Wholesalers’ Pharmacy Group vs. Other Dispensing Formats, 2017
Exhibit 19: Largest Pharmacy Services Administration Organizations, by Members and Ownership, 2017
Exhibit 20: Pharmacy Buying Groups and Primary/Preferred Wholesaler Relationships, by Number of Pharmacies, 2017
Exhibit 21: Wholesaler Generic Source Programs, Number of SKUs and Manufacturers, 2011-2015
Exhibit 22: Largest U.S. Pharmacies and Their Primary Wholesale Suppliers, 2016
Exhibit 23: Alignment Between the Big Three Wholesalers and Top Five Pharmacies
Exhibit 24: Full-Line Wholesaler Sales to Retail Chain Warehouses, 2008 to 2016E
Exhibit 25: Share of U.S. Generic Purchasing Volume, by Organization, 2017
Exhibit 26: Specialty Drug Prescription Revenues, by Dispensing Format, 2016
Exhibit 27: Prescription Revenues and Market Share from Specialty Pharmaceuticals, by Company, 2016
Exhibit 28: Alternative Channels to Specialty Pharmacies in Limited Dispensing Networks
Exhibit 29: Diplomat Pharmacy, Drug Purchases, by Supplier, 2012-2016
Exhibit 30: Medical Benefit Spending on Provider-Administered Drugs, by Drug Category and Payer, 2015
Exhibit 31: Commercial Medical Benefit Spending for Outpatient Specialty Drugs, by Site of Care, 2011 vs. 2015
Exhibit 32: Commercial Medical Benefit Claims for Outpatient Provider-Administered Drugs, by Site of Care and Therapy Class, 2015
Exhibit 33: Buy-and-Bill System for Distribution and Reimbursement of Provider-Administered Outpatient Drugs
Exhibit 34: Reimbursement Method for Provider-Administered Drugs Paid Under the Commercial Medical Benefit, by Site of Care, 2016
Exhibit 35: Commercial Medical Benefit Cost per Claim for Outpatient Specialty Drugs, by Site of Care, 2015
Exhibit 36: Full-Line Wholesaler Chargebacks As a Percentage of Net Sales, 2009-2015
Exhibit 37: Revenue Mix at Oncology Practices, by Category, 2014
Exhibit 38: Most Important Services Offered by Community Practice GPOs
Exhibit 39: Specialty Physician Practice GPOs and Ownership, 2017
Exhibit 40: Percentage of Practices With In-Practice Oral Oncology Drug Dispensing, 2013-2016
Exhibit 41: Patient-Administered Oncology Volume, by Dispensing Channel, 2016
Exhibit 42: Share of Community Hospitals, by Health System Affiliation, 1999-2015
Exhibit 43: Hospital Costs, by Type of Expense, 2015
Exhibit 44: Prescription Drug Costs As a Percentage of Hospital Expense, 2006- 2015
Exhibit 45: Hospital Pharmaceutical Expenses per Staffed Bed, by Ownership and IDN Affiliation, 2016
Exhibit 46: Largest Group Purchasing Organizations, by Total Purchasing Volume, 2017
Exhibit 47: Hospital Ownership of Specialty Pharmacy, by Number of Staffed Beds, 2016
Exhibit 48: Hospitals’ 340B Drug Purchases As a Percentage of Total Hospital Drug Purchases, 2007-2016
Exhibit 49: Key Elements on a Wholesaler Income Statement
Exhibit 50: Sources of a Wholesaler’s Gross Margin from Brand-Name Drugs
Exhibit 51: Estimated Buy-Side and Sell-Side Contributions to Wholesalers’ Gross Margin, 2017
Exhibit 52: U.S. Drug Distribution Gross Margins, Big Three Wholesalers, 2013 to 2017
Exhibit 53: Estimated Drug Distribution Gross Margins, Brand-Name vs. Generic Drugs, 2017
Exhibit 54: Big Three Wholesalers, Revenues and Gross Profits, Brand vs. Generic Drugs, 2017
Exhibit 55: Typical Path of Wholesaler Gross Profits, Brand vs. Multi-Source Generic Drug
Exhibit 56: Average Sell-Side Discount for Generic Drugs Sold to Retail Pharmacies, by Number of Manufacturers, 2017
Exhibit 57: Example of Channel Profits from a Provider-Administered Generic Drug
Exhibit 58: Annual Invoice Price Increases for Brand-Name Drugs, 2011 to 2017E
Exhibit 59: Illustrative Value of a Wholesaler’s Fees with Brand-Name Pharmaceutical Price Inflation
Exhibit 60: Illustrative Effect of Inventory Revaluation on a Wholesaler’s Gross Profit
Exhibit 61: Full-line Wholesalers, Operating Expenses by Category, 2015
Exhibit 62: Big Three Wholesalers, Drug Distribution Operating Margin As a Percentage of Revenues, 2013-2017
Exhibit 63: Big Three Wholesalers, Distribution Operating Profits As a Percentage of Gross Profits, 2016 vs. 2017
Exhibit 64: Big Three Wholesalers, Total Short-Term and Long-Term Debt, 2017
Exhibit 65: Big Three Wholesalers, Debt-to-EBITDA Ratio, FY2015-FY2017
Exhibit 66: Big Three Wholesalers, Liquidity Ratios, FY2017
Exhibit 67: Big Three Wholesalers, Composition of Current Assets, 2017
Exhibit 68: Illustrative Wholesaler Cash Conversion Cycle for Brand-Name Drugs Sold to a Pharmacy Customer
Exhibit 69: Big Three Wholesalers, Cash Conversion Cycle, 2017
Exhibit 70: Big Three Wholesalers, Cash Conversion Cycle, 2010-2017
Exhibit 71: Big Three Wholesalers, Days of Sales in Inventory, 2013-2017
Exhibit 72: Percentage of Wholesalers’ Trade Accounts Receivable and DSO for Largest Customers, 2016-2017
Exhibit 73: Big Three Wholesalers, Days Payable Outstanding, 2010-2017
Exhibit 74: Big Three Wholesalers, Dividends and Share Repurchases As a Percentage of Operating Cash Flow, FY2015-FY2017
Exhibit 75: Big Three Wholesalers, Return on Invested Capital, 2013-2017
Exhibit 76: Forward Price-to-Earnings Ratio, Big Three Wholesalers vs. S&P 500, 2013-2017
Exhibit 77: One- and Five-Stock Price Performance, Big Three Wholesalers vs. Manufacturers and Overall Market, 2017
Exhibit 78: Total U.S. Drug Purchases, Annual Total, 2012 to 2021F
Exhibit 79: Average Year-Over-Year Change in Pricing of Mature Generic Drugs, 2014-2017
Exhibit 80: Total Change in 30-Day Equivalent Prescriptions Dispensed and Drugs Purchases, by Pharmacy Format, 2012-2016
Exhibit 81: Pharmacy Industry Prescription Revenues, Traditional vs. Specialty Drugs, 2011-2021
Exhibit 82: Oral Oncology Agents, by Dispensing Channel, 2009 vs. 2016
Exhibit 83: Share of Specialty Distributor Revenues from Independent Physician-Owned/Operated Clinics, 2011-2015
Exhibit 84: Percentage of Oncology Practices Owned by a Hospital or Health System, 2003-2015
Exhibit 85: Medicare Part B Spending on Provider-Administered Outpatient Drugs, by Location of Service, 2005-2015
Exhibit 86: Change in Medicare Part B Spending on Outpatient Drugs, by Location of Service, 2006-2015
Exhibit 87: Health Plans’ Perceived Pricing Competitiveness for Specialty Pharmacy Medications, by Site of Care, 2017
Exhibit 88: Oncology Drug Sourcing for In-Practice Administration, by Practice Type and Source, 2015
Exhibit 89: Oncology Drug Sourcing for In-Practice Administration, Use of External Specialty Pharmacies, 2014-2016
Exhibit 90: Number of U.S. Biosimilar Development Programs, 2013 to 2017
Exhibit 91: Medicare Payment Rate Per Unit, Remicade vs. Biosimilars, 2016-2017
Exhibit 92: AmerisourceBergen, Pharmaceutical Distribution, Profitability Metrics, 2013-2017
Exhibit 93: AmerisourceBergen, Estimated Revenues and Operating Profit, by Segment, FY2017E
Exhibit 94: AmerisourceBergen, Top 10 U.S. Drug Distribution Customers, FY2017
Exhibit 95: AmerisourceBergen, Revenues from Walgreens Boots Alliance, 2014-2017E
Exhibit 96: AmerisourceBergen, Days Sales Outstanding from Walgreens vs. All Other Customers, 2014-2017
Exhibit 97: AmerisourceBergen, Revenues from Express Scripts vs. Express Scripts Pharmacy Revenues, 2013-2017E
Exhibit 98: AmerisourceBergen, Revenues by Major Business Segment and Customer, FY2012 vs. FY2017E
Exhibit 99: AmerisourceBergen Distribution Company, Revenues and Growth, 2013-2017:Q2
Exhibit 100: AmerisourceBergen Specialty Group, Revenues and Growth, 2012-2017E
Exhibit 101: Animal Health Market, Distributor Market Share, by Company, 2017
Exhibit 102: Cardinal Health, Profitability Metrics, 2013-2017
Exhibit 103: Cardinal Health, Estimated Revenues and Operating Profit, by Segment, FY 2017
Exhibit 104: Cardinal Health, Top 10 U.S. Drug Distribution Customers, FY 2017
Exhibit 105: Cardinal Health, Revenues from CVS Health, 2013-2017
Exhibit 106: Cardinal Health, Days Sales Outstanding from CVS Health vs. All Other Customers, 2013-2017
Exhibit 107: Cardinal Health, U.S. Pharmaceutical Distribution, Revenues and Growth, 2013-2017:Q2
Exhibit 108: Cardinal Health China, Revenues, 2011-2017
Exhibit 109: McKesson, Distribution Solutions, Gross and Segment Operating Profitability Metrics, 2013-2017
Exhibit 110: McKesson, Estimated Revenues and Operating Profit, by Segment, FY 2017
Exhibit 111: McKesson, Top 10 U.S. Drug Distribution Customers, FY2017
Exhibit 112: McKesson, Revenues from CVS Health, 2013-2017
Exhibit 113: McKesson, Days Sales Outstanding from CVS Health vs. All Other Customers, 2013-2017
Exhibit 114: McKesson, U.S. Distribution, Revenues and Growth, 2013-2017:Q2
Exhibit 115: McKesson Health Mart, Store Count and Change, 2007 to 2017
Exhibit 116: McKesson’s OneStop Generic Program, Revenue Growth Rate, 2010-2017E
Exhibit 117: McKesson Europe, Revenues and Gross Profit, by Operating Segment, 2017

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