Pharmaceutical industry changes and market insights - Survey of leaders in the pharma value chain
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Pharmaceutical industry changes and market insights: a survey of leaders in the pharma value chain Ernst & Young LLP and YourEncore alliance overview Ernst & Young LLP and YourEncore have formed a strategic alliance to help life sciences and consumer products clients accelerate product development, strengthen regulatory compliance and improve productivity. This first-of-its-kind relationship unites EY advisory, transaction advisory and tax services with the real-world experience of YourEncore’s 10,000 on-demand industry experts to help clients innovate, drive growth, manage risk and comply with increasing regulatory challenges. About YourEncore Indianapolis-based YourEncore, named a “100 Most Brilliant Company” by Entrepreneur Magazine, is a leading provider of proven expertise, delivering flexible resourcing and consulting services to the biopharma, medical devices and diagnostics and consumer goods industries. With its network of highly experienced subject matter experts, including MDs, PhDs, regulators and scientists, YourEncore mobilizes the wisdom and know-how of its experts to help companies out-think, out-pace and outperform. For more information, visit www.yourencore.com. II | Parthenon-EY
Introduction Parthenon-EY and YourEncore recently conducted a nationwide survey of life sciences experts to query them on recent market trends, uncover their points of view on potential regulations, refine their current business models and gain insights into what discovery efforts might yield better results. With all the rhetoric surrounding the drug industry from political, news and personal channels, we wanted to know what “those who know” think of various ways to improve the system. We asked 10 simple questions, soliciting input from more than 50 past and present industry executives and experts from pharmaceutical, consulting and pharmacy backgrounds. What we heard was informative, provocative and in some cases unsurprising — but important to consider. Here is what we have learned. Parthenon-EY | 1
Pharmaceutical industry changes and market insights: a survey of leaders in the pharma value chain Q1 Which top regulations could have the greatest impact on accelerating discovery and getting breakthrough products to market faster? Overall, respondents did not mind operating in a regulated stem cell research, and that domestic restrictions on their environment, and we did not hear many say they would use will not stop experimentation. There is a belief that prefer an unregulated market. In fact, many believed that US restrictions may result in long-term harm if research patient safety regulations and those governing effective conducted in countries with fewer controls leads to harmful clinical trials are both necessary and protect the general or false therapies that eventually enter the US market. public. Of top concern for our respondents was the ability of the Food and Drug Administration (FDA) to review trial Figure 1: Number of new molecular entities (NME) approvals results, issue opinions and findings and provide consistent by the FDA, 2006-2016 guidelines by therapy area. Average: 36 This response was unexpected — we initially thought that drug approvals fewer regulations would be preferred. There was wide per year between 2011 and 2016 support for the standard clinical trial model, with some recommendations to create consistent protocols by 50 therapeutic area and streamline the process for disease- 45 specific reviews to include the same outcome measures, Average: 22 drug approvals 41 whether those are biomarkers or real-world evidence with 40 per year between 39 the same endpoints. 2006 and 2010 For novel therapies, especially in oncology, there was 30 30 a desire to allow smaller studies with greater definition 27 26 24 around endpoints and an accelerated approval path. 22 22 21 One participant responded, “a review of the clinical 20 The decline 18 requirements by therapeutic area should [occur] to ensure of NME approvals that the most streamlined processes are in place to speed in 2016 concerns up the development process. Inclusion of real-life evidence 10 stakeholders in supplemental applications [should also occur] across all across the value chain. therapeutic areas.” 0 There was also a consensus that the US is falling behind 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 other developed countries in the use of genomics and Food and Drug Administration 2 | Parthenon-EY
Q2 Which top regulations or agency reform would have the biggest impact on lowering the cost of drugs? Our respondents named several potential changes that could those in European countries where list prices are public help lower the cost of drugs. Mentioned quite often was and competition is more open. There was a broad reforming how the US uses generic drugs. For many years, consensus that pricing needs to be transparent, not only payers and pharmacy benefit managers (PBMs) have driven for manufacturers, but for everyone in the value chain — the “generic conversion rate” — mandating that patients particularly PBMs and pharmacies — that profits from switch from branded drugs to generics — with the belief unit price arbitrage vs. services provided. that costs would decline. Patient and provider education Role of generics Marketing and direct-to-consumer advertising is the one Drug prices have continued to rise due to how drugs area that most respondents agreed is a huge cost to are placed on formularies, the use of non-transparent manufacturers and drives up the wholesale price of the incentives, and the lack of generics in high-cost disease drug to recover investment for capturing patients. Use states. Several respondents indicated that the role of of paper for product inserts, packaging and marketing generics may be limited as new therapies and biologics hit materials, rather than moving to electronic labeling were also the market. Others believed that generics still have a long considered to drive up unit cost. Patients’ lack of allowed way to go and can be lower-cost alternatives for the right time with physicians creates both a greater burden to educate disease states. These respondents believed that payers the public and costs associated with paper-based materials. need better guidelines for how products are reimbursed, Formulary reviews such as comparing the net retail costs between a generic Other respondents believed that formularies need to be and brand after all incentives are included. Affordability overhauled and that exclusions, substitutions, and non-preferred for the patient should be the priority, not unit costs of a products need to be thoroughly reviewed with new guidelines single product. and clinical protocols, not just price comparisons. There was Accelerating generic drugs to market through improved a consensus that payers need to apply more clinical rigor in processes was seen as one path to less-expensive making decisions and focus on outcomes instead of unit price. alternatives making it to market faster. There was a belief that introducing competition to the pioneer product Figure 2: Year-over-year growth of branded drug prices in US, 2012-2015 earlier can impact overall drug costs. Rapid approval of biosimilars was another category believed to lower costs as brand patents expire. One respondent said savings could 12.5% 10.0 10.1% be realized if Code of Federal Regulations Part 314 were to 8.0% 8.3% 7.5 7.5% require third-line drug approvals to be superior to the first 5.0 two products on the market and have the same or better 2.5 safety and efficacy profile. 0.0 2012 2013 2014 2015 Medicare/Medicaid price negotiations Some said that Medicare, Medicaid and other government programs should be able to negotiate prices similar to EY analysis, Morgan Stanley and UBS industry analyst reports Parthenon-EY | 3
Pharmaceutical industry changes and market insights: a survey of leaders in the pharma value chain Q3 Which top regulations or agencies create the largest barrier to collaboration (research or otherwise)? In looking at the regulatory environment, we had to ask assume this role. Supporting biotech incubators and helping whether current legislation and agencies were a barrier to fund partnership creation were seen as a way to increase clinical collaboration between pharmaceutical manufacturers. competition and collaboration. We heard that there is significant concern about collusion, One respondent indicated Hatch-Waxman Amendments patent protection and sharing of information. However, (patent reform and generic drug regulations) may help when we queried the market, many told us that these fears with price, but they also favor generic drug companies. are overblown, and that internal legal and leadership risk Moreover, the respondent indicated patent protections tolerance represent the largest barrier. for new chemical entities should be extended so larger One respondent said that “regulations and agencies pharmaceutical companies have the money needed for are not a meaningful barrier to collaboration among additional research. companies or between companies and medical institutions/ Lastly, there is also a belief that PBMs and payers have not universities/NIH (National Institutes of Health). The barriers fostered collaboration when they could have largely helped are far more related to the diverging interests of these reconcile inconsistencies in the industry around common organizations.” Another responded, “Much could be done practices and data sharing. One respondent said insurance on the industry side to encourage collaboration, especially companies could have implemented clearer requirements in therapeutic areas that are advancing cures in areas of for routine standards of care and covered the increased unmet medical need. This has always been a problem due frequency of testing to capture data on valuable health to competitive environment and patent enforcement but outcomes. is worthy of a dialog session to discuss solutions.” Other respondents believed that the FDA and NIH can do more to foster collaboration, but that the current complexity of different departments with different processes makes it seem as though they are dealing with multiple agencies. Every submission and request seems to be a “first” or “one-time exception” rather than a standard operating procedure. Several respondents felt that funding should be directed to small start-ups and innovative companies that are willing to partner. These respondents suggested government assistance in identifying partners and financing or, alternatively, private equity and smaller investors could 4 | Parthenon-EY
Q4 What components of the value chain (discovery, manufacture, distribution) contribute the most to drug prices? Unsurprisingly, research and development (R&D) was There was, however, a new category that has emerged most often cited as the most expensive component and recently as a contentious element in the cost of drugs: contributor to drug prices. Obviously, the sunk cost of failed the expenses associated with “middlemen.” This includes trials was the primary driver, as these investments need to prescription benefit managers (PBMs) and wholesalers that be incorporated into the cost for successful programs. are using their dominant positions in the value chain to drive up profits by demanding more rebates or “discounts” According to one respondent, “In my opinion, manufacturing for products that are not passed on to consumers and do (i.e., cost of goods) has a major impact on the ultimate drug not add value to the process. One respondent called the price. Having said that, however, the cost of development is distribution chain an “antiquated model” that involves very high and very risky. Numbers of studies, numbers of far too many middlemen. Restrictions around distribution patients, late-stage failures all contribute to the soaring cost have created excessive handoffs before a product reaches of drug development and therefore drug prices.” the consumer. Phase 3 or late-stage clinical trials were also cited because The issue with the middleman has become very prominent of the number of endpoints that need to be evaluated and in recent national conversations, as the market asks why the manual process by which data is collected and evidence there is still a need for handoffs in a highly consolidated is submitted to the FDA for approvals. Several respondents sector. One respondent indicated “distribution, insofar indicated the clinical trial process heavily depends on as insurance companies and PBMs increase their profits inefficient processes that are not automated or consistent at the expense of patient choice and co-pay/co-insurance and even incremental improvements could yield significant increases … also leads to increased noncompliance to savings to the industry. prescribed therapies.” Other components cited were product recalls, packaging, destruction costs and labor associated with the management of product in the channel. Of course, also on the list was marketing, especially direct-to-consumer advertising, which is more expensive than a sales force that calls on physicians. Recent rules on how much time a drug rep can spend with a physician have shifted marketing expenses into digital and media advertising, which requires significant investment and constant updating. Parthenon-EY | 5
Pharmaceutical industry changes and market insights: a survey of leaders in the pharma value chain Q5 What changes to regulations would lower prices the most? While respondents indicated many diverse approaches and transitioning that information to electronic labeling” to lowering prices, many were in agreement that the could reduce costs. One respondent indicated “lowering the quantity and complexity of regulations can contribute to preclinical burden and opportunity potential for approval higher drug prices. One respondent said, “The relationship with one pivotal trial (or counting a good Phase II as a between regulatory expansion and higher prices cannot pivotal in some cases)” could also lower costs. This is done be ignored. Price increases caused by regulation have now in some orphan indications but “should be allowed a disproportionately negative effect on low-income more generally.” households. The poorest households tend to spend Some respondents believe that allowing Medicare and a larger proportion of their income on goods that are Medicaid to negotiate prices or limiting prices to a ceiling heavily regulated and are subject to both high and volatile based on European price lists will have an impact. The prices. This cost should be recognized in policymakers’ topic of value-based pricing came up quite a bit, and one efforts to consider the costs and benefits of new and respondent said, “Regulators should allow for more existing regulations.” value-based pricing innovation. The current minimum Other respondents focused significantly on the discounts and best price rules around Medicaid, manual, inefficient compliance processes that require Department of Defense (DoD), and the bloating of 340b documentation by requesting a “commonsense approach (the federal drug discount program used by hospitals to to documentation requirements.” “Eliminating the benefit lower income and vulnerable populations), [and] requirement for printed packaging and physician leaflets the complex negotiations with PBMs all conspire to cause Figure 3: Percentage of respondents indicating type of reform 40% 31% 30 20 19% 19% 12% 10 8% 4% 4% 4% 0 Clinical trial CMS Physician/consumer No change Value–based Documentation Drug Patent reform negotiation communication needed pricing reform packaging reform of prices Parthenon-EY and YourEncore pharmaceutical survey results, 2017 6 | Parthenon-EY
inflated list prices. Changing the rules to allow for more innovation and more simplified market competition would be beneficial. Allow drug companies to share information with payers, including Medicaid, about future drugs so that health systems can plan better.” Others discussed the rise of direct-to-consumer advertising in response to tight restrictions around profiling and educating physicians directly. One respondent said that we should “limit direct-to-consumer advertising and sales calls to physicians. Information on medicines should be provided to physicians from objective, peer-reviewed sources, funded publicly or by the industry as a whole — not by individual companies.” Some respondents indicated a preference for limits to direct-to-consumer advertising and rebalancing those with physician education and the establishment of “an industry-wide, peer-reviewed resource as a central depository for drug information.” Many respondents want to see more rapid approval of biosimilars and shortening of the time allowed before generic approvals. Respondents generally do not want to see broad decreases in FDA oversight, and they mentioned patient safety as a critical issue that the FDA should continue to oversee. Parthenon-EY | 7
Pharmaceutical industry changes and market insights: a survey of leaders in the pharma value chain Q6 What changes to the value chain (discovery, manufacture, distribution) need to occur to eliminate unnecessary costs or reduce prices? The responses to questions #5 and #6 had subtle savings could potentially be realized, some respondents differences. Responses to this question focused more on said, especially if trials could be conducted in a collaborative R&D, price transparency and stakeholder collaboration environment, reducing redundancies for similar trials. across the entire health care value chain. One respondent One interesting observation is that there may be issues indicated incentive structures are misaligned for some with near monopolies in the distribution channel as players in the value chain and questioned whether drug secondary and tertiary wholesalers and payers/PBMs companies should be publicly traded with Wall Street’s retain deep discounts they receive from the pharmaceutical financial performance expectations imposed. manufacturers. Respondents said that all discounts and One respondent said R&D is a long, risky process and savings, including rebates, should be passed on to consumers collaborations are needed to enable greater value delivery in the form of lower co-pays and co-insurance rates. One in product discovery. The respondent further indicated respondent said product liability expenses are a hidden there is a need for the public to differentiate between form of costs as well. a small number of “bad actors” that create a negative public perception of pharma, and the majority of honest companies that invest in research and development. There was also a willingness to work within an environment with greater price transparency for the market to see relative pricing/value along the entire distribution channel and know who really profits from drug delivery. Many respondents believe there are too many players profiting from low-value services, such as distribution and price triaging by intermediaries. Some respondents also referenced inefficient internal practices within pharma, such as excess production capacity in manufacturing plants that is not well-utilized. If fewer studies and patients studied were required, cost 8 | Parthenon-EY
Q7 What should providers be doing that they are not doing today to improve prescribing patterns or therapy outcomes? When asked specifically about providers, respondents commented on how the physicians’ role has changed and how critical their attention to the details surrounding appropriate drugs matters to overall clinical outcomes. Most respondents believe that physicians have a significant responsibility to better understand how drugs work in the body, when it is medically necessary to prescribe a drug and how it will interact with other agents. Several respondents commented about how most treatments are now a prescription vs. a procedure and that not allotting enough time to educate physicians may detrimentally Respondents want to see payers take more responsibility affect their efficacy in treating disease. in enabling physicians and electronic medical record (EMR) standards rather than delegating those standards Respondents want more time for physicians to learn to a fragmented provider market. A specific comment about new therapies/products and assess and ensure around EMRs was that “electronic medical records must the appropriateness of their use after initial availability. be reorganized to capture therapeutic outcomes so they There were comments about bringing more physicians can be a tool for real-world evidence (value) — and not into trials to better understand how investigations are just for cost assessment (price).” conducted and suggest improvements to the process. Many physicians are never a part of trials and often Many buzzwords were also mentioned, such as value- and don’t understand how to enable patient therapies, so outcome-based reimbursements, real-world evidence and only a small pool of physicians shapes how trials are evidence-based medicine. However, there were some specific conducted. recommendations for more head-to-head trials between competitor products in the same therapy class, especially A common barrier noted was the shortage of physicians with interchangeable products — the goal being to in primary care and payer pressure to see more patients. gather more data on the drivers for efficacy and better This pressure leaves little time for continuing medical understanding of clinical performance vs. patient behavior. education and patient counseling, thought to majorly impact clinical outcome improvement. Compliance and Other respondents wanted to see more pressure on adherence were mentioned repeatedly as a responsibility physicians to stop overprescribing, especially antibiotics of both the patient and the physician, who should check in and to polypharmacy patients, without doing more to evaluate the progress and efficacy of the therapy. research into the patients’ history. Parthenon-EY | 9
Pharmaceutical industry changes and market insights: a survey of leaders in the pharma value chain Q8 What improvements need to be made in the prescribing process to balance costs, access to therapies and patient safety? Many respondents indicated that the physician, being they are best educated about pharmaceuticals and better on the front lines of medical care, can drive change in understand how drugs work and how they affect patients: prescribing trends. Improving continuing medical education “I would like to see pharmacists prescribe, based on physician of physicians can position physicians to prescribe the most diagnosis. Pharmacists are the most underutilized brain effective medicine, either branded or generic, that provides trust in the US.” for improved clinical and financial outcomes. Lastly, one respondent made a bold statement that we Continuing medical education and the need to integrate need to “change the system totally. Insurance companies electronic medical records with pharma databases was have no value, they only add cost. The best system I’ve cited as critical for physicians to immediately access heard of has the care of each patient managed by a team important information around drugs and their impact on that includes providers and patient advocates. Without that, patient physiology. Once again, the topic of polypharmacy we have people who go to a doctor because they are bored patients and the “sickest of the sick” came up as a specific or because they heard an ad on TV. The present system area requiring much greater coordination, especially as including ACA [Affordable Care Act] will not work nor will these patients are the highest cost claimants. Medicare for all.” Some respondents also advocated for simplified national policies from regulators and guidelines from payers around how care should be triaged. One respondent said, “The US should adopt NICE-like (National Institute for Health and Care Excellence) reviews of therapies.” Others said that payers need to start making the hard trade-offs between products to rationalize the number of treatment options without denying care and reviewing it after the fact. Respondents want to see payers hold physicians accountable to complying with safety requirements and not just prescribe off label without the existence of a standardized protocol. Another respondent said the US can combat the shortage of physicians by allowing pharmacists to prescribe, as 10 | Parthenon-EY
Q9 What improvements need to be made in the reimbursement process to balance costs, access to therapies and patient safety? This question resulted in many very direct responses from Respondents want the reimbursement process to make our survey respondents. The role of the payer has been therapeutic outcomes the primary measurement of widely debated, and the responses from even a diverse reimbursement decisions, not price. Some want to see set of survey participants were quite blunt about payers’ PBMs “disappear” and be replaced with a single-payer responsibility to contribute to positive outcomes and not system and greater empathy for getting new therapies focus solely on costs. to patients with life-threatening diseases. One respondent said, “Currently, payers look at drug Lastly, respondents want to see a shift in “giving more costs over the short term, because most of their insured power to personal physicians (of course with supportive population will be covered by that particular payer for documentation) rather than layers and layers of ‘case only a few years. Thus, payers have no real incentive to management’ who do not care about individual responses spend on preventive and long-term therapies that could or needs. Make the physician responsible to confirm why benefit the patient in the long run. So payers tend to the patient needs certain drugs or therapies. Now with focus only on the immediate cost of drugs, not the value-based purchasing being tested in nine states, patients long-term cost/benefit ratio.” are the guinea pigs – i.e., their orthopedist may limit or deny necessary home care or outpatient PT after a joint In fact, several respondents agreed that “payers need to replacement.” look at costs from an immediate and long-term perspective. Some expensive therapies are not covered, which can lead to longer term use of less expensive therapies that erode the cost savings they seem to provide. We need revised standards of care based on independent review of therapies and outcomes.” Another said, “Patients do not have transparent information as to the cost of care. Require that the cost of doctors, hospitals and drugs all be made clear when treatment options are discussed. Patients learn about costs at the back end after treatment is given — that is too late to get involved in the right dialog. Weirdly, the only cost patients know in advance is at the pharmacy. Doctor offices, diagnostics centers and hospitals all say ’the cost to the patient is up to the insurance company’ and never answer what their billings will be or the net to the patient. Both payers and providers need to start to deal directly with the public on pricing.” Parthenon-EY | 11
Pharmaceutical industry changes and market insights: a survey of leaders in the pharma value chain Q10 What practices do payers employ that don’t contribute to improved clinical outcomes or cost reduction? Once again, we heard from respondents that “arbitrary more expensive treatments, non-reimbursement for and generalized limitations imposed on prescribers, solely companion diagnostics, and excessive and burdensome based on cost, interfere with the individualization of the prior authorization practices were cited as other drivers patient-physician decision-making relationship” and that of hidden costs. One respondent said payers “should there is a “great amount of administrative costs that require less outcomes/pharmacoeconomic data on novel are burdensome to users and especially patients.” One products where there is no appropriate generic. The cost respondent said “the fix would be either regulation of the of copays in tier three+ products is generally too high payers in a way that requires a long-term perspective, or and restricts use of good drugs in patients who are likely a single-payer option for pharmaceutical coverage.” to benefit.” Another respondent believes forcing the use of generics Finally, one respondent said what we need is greater does not always result in equivalent efficacy, safety or transparency overall, as well as the elimination of manufacturing integrity. Several respondents said forcing paperwork, constantly changing reimbursement rules prescribers to use generics does not always result in lower and hidden pricing deals with intermediaries. costs and may in fact require multiple switches when there are newer and better therapies available in brand-name products. “Standard of care is for the average person. It’s a waste of time and money for all of those instances where a patient is not showing typical symptoms,” one respondent said. The use of step edits and second-guessing of physicians drive up hidden costs to the system, according to several respondents, as patients need more phone calls, consultation time or additional visits with their doctor to get on the right medication. Fail-first mandates, mandatory generic switching, higher co-pay tiers for 12 | Parthenon-EY
Conclusion There are many conversations taking place models is needed and welcomed by the in both public and private forums around the community of leaders in the industry. current state of pharmaceuticals, drug prices and public policy changes. Parthenon-EY and Parthenon-EY has been helping clients YourEncore decided to conduct a survey to across the entire life sciences value chain ask leaders in the industry value chain what assess whether they need to change their they thought of the regulatory environment business, operating and economic models and how changes may impact the industry. to help them be better positioned in the What we heard was both interesting and future. There is broad openness to doing affirming of many of the sentiments being things differently, but many clients are reported by the general press. Everyone looking for guidance from regulatory seems to want change and there is still authorities to help them design more optimal widespread support around patient safety solutions. There are many ideas but little and efficacy as a priority. The types of clarity around expectations and desired changes needed range from simplification outcomes, much less how success will be of rules and guidelines to wholesale changes measured. Restrictions around sharing around the economic models to usher in information make it difficult for companies greater transparency. The myriad of models to innovate and change their infrastructure, and processes that have evolved over the so there is considerable stasis around years are putting additional burdens and wholesale change. The will exists, the way needs to be paved. costs on a constrained system, so thoughtful restructuring of business and economic Parthenon-EY | 13
Parthenon-EY Life Sciences practice Our team YourEncore contributors Alex Jung Kyle Fenstermaker Managing Director Managing Director, YourEncore Parthenon-EY Bio-Pharmaceutical Practice Ernst & Young LLP 1 609 240 5945 1 312 879 2778 Kyle.Fenstermaker@yourencore.com alex.jung@parthenon.ey.com Daniel Mater Joseph Lamendola Consultant Senior Vice President, YourEncore Parthenon-EY Bio-Pharmaceutical Practice Ernst & Young LLP 1 609 937 4552 1 312 879 3345 Joseph.Lamendola@yourencore.com daniel.mater@parthenon.ey.com For more information on our Life Sciences practice and our team, please visit parthenon.ey.com. About Parthenon-EY Parthenon joined Ernst & Young LLP on 29 August 2014. Parthenon-EY is a strategy consultancy, committed to bringing unconventional yet pragmatic thinking together with our clients’ smarts to deliver actionable strategies for real impact in today’s complex business landscape. Innovation has become a necessary ingredient for sustained success. Critical to unlocking opportunities is Parthenon-EY’s ideal balance of strengths — specialized experience with broad executional capabilities — to help you optimize your portfolio of businesses, uncover industry insights to make investment decisions, find effective paths for strategic growth opportunities and make acquisitions more rewarding. Our proven methodologies along with a progressive spirit can deliver intelligent services for our clients, amplify the impact of our strategies and make us the global advisor of choice for business leaders. About the Parthenon-EY Life Sciences practice The Parthenon-EY Life Sciences practice has dedicated life sciences professionals across member firms in 17 countries spanning the Americas, Europe, Middle East and Asia-Pacific. Our global hub is based in the US and has life science leaders in Boston, New York, Chicago and San Francisco. All Parthenon-EY Life Sciences professionals have extensive experience in life sciences strategy consulting and academic degrees in science, clinical and business disciplines. The practice coordinates with the Parthenon-EY Health care and Consumer practices as well, bringing the full gamut of convergence in consumer, health care and life sciences offerings to clients in companies, investor groups, payers and providers worldwide. EY | Assurance | Tax | Transactions | Advisory About EY EY is a global leader in assurance, tax, transaction and advisory services. The insights and quality services we deliver help build trust and confidence in the capital markets and in economies the world over. We develop outstanding leaders who team to deliver on our promises to all of our stakeholders. In so doing, we play a critical role in building a better working world for our people, for our clients and for our communities. EY refers to the global organization, and may refer to one or more, of the member firms of Ernst & Young Global Limited, each of which is a separate legal entity. Ernst & Young Global Limited, a UK company limited by guarantee, does not provide services to clients. For more information about our organization, please visit ey.com. Ernst & Young LLP is a client-serving member firm of Ernst & Young Global Limited operating in the US. Parthenon-EY refers to the combined group of Ernst & Young LLP and other EY member firm professionals providing strategy services worldwide. Visit parthenon.ey.com for more information. © 2017 Ernst & Young LLP All Rights Reserved. SCORE No. 03522-171US ED None This material has been prepared for general informational purposes only and is not intended to be relied upon as accounting, tax or other professional advice. Please refer to your advisors for specific advice. ey.com
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