Healthcare Forecasts Amidst Global Economic Turmoil

7/29/2019 Healthcare Forecasts Amidst Global Economic Turmoil

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World Markets Healthcare Forecasting Special Report

Healthcare Forecasts Amidst Global Economic Turmoil:RecessionProof or Leaking Roof?

Report Author

Jing Zhang

Healthcare Economist

IHS

First published November 2011


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Healthcare Forecasts Amidst Global Economic Turmoil: Recession-Proo or Leaking Roo?

Copyright 2011. all rights reserved.

All information contained herein is obtained by IHS GLOBAL INSIGHT, Inc. from sources believed by it to be accurate and reliable. All forecasts and predictions contained herein are

believed by IHS GLOBAL INSIGHT, Inc. to be as accurate as the data and methodologies will allow. However, because of the possibilities of human and mechanical error, as well as

other factors such as unforeseen and unforeseeable changes in political and economic circumstances beyond IHS GLOBAL INSIGHTs control, the information herein is provided as

is without warranty of any kind and IHS GLOBAL INSIGHT, Inc., And all third party providers make no representations or warranties express or implied to any subscriber or any other

person or entity as to the accuracy, timeliness, completeness, merchantability or tness for any particular purpose of any of the information or forecasts contained herein.

www.ihs.com

Contents:

Key fndings 3

Introduction 3

Chart 1: Total Health Spending Growth, Developed vs Emerging Markets 4

US Plans Cuts in Medicare Payments 4

Chart 2: US Total Health Spending Growth 5

e Eurozone 5

France Implements P&R Cuts 6

Chart 3: French Total Health Spending Growth 6

Germany Implements Price Cuts, Sees High Generic Penetration 6

Chart 4: German Total Health Spending Growth 7

UK Continues Increases in Public Health Expenditure and Improves Access to Medicines 7

Chart 5: UK Total Health Spending Growth 7

Italy Introduces Austerity Measures 8

Chart 6: Italy Total Health Spending Growth 8

Spains Defcit Reduction and Cost-Containment Measures 8

Cost-Containment Measures in CzechRepublic, Hungary and Slovakia 8

Chart 7: Total Health Spending Growth in Czech, Hungary and Slovakia 9

Impact o Developed Markets on Emerging Markets 9

Chinas Healthcare Reorm 9

Chart 8: China Total Health Spending Growth 10

Indias Health-Insurance Coverage Expansion and Price Controls 10

Chart 9: India Total Health Spending Growth 10

Brazils Rising Domestic Drug Production and Lowered Drug Prices 11

Outlook and Implications 11

Chart 10: Brazil Total Health Spending Growth 11


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Key fndings:

In parallel with the great divide between emerging and developed markets in terms oGDP growth, there is also a divide in their health spending. Health spending growth willcontinue to be strong in the emerging market economies while weakening in thedeveloped market economies, going orward.

A slow economy and high unemploymentplus reorm initiativesare among theactors expected to aect US health spending adversely in the short and medium term,

while Medicare expenditure will be a major actor in the long term.

e French government is aiming at containing health-spending growth below a 3%threshold and has cut reimbursement or 200 drugs to 15% (down rom 35%).

e German healthcare system has undergone considerable reorm over the past decade,as the government seeks to contain spiralling costs, particularly in terms o expenditureon pharmaceuticals.

e Italian governments austerity measurescutting spending or healthcare access,imposing high co-payments and reducing drug priceswill raise out-o-pocket (OOP)expenses while lowering health spending and drug sales.

Spain made substantial reductions to generic and o-patent brand prices in order toencourage higher generic utilisation and lower health-system costs.

Unlike most o its European neighbours, the United Kingdom is actively seeking tobring expenditure levels up to be more in line with European norms.

Cost-containment measures in the Czech Republic, Hungary and Slovakiaintroducingfxed co-payments while cutting reerence prices and drug reimbursement expenditure

will raise OOP expenses and lower growth in drug sales and health spending going orward.

India and Chinas healthcare reormsincluding expanding medical insurancecoverageshould translate into stronger growth in drug sales and health spending.

e Brazilian governments eortsboosting domestic manuacturers drug production,

hence shrinking the share o more expensive imported drugs; and reducing drug pricesthrough direct negotiation with multinational drug makerswill decrease drug prices.

Introduction:

e global economy is being dragged down by Europe and the United States. Markets are crashingbecause fscal austerity programmes are being implemented at the very moment that economic growthhas disappeared. Although IHS Global Insight had been anticipating what Morgan Stanley has calleda bumpy, below-par and brittle (BBB) recovery in the developed markets (DM), the path now lookseven more BBB.

I growth in the frst hal oers any clues, the US and the euro area will be dangerously close to reces-sion over the next several quarters. e risks to global recovery include oil prices (should unrest inthe Middle East and North Arica spread to the big oil-producing countries) and altering growth inemerging markets (EM). e single biggest risk acing both the US and Europe, however, is a policymistake, specifcally an advertent or inadvertent tightening o policy.

EM economies will not be immune to the DM slowdown, even though the great EM-DM growthdivide continues. Although EM GDP keeps cruising above its 20-year trend rate o 5%, there is asignifcant urther cooling o growth compared with last years bonanza. e current slowdown in EMgrowth now looks set to be prolonged into 2012 by the weaker DM outlook. Despite slowing growth,however, EM economieswhich account or hal o global GDP (using purchasing power parity

weights)will generate ully 80% o global GDP growth or 201112.

ere is a DM-EM divide in health spending as well. Health-spending growth will continue to bestrong in the EM economies, especially in India and China, largely because o healthcare reorm andhigh GDP growth, while weakening in the DM economies will be driven by anaemic economy andcost-containment measures, including higher generic utilisation, higher co-payments and cuts in drugpricing and reimbursement.

Health-spending growth will

continue to be strong in the

EM economies, especially

in India and China, largely

because of healthcare reform

and high GDP growth.


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Generics are identifed as being among the key market dynamics expected to drive healthcare spend-ing through to 2015. To gauge the DM-EM growth divide in health spending, we have compared thespending growth in the G7 economies (France, Germany, Italy, Japan, the UK, US and Canada) withthat o the BRIC5 economies (Brazil, Russia, India, China and South Arica). We expect spending inthe G7 to grow by 6.5% in 2011 and 3.2% in 2012, and spending in the BRIC5 to grow by 20.8%in 2011 and 17.3% in 2012.

Chart 1: Total Health Spending Growth, Developed vs Emerging Markets

US Plans Cuts in Medicare Payments

e US economy is now at stall speed, with the prospect o adverse shocks rom a European fnancialcrisis, spikes in oil prices and confdence declines on the part o businesses and households. e disap-

pointment in the frst halwith GDP up by an annual average rate o less than 1%illustrates thebrittleness o the US recovery in the ace o external shocks (oil, Japans earthquake), despite ongoingquantitative easing and fscal stimulus at the time.

e economy is idling, waiting or the usual drivers o recoveryhousing and consumer spendingtocatch up. It is going to be a long wait, given the persistently high unemployment rate. Small business,

which employs over hal o all private-sector employees, saw its August optimism index all to the lowestlevel since July 2010. Small businesses outlook on the economy and better sales has plunged. e odds oa recession have risen to 40% in the US, but a double-dip downturn is still not the most likely scenario.

A slow economy and high unemployment, plus reorm initiatives, are among the actors expected toaect US health spending adversely in the short and medium term. e persistent issue o cost con-tainment poses the greatest concern to the innovative pharmaceutical industry. Pricing pressures are

only likely to increase in the uture as employers and the US governmentwhich will take a moreactive role as a third-party payor in the health-insurance marketdemand that health insurers reducetheir burden o healthcare costs through aggressive cost-containment strategies. e use o tiered co-payments and step therapy programmes, which promote lower costs and generic drugs, has rapidlygrown over the past three years.

Other measures, such as increasing disclosure requirements o spread amounts, rebates, discounts andgenerics dispensation or Pharmacy Beneft Managers will urther dampen sentiment in the industry.In 2012, the reorm process will move ahead with norms on annual ees on the pharmaceutical indus-try, value-based purchasing or Medicare, health insurance exchanges and renewed eorts to reducehealthcare disparities. Health insurance exchanges are set to be operational in two years time. roughthe health reorm, the US government is aiming to reduce the number o uninsured rom almost 20%

o the population to just 8% in the next fve years. is will expand the insurance market and add tothe rise in health expenditure.

A slow economy and high

unemployment, plus reforminitiatives, are among the

factors expected to affect US

health spending adversely in

the short and medium term.


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We expect total health spending to grow 4.7% in 2011 and 5.0% in 2012. As Congress opens a po-litically charged exploration o ways to pare the defcit, President Barack Obama is expected to seekUSD300 billion to USD500 billion o savings over 10 years in Medicare and Medicaid. I approved,this will hurt healthcare demand and public health spending going orward. We expect public healthspending to grow 6.4% in 2011 and 6.9% in 2012.

Chart 2: US Total Health Spending Growth

In the long term, Medicare expenditure will be a major actor aecting US health spending. eBudget Control Act enables a short reprieve or Medicare until the bipartisan committee announcesits savings measures, which will inevitably include Medicare and, to a much lesser extent, i at all,Medicaid. e direct impact o the legislation will be elt by treatment providers, primarily due topayment cuts.

Along with the considerations o raising eligibility (e.g. or Medicare benefciaries to 67 years rom 65)and a means test, the committee is also expected to consider a much larger ocus on pharmaceuticalproduct prices and treatment costs.

For fscal year 2012, Social Security and Medicare account or the largest mandatory expenditureprogrammes, with Social Security at USD761 billion and Medicare at USD468 billion. Medicaid islower, at USD269 billion. Furthermore, Medicare expenditure accounted or 3.3% o GDP in 2010,and that fgure is expected to increase to over 5% by 2035. e projected low growth in Medicareexpenditure will help contain growth in total health spending and drug sales during the period.

The Eurozone: The Weakest Link

Despite the problems in the US, the Eurozone is clearly the weakest link in the global chain. Whilethe crisis was unolding, the outlook or domestic growth and the sovereign debt crisis in the Eurozone

were both worsening. Part o the concern is deteriorating fscal balances due to weak growth. A big-ger worry is the ragility o the banking systems and the large exposure to sovereign debt. Eurozoneeconomic activity has already had to cope with the act that fscal policy is becoming increasinglyrestrictive across the Eurozone during 2011.

Debt-encumbered economies such as Spain and Italy have to take the strongest action to improvetheir public fnances, while other countries, including France, have also come under serious pressureto bite the fscal bullet harder. Germany is also tightening fscal policy in 2011, albeit to a limitedextent. Looking ahead, recurrent serious Eurozone sovereign debt tensions are likely to continue to

weigh down growth periodically by damaging confdence and pushing up market interest rates or the

vulnerable countries in the area.

For scal year 2012,

Social Security and

Medicare account for

the largest mandatory

expenditure programmes,

with Social Security atUSD761 billion and

Medicare at USD468 billion.


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France Implements P&R Cuts

e Eurozone sovereign debt crisis has threatened France. e economy endured surprise alls in con-sumer spending during the second quarter. e rising risk o contagion towards the core o Europepushed unding costs higher and induced the French government to commit to additional austeritymeasures. As part o its austerity strategy, it has had extensive use o emergency measuresincludingprice and reimbursement cutsto contain growth in drug sales and health spending.

e government is aiming at containing health spending growth below a 3% threshold and has cutreimbursement or 200 drugs to 15% (down rom 35%); the French statutory health insurer has an-

nounced price cuts or patented and generic drugs; and generics launched rom 2009 are priced 55%below their originators. We expect total health spending to grow 3.7% in 2011 and 4.0% in 2012.

Chart 3: French Total Health Spending Growth

Germany Implements Price Cuts, Sees High Generic Penetration

Despite increasing employment and wage growth, consumer spending has also altered in Germany,reecting the unsettling impact o the Eurozone debt crisis. German growth will stay airly weak dur-ing the second hal o 2011. Like France, Germany is also tightening fscal policy in 2011, albeit to alimited extent.

e German healthcare system has undergone considerable reorm over the past decade as the gov-ernment seeks to contain spiralling costs, particularly in terms o expenditure on pharmaceuticals.e government plans to increase orced discounts on prescription drugs rom 6% to 16% (a costo around EUR4 billion or the pharma industry by 2013) and to impose a three-year price reeze

on drug prices, until 31 December 2013. e latest policy changes are expected to reduce growth opublic expenditure on medicine noticeably.

Germanys drug-reimbursement spending growth slowed to 1% in 2010, ollowing 4.8% growth in2009, driven mainly by the three-year reeze on drug prices and increase in mandatory discounts orinnovative drugs reimbursed by the unds, implemented in August 2010. We expect public healthspending to grow 1.7% in 2011 and 4.2% in 2012. Germany has a high generic penetration: 28% othe public health insurance market by value and 62% by volume in 2009. Discounts, a price reezeand high generic penetration will help decrease value-based drug sales and health spending. We expecttotal health spending growth to reach -1.1% in 2011 and 5.1% in 2012.

The French government is

aiming at containing health

spending growth below a

3% threshold and has cut

reimbursement for 200 drugs

to 15% (down from 35%).

The government plans to

increase forced discounts

on prescription drugs from

6% to 16% (a cost of around

EUR4 billion for the pharma

industry by 2013) and to

impose a three-year price

freeze on drug prices, until

31 December 2013.


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Chart 4: German Total Health Spending Growth

UK Continues Increases in Public Health Expenditure and Improves Access to

Medicines

e debt crisis and speculation about the possibility o sovereign deaults cast doubt on the resilienceo the UKs recovery. e country is acing weaker economic growth in 2012, as the growth outlookor its key trading partners has deteriorated substantially; recovery in the UK will thereore take longer.

We expect total health spending growth to reach 5.3% in 2011 and -3.3% in 2012.

Unlike most o its European neighbours, which are implementing cost-containment policies in a bid

to reduce expenditure, the UK government is actively seeking to bring expenditure levels more in linewith European norms. Ater years o under-unding, the UK government is now ploughing moneyinto the public healthcare system, with a continued rise in expenditure expected throughout the nextdecade. Continued increases in public health expenditure and a political push to improve access toinnovative medicines will have a positive impact on drug sales and public health spending or sometime to come. We expect public health spending growth to reach 1.9% in 2011 and -1.5% in 2012

Chart 5: UK Total Health Spending Growth

Unlike most of its European

neighbours, which are

implementing cost-

containment policies in a bid

to reduce expenditure, the

UK government is actively

seeking to bring expenditure

levels more in line with

European norms.


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Italy Introduces Austerity Measures

e Eurozone sovereign debt crisis has spread to Italy. e rising risk o contagion towards the coreo Europe pushed unding costs higher and induced the Italian government to commit to additionalausterity measures. e Italian government has approved new austerity measures worth EUR45.5 bil-lion to balance the public-sector budget by 2013. ese austerity measures, howevercoupled withother actors including slowing global demand and tighter credit conditionsare likely to trigger arecession in 2012.

Italy has made substantial reductions to generic and o-patent brand prices in order to encourage

higher generic utilisation and lower health-system costs. e Italian drug agency AIFA carried out ablanket cut in the price o thousands o reimbursed drugs, leading to reductions in state drug reim-bursement. Furthermore, eective in 2014, more co-payments will be charged to Italians or phar-maceuticals provided as part o public healthcare. e Italian governments austerity measuresbycutting spending or healthcare access, imposing high co-payments and reducing drug priceswillraise out-o-pocket (OOP) expenses and lower health spending and drug sales. We expect total healthspending to grow 0.8% in 2011 and 0.6% in 2012.

Chart 6: Italy Total Health Spending Growth

Spains Defcit Reduction and Cost-Containment Measures

Spains recovery prospects continue to be limited by very high unemployment, high debt levelsand an ongoing major correction in the construction sector. e rising risk o contagion towardsthe core European countries pushed unding costs higher and induced the Spanish government tocommit to additional austerity measures. e government raised value-added tax in 2010 as part oits fscal consolidation.

During 2010, several measures were taken in order to lower pharmaceutical expenditure. Spain madesubstantial reductions to generic and o-patent brand prices to encourage higher generic utilisationand lower health-system costs. ese measures will lower value-based drug sales and health spending.

We expect total health spending growth to reach 6.5% in 2011 and -0.1% in 2012.

Cost-Containment Measures in Czech Republic, Hungary and Slovakia

Compared with the major DM economies, Central Europe appeared to be aring better in terms oeconomic recovery. Despite ongoing fscal tightening, the Czech economy is expected to maintainits growth momentum, driven primarily by strong oreign demand. Hungarys recovery in economicactivity continues, driven mainly by inventory accumulation and external demand.

e global recession aected the Slovak economy to a greater extent than most other Organisation orEconomic Co-operation and Development countries, primarily owing to its exposure to world trade.In tandem with developments in its main trading partner economies, however, the economy is nowrecovering at an above-average pace.

Effective in 2014, more co-

payments will be charged to

Italians for pharmaceuticals

provided as part of public

healthcare.


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e Czech Republics introduction o fxed co-payments or prescriptions has resulted in a decline inthe volume o drug sales. e Czech government has also imposed a one-year 7% blanket price cut ora large group o drugs, coupled in many cases with a 7% reduction in reimbursement.

Hungary has introduced therapeutic reerence pricing or reimbursable drugs. e Hungarian govern-ment has introduced an amendment to the Pharma Economic Act, under which generics priced 40%higher than the benchmark price are automatically taken o the reimbursement list. Approximately406 reimbursed drugs in Hungary will eventually see their prices cut by up to 10%.

Slovakias cost-containment pressures and the desire to reorm the system have led the governmentto introduce patient co-payments, a reerence-pricing system and prescribing controls. e Slovakiangovernment also introduced an international reerence-pricing system, which means that drug pricesare reerenced to the average o the cheapest six markets in the EU.

Cost-containment measures in the Czech Republic, Hungary and Slovakiaby introducing fxed co-payments, cutting reerence prices and drug reimbursement expenditurewill raise OOP expensesand lower growth in drug sales and health spending going orward. We expect the combined totalhealth spending to grow 5.8% in 2011 and 4.8% in 2012.

Chart 7: Total Health Spending Growth in Czech Republic, Hungary and Slovakia

Impact o Developed Markets on Emerging Markets

e current slowdown in EM growth now looks set to be prolonged throughout 2012 by the weakerDM outlook. e EM will not do well i there is a US or European recession. A persistently higherination rate in the recent past is eroding consumers purchasing power and weakening consumption

growth. e stagation risk has risen, as the moderation in domestic demand growth is taking place ata time when exports have started to weaken again, amid a slowdown in the DM economies. However,EM giants such as China and India show better resilience than their respective regions.

Growth in Brazil will be a little lower than the downgrade or the region as a whole though. e goodnews is that policy-makers in the EM economies are moving in the right direction, initiating structuralchanges to boost domestic demand on a sustainable basis. ere are already signs that some orm oeasing is either under way or in the works in some large EM economies.

Chinas Healthcare Reorm

Amid the slowdown in the DM economies, the downside risks to growth will become a bigger concernthan upside risks to ination or China. Policy-makers are steadily initiating measures, such as a ruralpension scheme, provision o low-cost housing and increasing minimum wages. Fiscal policy willpossibly be more active. e increase in government spending is likely to ocus on supporting social-housing construction, selective inrastructure projects and incentives or boosting consumer spending.e recently announced income-tax cut or individuals and cuts in reserve requirements at the locallevel highlight a mild easing bias that may already be in place.

Hungary has

introduced therapeutic

reference pricing for

reimbursable drugs. The

Hungarian government

has introduced an

amendment to the

Pharma Economic Act,

under which generics

priced 40% higher than

the benchmark price are

automatically taken off

the reimbursement list.


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Benefting rom the three-year healthcare reorm due to be fnished by the end o 2011, 1.27 billionChinese are under medical insurance coverage, which will boost the insurance-coverage ratio to 95%,rom 15% o the total population a decade ago. To contain healthcare costs, the government imple-mented several drug-price cuts, lowering prices by 2030%.

e price cuts, especially on essential drugs, are likely to deepen even urther. Chinas healthcare re-ormthrough expanding medical-insurance coverage, upgrading grassroots medical institutions andsetting up the basic medicine systemshould translate into stronger growth in drug sales and healthspending, although the extent o growth may be limited by the governments steep drug-price cuts. We

expect total health spending to grow 16.6% in 2011 and 14.3% in 2012.

Chart 8: China Total Health Spending Growth

Indias Health-Insurance Coverage Expansion and Price ControlsIn India, investors ocus will shit rom upside risks to ination to downside risks to growth. A com-bination o actorsincluding persistently high ination, a higher cost o capital, a cut in fscal spend-ing, the weak global capital markets environment and a slow pace o investmentwill cause a urtherslowdown in growth or India. e government is likely to accelerate the policy reorms needed toboost private investment, including inrastructure projects.

Chart 9: India Total Health Spending Growth

We expect total health

spending in China to grow

16.6% in 2011 and 14.3%

in 2012.


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Indias latest initiativestaken by state governments to improve insurance coverage and aordabilityand access to healthcarewill help reduce OOP expenditure or benefciaries and lead to increaseddemand or pharmaceuticals. e consumption o drugs is expected to boom over the long haul, asthe nations middle class expands. In the short-to-medium term, drug pricing controls are expectedto persist and will continue to eature as a policy initiative. Indian drug regulators latest price-controlmeasures coupled with health-insurance coverage expansionwill reduce OOP expenses and boosthealth spending and volume-based drug sales. We expect total health spending to grow 12.0% in 2011and 11.3% in 2012.

Brazils Rising Domestic Drug Production and Lowered Drug Prices

Brazil is currently acing a weaker-than-expected global environment than a ew months ago. ecountrys labour markets are showing some signs o moderation, but remain airly robust, ensuring astable demand or health spending and drugs. We expect total health spending to grow 20.7% in 2011and 15.0% in 2012.

Brazils drug companies are planning to increase their research and development and bring their ownpatented drugs or domestic and oreign markets. e government is considering investing USD890million on new drugs, vaccines and medical-technology research or the 201115 period. Generic-drug sales are expected to grow aster than the overall branded pharmacy sector and are likely to ac-count or more than 20% o the market by end-2011, which will erode the market share o innovativedrugs. e Brazilian governments eortsby boosting the drug production o domestic manuactur-

ers, hence shrinking the share o more expensive imported drugs, and by reducing drug prices throughdirect negotiation with multinational drug makerswill decrease drug prices.

Chart 10: Brazil Total Health Spending Growth

Outlook and Implications

ere is going to be a long wait or a recovery in the DM, as fscal austerity programmes are beingimplemented at the very moment that economic growth has disappeared. Reecting governmenthealthcare cost-containment agenda, pharmaceutical products are increasingly subject to strict pricingand reimbursement conditions in many European countries, and it is widely believed that the US isollowing suit. ere is no mistaking the adverse macro impact o pricing and reimbursement regu-lation on growth in drug sales and health spending going orward. In addition, there is the adversemicro consequence that pricing and reimbursement regulation may have on pharmaceutical innova-tion, by reducing the value o pharmaceutical projects and by curtailing the resources available to carrythem out. Meanwhile, strong growth in health spending looks set to continue in the EM, driven by

strong economic growth and an increasingly accommodative policy stance, the negative externality othe DM stalling growth notwithstanding.

Indian drug regulators

latest price-control

measures coupled with

health-insurance coverage

expansionwill reduce OOP

expenses and boost health

spending and volume-based

drug sales.

Generic-drug sales are

expected to grow faster

than the overall branded

pharmacy sector and are

likely to account for more

than 20% of the market

by end-2011, which will

erode the market share of

innovative drugs.


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Meet the Expert:

Jing Zhang,Healthcare Economist, IHS

Jing Zhang is a healthcare

economist at IHS, responsible orhealthcare and pharma orecastand analysis. He leads the WorldMarkets Healthcare ForecastingService. Jing holds a Ph. Ddegree in economics rom TempleUniversity. Beore joining IHS,

Jing worked as an economistin the ederal government atFDIC, National Credit Union

Administration and IRS.

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Healthcare Forecasts Amidst Global Economic Turmoil