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Healthcare in a Recession (OTC, Generics, Out of Pocket Spending,
Healthcare Legislation, Retail Clinics, Outsourcing and Other Topics)
April 1, 2009
Current economic conditions dominate business strategies. While healthcare has fared
better than other industries, it will not be immune from the effects of the current
recession. But what aspects of healthcare will be impacted? How much of spending will
be out of the consumer's pocket? How will some novel trends (retail clinics, medical
tourism) fit into this economy? It is commonly asserted that OTC and generic drugs
sales will be boosted. Will this pan out? What will be the possible effects of various
types of healthcare plans that might be implemented?
In Healthcare in a Recession,Kalorama Information has examined all of the key medical
markets in the past and has witnessed change and in some sector's profits due to
economic conditions. Kalorama has consulted its experts in key areas and asked about
the effect of the recession. This report takes a broad look at the healthcare market in a
recession from the many areas of healthcare that have changed or will changed.
Specifically the report address:
The State of the Pharmaceutical Industry
Outsourcing and Offshoring
Generic Drugs: A Coming Boom?
Over the Counter Drugs
Possible impact of Healthcare Legislation
Out of Pocket Healthcare Spending: Current and Future
The Retail Clinic Phenomenon
Availability of Health Insurance
Medical Tourism: Boom or Bust?
Influential Pharmacists
As part of its research, Kalorama has profiled and detailed the activities of several
companies in the pharmaceutical, retail, healthcare financing and information
technology fields that likely to play some role in the healthcare economy of 2009:
APFUSA
Atlantic Care
Aurora Quick Care
Capitol One Healthcare Finance

2. Care Credit
Cerner Corporation
Credit Medical
CSI Financial Services
E- Financing Solutions
GlaxoSmithKline
Hospira Inc.
Med Basics
McKesson Corporation
Medco Health Solutions, Inc.
Merck & Co. Inc
Med choice Financial
MedDirect
Minute Clinic
Novartis
My Healthy Access
Now Medical Centers
PFS
Quick Health
Rediclinic
Reliance Medical Finance
Solantic
Take Care Health Systems
Target Clinic Medical Associates
TEVA Pharmaceutical Industries, Ltd.
Wyeth (Pfizer)
Siemens Medical Solutions
Wal - Mart
TABLE OF CONTENTS
CHAPTER ONE: EXECUTIVE SUMMARY
Out of Pocket Spending
Healthcare Legislation
State of the Pharmaceutical Industry, 2009 • Meeting Investor Expectations •
Erosion of Blockbuster Sales • Increased Generic Competition • Pricing
Pressures • Pipeline Output Slowing Compared to ROI • Mergers &Aquisitions
Retail Clinics
OTC/Generic Drugs
CHAPTER TWO: INTRODUCTION
The U.S. Healthcare System Today

3. Overview THE NEED FOR ALTERNATIVES
High Cost of Care
Healthcare Reform
CHAPTER THREE: OUT-OF-POCKET EXPENDITURES: THE MARKET IN 2009
Types of Expenditures
Insurance Co-Payments
Direct Payments
Premiums and Plan Fees
Cash or Check
Credit Cards
Loans and Lines of Credit
Flexible Spending Accounts
Health Savings Accounts
Medical Financing
Elective Procedures
Non-Elective Procedures and Prescription Drugs Consumers Who Pay Out Of
Pocket
The Uninsured and Underinsured
Medicaid Recipients
The Disabled
Senior Citizens
The Mentally Ill
The Obese
Persons with Chronic Conditions
CHAPTER FOUR: OUT-OF-POCKET EXPENDITURES: THE MARKET IN 2009 - 2013
Out-of-pocket Expenditure Growth Drivers
Payment Methods
Consumers Who Pay Out-of-pocket
CHAPTER FIVE: OVER THE COUNTER DRUGS: IN POSITION
United States Market
OTC and Recession: Avoiding the Copay
Behind the Counter Drugs?
CHAPTER SIX: INFLUENTIAL PHARMACISTS
Markets - Pharmacists Impact
The Prescribing Pharmacist
Main Drivers For Increased Pharmacist Prescription Authority
CHAPTER SEVEN: MEDICAL TOURISM: BOOM OR BUST?

4. Motivations for Medical Tourism
Impact of Recession
True Medical Tourism vs. All Healthcare for Foreigners
CHAPTER EIGHT: STATE OF THE PHARMACEUTICAL MARKET: OFFSHORING
AND OUTSOURCING
Meeting Investor Expectations
Erosion of Blockbuster Sales
Increased Generic Competition
Pricing Pressures
Pipeline Output Slowing Compared to ROI
M&A Offshoring Clinical Trials
Size and Growth of the Market
Outsourcing: No Longer Optional For Pharma
Strategic Outsourcing
Outsourcing Manufacturing Operations
CHAPTER NINE: GENERIC DRUGS: COMING BOOM?
Overview
Issues in Generics
CHAPTER TEN: RETAIL CLINICS
Retail Clinics Business
Competition with Primary Care Providers
Regulation
CHAPTER ELEVEN: IMPACT OF HEALTHCARE LEGISLATION
Overview
Change for Pharma
Focus on Cost - Cutting
Healthcare Reform
CHAPTER TWELVE: COMPANY PROFILES
APFUSA
Atlantic Care
Aurora Quick Care
Capitol One Healthcare Finance
Care Credit
Cerner Corporation
Products and Service
Key Competitors

5. Credit Medical
CSI Financial Services
E- Financing Solutions
GlaxoSmithKline
History and Lines of Business
Strategic Alliances
Vaccine Products
OTC Products
Financial Information
Hospira Inc.
Med Basics
McKesson Corporation
Company Overview
Products and Service
Medco Health Solutions, Inc.
Merck & Co. Inc
History and Lines of Business
Strategic Alliances
Vaccine Products
Financial Information
Med choice Financial
MedDirect
Minute Clinic
Novartis
History and Lines of Business
Strategic Alliances
Vaccine Products
My Healthy Access
Now Medical Centers
Pfs
Quick Health
Rediclinic
Reliance Medical Finance
Solantic
Take Care Health Systems
Target Clinic Medical Associates
TEVA Pharmaceutical Industries, Ltd.
Wyeth (Pfizer)
History and Lines of Business
Vaccine Products
OTC Products
Financial Information
Siemens Medical Solutions
Key Competitors
Growth Strategy
Locations

6. Wal - Mart
LIST OF EXHIBITS CHAPTER TWO: INTRODUCTION
Figure 2-1:National Health Expenditures (NHE) and NHE as a Percent of GDP,
1980 - 2013
Figure 2-2: Unnecessary Deaths Resulting From Variations in Health Care
Quality, by Condition (Prenatal Care, Diabetes Care, Beta Blocker Treatment,
Breast Cancer Screening, Cholesterol Management, High Blood Pressure,
Diabetes)
Figure 2-3:HEDIS Scores by Quality of Health Care Plan, 2008
Table 2-1: U.S. Health Care Coverage by State, 2008
CHAPTER THREE: OUT-OF-POCKET EXPENDITURES THE MARKET IN 2009
Figure 3-1:Premium Increases vs. Increases in Workers Earnings and Prices,
1989 - 2008
Figure 3-2: Consumer Out-of-pocket Health Care Expenditures,
Figure 3-3:Consumer Out-of-pocket Health Care Expenditures by Payment
Type,2008
Table 3-1: Credit Card Debt of Consumers With Medical Debt, 2007
Table 3-2: Credit Card Debt of Consumers With Medical Debt, 2007
Table 3-3: Main Business Activities of Selected Medical Financing Companies,
Figure 3-4:by Percentile of Total Health Spending,
Figure 3-5:Methods of Financing Elective Procedures,
Figure 3-6: Average Share Paid Out-of-pocket by U.S. Residents with Health
Care Spending by Type of Service, 2008
Figure 3-7: by Percentile of Total Health Spending and Type of Service, 2008
Figure 3-8: Distribution of Out-of-pocket Spending on Non-Elective Procedures
for the Average Person, 2008
Figure 3-9: Distribution of Out-of-pocket Spending for the Average Person, by
Spending Level, 2008
Figure 3-10: Drug Cost Coverage by Payor Type (Public, Private, Cash) 1965,
1986, 2000, 2004, 2008
Table 3-4: Obesity in the United States, 1980 - 2013
Figure 3-11: Proportion of Adults Under Age 65 With Chronic Conditions, 2008
CHAPTER FOUR: FORECASTED OUT-OF-POCKET EXPENDITURES: THE MARKET
IN 2009 - 2013
Table 4-1: Selected Rx-to-OTC Switches in the United States, 1990 - Present
Table 4-2: Rx-to-OTC Switch Candidates in the United States, 2009 - 2013
Table 4-3: Consumer Out-of-pocket Expenditures per Worker 2003-2013 (in $)
Table 4-4: Consumer Out-of-pocket Expenditures by Type, 2003-2013
Figure 4-1: Proportion of Consumer Out-of-pocket Spending by Type of Health
Care Expenditure

7. Table 4-5: Consumer Out-of-pocket Expenditures by Type, 2001-2011
Figure 4-2: Proportion of Consumer Out-of-pocket Spending by Payment Type,
2003, 2008, 2013
Table 4-6: Amount of Consumer Out-of-pocket Expenditures for Elective
Procedures That Are Financed, 2003-2013
Table 4-7: Amount of Consumer Out-of-pocket Expenditures for Non-Elective
Procedures That Are Financed, 2001-2011
Figure 4-3: Proportion of Consumer Out-of-pocket Spending for Elective
ProceduresThat is Financed (All Methods),
Figure 4-4: Distribution of Out-of-pocket Spending on Non-Elective Procedures
for the Average Person, 2008, 2013
Figure 4-5: Proportion of Consumer Out-of-pocket Spending for Non-Elective
Procedures That is Financed (All Methods),2008 - 2013
Table 4-8: Size of High Risk Groups for High Out-of-pocket Health Care
Expenditures, 2003-2013 (Millions of Persons)
CHAPTER FIVE: OVER THE COUNTER DRUGS: IN POSITION
Table 5-1: Projected US OTC Revenues 2008-2012
CHAPTER SIX: INFLUENTIAL PHARMACISTS
Figure 6-1: Declining Drug Purchases Not Influenced By Pharmacists, 2006-2012
Table 6-1: Pharmacists Influence in Drug Selection and/or Therapy Aspect: 2007
and 2012
Table 6-2: States Likely to Implement Independent Prescribing First
CHAPTER SEVEN: MEDICAL TOURISM: BOOM OR BUST?
Table 7-1: Cost Savings From Medical Tourism For Various Procedures, 2008
Figure 7-1: US ‘True Medical Tourism’ Revenues, 2008, 2010
CHAPTER EIGHT: STATE OF THE PHARMACEUTICAL MARKET,: OFFSHORING
AND OUTSOURCING
Table 8-1: Clinical Trial Market in Select Countries 2006-2012
Table 8-2: Global Prescription Pharmaceutical Contract Manufacturing Market
Primary, Secondary and Biomanufacturing 2003-2013
CHAPTER NINE: GENERIC DRUGS: COMING BOOM?
Table 9-1: US Generic Drug Market 2008-2012
CHAPTER TEN: RETAIL CLINICS
Figure 10-1: Growth of U.S. Retail Clinic Services

8. CHAPTER ELEVEN: IMPACT OF HEALTHCARE LEGISLATION
Table 11-1: Likely Impact of Events and Proposed Legislation (Propsed Change,
Probability, Positive Impact, Negative Impact)
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