Healthcare forecasts amidst_global_economic_turmoil

World Markets Healthcare Forecasting Special Report

Healthcare Forecasts Amidst Global Economic Turmoil:
Recession–Proof or Leaking Roof?
First published November 2011

Report Author
Jing Zhang
Healthcare Economist
IHS

Healthcare Forecasts Amidst Global Economic Turmoil: Recession-Proof or Leaking Roof?

Contents:
Key findings 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

The 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

Spain’s Deficit 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 of Developed Markets on Emerging Markets 9

China’s Healthcare Reform 9

Chart 8: China Total Health Spending Growth 10

India’s Health-Insurance Coverage Expansion and Price Controls 10

Chart 9: India Total Health Spending Growth 10

Brazil’s 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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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
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2


Key findings:

• In parallel with the great divide between emerging and developed markets in terms of
GDP growth, there is also a divide in their health spending. Health spending growth will
continue to be strong in the emerging market economies while weakening in the
developed market economies, going forward.

• A slow economy and high unemployment—plus reform initiatives—are among the
factors expected to affect US health spending adversely in the short and medium term,
while Medicare expenditure will be a major factor in the long term.

• 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 German healthcare system has undergone considerable reform over the past decade,
as the government seeks to contain spiralling costs, particularly in terms of expenditure
on pharmaceuticals.

• The Italian government’s austerity measures—cutting spending for healthcare access,
imposing high co-payments and reducing drug prices—will raise out-of-pocket (OOP)
expenses while lowering health spending and drug sales.

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

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

• Cost-containment measures in the Czech Republic, Hungary and Slovakia—introducing
fixed co-payments while cutting reference prices and drug reimbursement expenditure
will raise OOP expenses and lower growth in drug sales and health spending going forward.

• India and China’s healthcare reforms—including expanding medical insurance
coverage—should translate into stronger growth in drug sales and health spending.

• The Brazilian government’s efforts—boosting domestic manufacturers’ drug production,
hence shrinking the share of more expensive imported drugs; and reducing drug prices
through direct negotiation with multinational drug makers—will decrease drug prices.

Introduction:
The global economy is being dragged down by Europe and the United States. Markets are crashing
because fiscal austerity programmes are being implemented at the very moment that economic growth
has disappeared. Although IHS Global Insight had been anticipating what Morgan Stanley has called
a “bumpy, below-par and brittle” (BBB) recovery in the developed markets (DM), the path now looks
even more “BBB”.

If growth in the first half offers any clues, the US and the euro area will be dangerously close to reces-
sion over the next several quarters. The risks to global recovery include oil prices (should unrest in
the Middle East and North Africa spread to the big oil-producing countries) and altering growth in
emerging markets (EM). The single biggest risk facing both the US and Europe, however, is a policy
mistake, specifically an advertent or inadvertent tightening of policy.

EM economies will not be immune to the DM slowdown, even though the great EM-DM growth
divide continues. Although EM GDP keeps cruising above its 20-year trend rate of 5%, there is a
significant further cooling of growth compared with last year’s bonanza. The current slowdown in EM
growth now looks set to be prolonged into 2012 by the weaker DM outlook. Despite slowing growth,
however, EM economies—which account for half of global GDP (using purchasing power parity
“Health-spending growth will
weights)—will generate fully 80% of global GDP growth for 2011–12. continue to be strong in the
EM economies, especially
There is a DM-EM divide in health spending as well. Health-spending growth will continue to be
strong in the EM economies, especially in India and China, largely because of healthcare reform and
in India and China, largely
high GDP growth, while weakening in the DM economies will be driven by anaemic economy and because of healthcare reform
cost-containment measures, including higher generic utilisation, higher co-payments and cuts in drug and high GDP growth.”
pricing and reimbursement.

3


Generics are identified 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 the
spending growth in the G7 economies (France, Germany, Italy, Japan, the UK, US and Canada) with
that of the BRIC5 economies (Brazil, Russia, India, China and South Africa). We expect spending in
the 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
The US economy is now at stall speed, with the prospect of adverse shocks from a European financial
crisis, spikes in oil prices and confidence declines on the part of businesses and households. The disap-
pointment in the first half—with GDP up by an annual average rate of less than 1%—illustrates the
brittleness of the US recovery in the face of external shocks (oil, Japan’s earthquake), despite ongoing
quantitative easing and fiscal stimulus at the time.

The economy is idling, waiting for the usual drivers of recovery—housing and consumer spending—to
catch up. It is going to be a long wait, given the persistently high unemployment rate. Small business,
which employs over half of all private-sector employees, saw its August optimism index fall to the lowest
level since July 2010. Small businesses’ outlook on the economy and better sales has plunged. The odds of
a 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 reform initiatives, are among the factors expected to
affect US health spending adversely in the short and medium term. The persistent issue of cost con- “A slow economy and high
tainment poses the greatest concern to the innovative pharmaceutical industry. Pricing pressures are unemployment, plus reform
only likely to increase in the future as employers and the US government—which will take a more
active role as a third-party payor in the health-insurance market—demand that health insurers reduce initiatives, are among the
their burden of healthcare costs through aggressive cost-containment strategies. The use of tiered co- factors expected to affect US
payments and step therapy programmes, which promote lower costs and generic drugs, has rapidly health spending adversely in
grown over the past three years.
the short and medium term.”
Other measures, such as increasing disclosure requirements of spread amounts, rebates, discounts and
generics dispensation for Pharmacy Benefit Managers will further dampen sentiment in the industry.
In 2012, the reform process will move ahead with norms on annual fees on the pharmaceutical indus-
try, value-based purchasing for Medicare, health insurance exchanges and renewed efforts to reduce
healthcare disparities. Health insurance exchanges are set to be operational in two years’ time. Through
the health reform, the US government is aiming to reduce the number of uninsured from almost 20%
of the population to just 8% in the next five years. This will expand the insurance market and add to
the rise in health expenditure.

4


We expect total health spending to grow 4.7% in 2011 and 5.0% in 2012. As Congress opens a po-
litically charged exploration of ways to pare the deficit, President Barack Obama is expected to seek
USD300 billion to USD500 billion of savings over 10 years in Medicare and Medicaid. If approved,
this will hurt healthcare demand and public health spending going forward. We expect public health
spending 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 factor affecting US health spending. The
Budget Control Act enables a short reprieve for Medicare until the bipartisan committee announces
its savings measures, which will inevitably include Medicare and, to a much lesser extent, if at all,
Medicaid. The direct impact of the legislation will be felt by treatment providers, primarily due to
payment cuts.

Along with the considerations of raising eligibility (e.g. for Medicare beneficiaries to 67 years from 65)
and a means test, the committee is also expected to consider a much larger focus on pharmaceutical
product prices and treatment costs.

For fiscal year 2012, Social Security and Medicare account for the largest mandatory expenditure
programmes, with Social Security at USD761 billion and Medicare at USD468 billion. Medicaid is “For fiscal year 2012,
lower, at USD269 billion. Furthermore, Medicare expenditure accounted for 3.3% of GDP in 2010, Social Security and
and that figure is expected to increase to over 5% by 2035. The projected low growth in Medicare
expenditure will help contain growth in total health spending and drug sales during the period. Medicare account for
the largest mandatory
expenditure programmes,
The Eurozone: The Weakest Link
Despite the problems in the US, the Eurozone is clearly the weakest link in the global chain. While with Social Security at
the crisis was unfolding, the outlook for domestic growth and the sovereign debt crisis in the Eurozone USD761 billion and
were both worsening. Part of the concern is deteriorating fiscal balances due to weak growth. A big- Medicare at USD468 billion.”
ger worry is the fragility of the banking systems and the large exposure to sovereign debt. Eurozone
economic activity has already had to cope with the fact that fiscal policy is becoming increasingly
restrictive across the Eurozone during 2011.

Debt-encumbered economies such as Spain and Italy have to take the strongest action to improve
their public finances, while other countries, including France, have also come under serious pressure
to bite the fiscal bullet harder. Germany is also tightening fiscal policy in 2011, albeit to a limited
extent. Looking ahead, recurrent serious Eurozone sovereign debt tensions are likely to continue to
weigh down growth periodically by damaging confidence and pushing up market interest rates for the
vulnerable countries in the area.

5


France Implements P&R Cuts
The Eurozone sovereign debt crisis has threatened France. The economy endured surprise falls in con- “The French government is
sumer spending during the second quarter. The rising risk of contagion towards the core of Europe aiming at containing health
pushed funding costs higher and induced the French government to commit to additional austerity
spending growth below a
measures. As part of its austerity strategy, it has had extensive use of emergency measures—including
price and reimbursement cuts—to contain growth in drug sales and health spending. 3% threshold and has cut
reimbursement for 200 drugs
The government is aiming at containing health spending growth below a 3% threshold and has cut
to 15% (down from 35%).”
reimbursement for 200 drugs to 15% (down from 35%); the French statutory health insurer has an-
nounced price cuts for patented and generic drugs; and generics launched from 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 faltered in Germany,
reflecting the unsettling impact of the Eurozone debt crisis. German growth will stay fairly weak dur-
ing the second half of 2011. Like France, Germany is also tightening fiscal policy in 2011, albeit to a
limited extent.

The German healthcare system has undergone considerable reform over the past decade as the gov-
ernment seeks to contain spiralling costs, particularly in terms of expenditure on pharmaceuticals.
The government plans to increase forced discounts on prescription drugs from 6% to 16% (a cost “The government plans to
of around EUR4 billion for the pharma industry by 2013) and to impose a three-year price freeze increase forced discounts
on drug prices, until 31 December 2013. The latest policy changes are expected to reduce growth of
on prescription drugs from
public expenditure on medicine noticeably.
6% to 16% (a cost of around
Germany’s drug-reimbursement spending growth slowed to 1% in 2010, following 4.8% growth in EUR4 billion for the pharma
2009, driven mainly by the three-year freeze on drug prices and increase in mandatory discounts for
industry by 2013) and to
innovative drugs reimbursed by the funds, implemented in August 2010. We expect public health
spending to grow 1.7% in 2011 and 4.2% in 2012. Germany has a high generic penetration: 28% of impose a three-year price
the public health insurance market by value and 62% by volume in 2009. Discounts, a price freeze freeze on drug prices, until
and high generic penetration will help decrease value-based drug sales and health spending. We expect
31 December 2013.”
total health spending growth to reach -1.1% in 2011 and 5.1% in 2012.

6


Chart 4: German Total Health Spending Growth

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

The debt crisis and speculation about the possibility of sovereign defaults cast doubt on the resilience
of the UK’s recovery. The country is facing weaker economic growth in 2012, as the growth outlook “Unlike most of its European
for its key trading partners has deteriorated substantially; recovery in the UK will therefore take longer.
We expect total health spending growth to reach 5.3% in 2011 and -3.3% in 2012. neighbours, which are
implementing cost-
Unlike most of its European neighbours, which are implementing cost-containment policies in a bid containment policies in a bid
to reduce expenditure, the UK government is actively seeking to bring expenditure levels more in line
with European norms. After years of under-funding, the UK government is now ploughing money to reduce expenditure, the
into the public healthcare system, with a continued rise in expenditure expected throughout the next UK government is actively
decade. Continued increases in public health expenditure and a political push to improve access to seeking to bring expenditure
innovative medicines will have a positive impact on drug sales and public health spending for some
time to come. We expect public health spending growth to reach 1.9% in 2011 and -1.5% in 2012 levels more in line with
European norms.”
Chart 5: UK Total Health Spending Growth

7


Italy Introduces Austerity Measures
The Eurozone sovereign debt crisis has spread to Italy. The rising risk of contagion towards the core
of Europe pushed funding costs higher and induced the Italian government to commit to additional
austerity measures. The Italian government has approved new austerity measures worth EUR45.5 bil-
lion to balance the public-sector budget by 2013. These austerity measures, however—coupled with
other factors including slowing global demand and tighter credit conditions—are likely to trigger a
recession in 2012.

Italy has made substantial reductions to generic and off-patent brand prices in order to encourage
higher generic utilisation and lower health-system costs. The Italian drug agency AIFA carried out a “Effective in 2014, more co-
blanket cut in the price of thousands of reimbursed drugs, leading to reductions in state drug reim- payments will be charged to
bursement. Furthermore, effective in 2014, more co-payments will be charged to Italians for phar- Italians for pharmaceuticals
maceuticals provided as part of public healthcare. The Italian government’s austerity measures—by
cutting spending for healthcare access, imposing high co-payments and reducing drug prices—will provided as part of public
raise out-of-pocket (OOP) expenses and lower health spending and drug sales. We expect total health healthcare.”
spending to grow 0.8% in 2011 and 0.6% in 2012.

Chart 6: Italy Total Health Spending Growth

Spain’s Deficit Reduction and Cost-Containment Measures
Spain’s recovery prospects continue to be limited by very high unemployment, high debt levels
and an ongoing major correction in the construction sector. The rising risk of contagion towards
the core European countries pushed funding costs higher and induced the Spanish government to
commit to additional austerity measures. The government raised value-added tax in 2010 as part of
its fiscal consolidation.

During 2010, several measures were taken in order to lower pharmaceutical expenditure. Spain made
substantial reductions to generic and off-patent brand prices to encourage higher generic utilisation
and lower health-system costs. These 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 faring better in terms of
economic recovery. Despite ongoing fiscal tightening, the Czech economy is expected to maintain
its growth momentum, driven primarily by strong foreign demand. Hungary’s recovery in economic
activity continues, driven mainly by inventory accumulation and external demand.

The global recession affected the Slovak economy to a greater extent than most other Organisation for
Economic 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 now
recovering at an above-average pace.

8


The Czech Republic’s introduction of fixed co-payments for prescriptions has resulted in a decline in
the volume of drug sales. The Czech government has also imposed a one-year 7% blanket price cut for “Hungary has
a large group of drugs, coupled in many cases with a 7% reduction in reimbursement. introduced therapeutic
reference pricing for
Hungary has introduced therapeutic reference pricing for reimbursable drugs. The Hungarian govern-
ment has introduced an amendment to the Pharma Economic Act, under which generics priced 40% reimbursable drugs. The
higher than the benchmark price are automatically taken off the reimbursement list. Approximately Hungarian government
406 reimbursed drugs in Hungary will eventually see their prices cut by up to 10%.
has introduced an
Slovakia’s cost-containment pressures and the desire to reform the system have led the government amendment to the
to introduce patient co-payments, a reference-pricing system and prescribing controls. The Slovakian Pharma Economic Act,
government also introduced an international reference-pricing system, which means that drug prices
under which generics
are referenced to the average of the cheapest six markets in the EU.
priced 40% higher than
Cost-containment measures in the Czech Republic, Hungary and Slovakia—by introducing fixed co- the benchmark price are
payments, cutting reference prices and drug reimbursement expenditure—will raise OOP expenses
automatically taken off
and lower growth in drug sales and health spending going forward. We expect the combined total
health spending to grow 5.8% in 2011 and 4.8% in 2012. the reimbursement list.”

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

Impact of Developed Markets on Emerging Markets
The current slowdown in EM growth now looks set to be prolonged throughout 2012 by the weaker
DM outlook. The EM will not do well if there is a US or European recession. A persistently higher
inflation rate in the recent past is eroding consumers’ purchasing power and weakening consumption
growth. The stagflation risk has risen, as the moderation in domestic demand growth is taking place at
a 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 for the region as a whole though. The good
news is that policy-makers in the EM economies are moving in the right direction, initiating structural
changes to boost domestic demand on a sustainable basis. There are already signs that some form of
easing is either under way or in the works in some large EM economies.

China’s Healthcare Reform
Amid the slowdown in the DM economies, the downside risks to growth will become a bigger concern
than upside risks to inflation for China. Policy-makers are steadily initiating measures, such as a rural
pension scheme, provision of low-cost housing and increasing minimum wages. Fiscal policy will
possibly be more active. The increase in government spending is likely to focus on supporting social-
housing construction, selective infrastructure projects and incentives for boosting consumer spending.
The recently announced income-tax cut for individuals and cuts in reserve requirements at the local
level highlight a mild easing bias that may already be in place.

9


Benefiting from the three-year healthcare reform due to be finished by the end of 2011, 1.27 billion
Chinese are under medical insurance coverage, which will boost the insurance-coverage ratio to 95%, “We expect total health
from 15% of the total population a decade ago. To contain healthcare costs, the government imple- spending in China to grow
mented several drug-price cuts, lowering prices by 20–30%.
16.6% in 2011 and 14.3%
The price cuts, especially on essential drugs, are likely to deepen even further. China’s healthcare re- in 2012.”
form—through expanding medical-insurance coverage, upgrading grassroots medical institutions and
setting up the basic medicine system—should translate into stronger growth in drug sales and health
spending, although the extent of growth may be limited by the government’s 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

India’s Health-Insurance Coverage Expansion and Price Controls
In India, investors’ focus will shift from upside risks to inflation to downside risks to growth. A com-
bination of factors—including persistently high inflation, a higher cost of capital, a cut in fiscal spend-
ing, the weak global capital markets environment and a slow pace of investment—will cause a further
slowdown in growth for India. The government is likely to accelerate the policy reforms needed to
boost private investment, including infrastructure projects.

Chart 9: India Total Health Spending Growth

10


India’s latest initiatives—taken by state governments to improve insurance coverage and affordability
and access to healthcare—will help reduce OOP expenditure for beneficiaries and lead to increased “Indian drug regulator’s
demand for pharmaceuticals. The consumption of drugs is expected to boom over the long haul, as latest price-control
the nation’s middle class expands. In the short-to-medium term, drug pricing controls are expected
to persist and will continue to feature as a policy initiative. Indian drug regulator’s latest price-control
measures coupled with
measures coupled with health-insurance coverage expansion—will reduce OOP expenses and boost health-insurance coverage
health spending and volume-based drug sales. We expect total health spending to grow 12.0% in 2011 expansion—will reduce OOP
and 11.3% in 2012.
expenses and boost health
spending and volume-based
Brazil’s Rising Domestic Drug Production and Lowered Drug Prices drug sales.”
Brazil is currently facing a weaker-than-expected global environment than a few months ago. The
country’s labour markets are showing some signs of moderation, but remain fairly robust, ensuring a
stable demand for health spending and drugs. We expect total health spending to grow 20.7% in 2011
and 15.0% in 2012.

Brazil’s drug companies are planning to increase their research and development and bring their own
patented drugs for domestic and foreign markets. The government is considering investing USD890
million on new drugs, vaccines and medical-technology research for the 2011–15 period. Generic-
drug sales are expected to grow faster than the overall branded pharmacy sector and are likely to ac-
count for more than 20% of the market by end-2011, which will erode the market share of innovative
drugs. The Brazilian government’s efforts—by boosting the drug production of domestic manufactur-
ers, hence shrinking the share of more expensive imported drugs, and by reducing drug prices through
direct negotiation with multinational drug makers—will decrease drug prices.

Chart 10: Brazil Total Health Spending Growth

“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.”

Outlook and Implications
There is going to be a long wait for a recovery in the DM, as fiscal austerity programmes are being
implemented at the very moment that economic growth has disappeared. Reflecting government
healthcare cost-containment agenda, pharmaceutical products are increasingly subject to strict pricing
and reimbursement conditions in many European countries, and it is widely believed that the US is
following suit. There is no mistaking the adverse macro impact of pricing and reimbursement regu-
lation on growth in drug sales and health spending going forward. In addition, there is the adverse
micro consequence that pricing and reimbursement regulation may have on pharmaceutical innova-
tion, by reducing the value of pharmaceutical projects and by curtailing the resources available to carry
them 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 of
the DM stalling growth notwithstanding.

11


Meet the Expert:
World Markets Healthcare Forecasting Service
Jing Zhang,
Healthcare Economist, IHS
In this environment of rising healthcare costs, post-recession strapped
budgets, and complicated regulations, do you have a clear view on global Jing Zhang is a healthcare
economist at IHS, responsible for
healthcare and pharmaceutical expenditure and sales in the near term? healthcare and pharma forecast
and analysis. He leads the World
The World Markets Healthcare Forecasting Service (WMHCF) provides a Markets Healthcare Forecasting
Service. Jing holds a Ph. D
comprehensive view of healthcare markets, their key drivers, and the market degree in economics from Temple
impact of key events. Featuring a forecast database and primary research, University. Before joining IHS,
the service gives you the tools you need to quantify future market growth. Jing worked as an economist
in the federal government at
WMHFS brings you clarity on these uncertain markets through: FDIC, National Credit Union
Administration and IRS.
• Macroeconomic forecasts
• Quarterly updated database:
• Ten-year expenditure forecasts for 36 countries
• Pharmaceutical sales forecasts for 30 countries and 11 therapeutic areas

The service helps you:

• Plan sales and budgets with greater accuracy
• Identify market growth opportunities and quantify market size
• Hedge exposure to contracting markets
• Understand what drives healthcare market forecasts

Learn more about the World Markets Healthcare
Forecasting Service at www.ihs.com/healthcare
or use your smart phone to scan the QR code:

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