HOSPITAL DRUG MARK-UPS IN THE UNITED STATES: A SYSTEMATIC REVIEW OF ACADEMIC AND POLICY LITERATURE
Author(s)
Ulrich Neumann, MSc, MBA, MA1, Chang Xu, MS2, Kwame Adjei, PharmD, PhD3;
1Johnson and Johnson, Center for US Healthcare Policy Research, Titusville, NJ, USA, 2Johnson and Johnson, Scientific Evidence and Policy Research, Titusville, NJ, USA, 3Rutgers University, Center for Health Outcomes, Policy, and Economics, New Brunswick, NJ, USA
1Johnson and Johnson, Center for US Healthcare Policy Research, Titusville, NJ, USA, 2Johnson and Johnson, Scientific Evidence and Policy Research, Titusville, NJ, USA, 3Rutgers University, Center for Health Outcomes, Policy, and Economics, New Brunswick, NJ, USA
OBJECTIVES: Synthesize evidence on hospital mark-up practices for hospital-acquired drugs in the United States, including magnitude, variation by facility type, and policy implications.
METHODS: A systematic review under PRISMA guidelines with parallel searches of peer-reviewed and grey-literature sources (Jan 1, 2015-Nov 12, 2025). Peer-reviewed searches covered PubMed, Embase, EconLit, EBSCOhost, Scopus, and Web of Science. Grey-literature searches included government reports, transparency databases, and think-tank analyses. Studies were eligible if they reported quantitative estimates of the difference between hospital acquisition cost and billed or reimbursement price in the U.S.; studies of pricing without hospital acquisition were excluded. Two reviewers independently screened records and extracted data on study design, pricing metrics, mark-up calculations, drivers, limitations, and recommendations. Study quality was assessed using PRISMA-based criteria and findings were summarized.
RESULTS: Database searches identified 1,821 records, yielding 1,029 unique articles after deduplication; grey-literature searches returned over 4,000 records. After screening, 34 records met inclusion criteria (15 peer-reviewed and 19 grey literature). Study-reported hospital drug mark-ups ranged from near cost parity (<10% increase) to over 1,000%, with one analysis finding 1,402% (i.e. 15x). A site-of-care comparison showed median mark-ups lowest in independent physician offices (~12%) and substantially higher in hospital outpatient departments, with 340B hospitals exhibiting the greatest mark-ups (~208%) compared to non-340B hospitals (~144%). Therapeutic area and drug variation was pronounced, with certain oncology treatments exceeding 600%.
CONCLUSIONS: The evidence review suggests that mark-ups on hospital-acquired drugs can be substantial, influenced by site-of-are, drug type, institutional characteristics, and policy factors such as 340B. Major limitations in the literature include inconsistent methodologies, reliance on imputed prices and limited research on patient and community impacts. Mark-ups add costs that can raise premiums and individual financial burdens, underscoring the need for greater transparency, standardized reporting, and optimized regulation. Further research should quantify patient-level effects and premium impacts using actual transaction data.
METHODS: A systematic review under PRISMA guidelines with parallel searches of peer-reviewed and grey-literature sources (Jan 1, 2015-Nov 12, 2025). Peer-reviewed searches covered PubMed, Embase, EconLit, EBSCOhost, Scopus, and Web of Science. Grey-literature searches included government reports, transparency databases, and think-tank analyses. Studies were eligible if they reported quantitative estimates of the difference between hospital acquisition cost and billed or reimbursement price in the U.S.; studies of pricing without hospital acquisition were excluded. Two reviewers independently screened records and extracted data on study design, pricing metrics, mark-up calculations, drivers, limitations, and recommendations. Study quality was assessed using PRISMA-based criteria and findings were summarized.
RESULTS: Database searches identified 1,821 records, yielding 1,029 unique articles after deduplication; grey-literature searches returned over 4,000 records. After screening, 34 records met inclusion criteria (15 peer-reviewed and 19 grey literature). Study-reported hospital drug mark-ups ranged from near cost parity (<10% increase) to over 1,000%, with one analysis finding 1,402% (i.e. 15x). A site-of-care comparison showed median mark-ups lowest in independent physician offices (~12%) and substantially higher in hospital outpatient departments, with 340B hospitals exhibiting the greatest mark-ups (~208%) compared to non-340B hospitals (~144%). Therapeutic area and drug variation was pronounced, with certain oncology treatments exceeding 600%.
CONCLUSIONS: The evidence review suggests that mark-ups on hospital-acquired drugs can be substantial, influenced by site-of-are, drug type, institutional characteristics, and policy factors such as 340B. Major limitations in the literature include inconsistent methodologies, reliance on imputed prices and limited research on patient and community impacts. Mark-ups add costs that can raise premiums and individual financial burdens, underscoring the need for greater transparency, standardized reporting, and optimized regulation. Further research should quantify patient-level effects and premium impacts using actual transaction data.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR160
Topic
Health Policy & Regulatory
Topic Subcategory
Public Spending & National Health Expenditures
Disease
No Additional Disease & Conditions/Specialized Treatment Areas