Hatch-Waxman Turns 30: Do We Need a Re-Designed

Approach for the Modern Era?

Aaron S. Kesselheim & Jonathan J. Darrow

Abstract:
In 1984, Congress passed the Hatch-Waxman Act, which catalyzed the
creation of the modem generic drug industry. Generic drugs today account for
eighty-four percent of all prescriptions dispensed, but less than twenty percent of
drug costs. Despite this success, numerous problems in the generic drug market
have emerged. Some involve the deliberate manipulation of the Hatch-Waxman
system, while others have arisen more unexpectedly, such as the Supreme
Court's 2011 decision in Pliva v. Mensing that could undermine consumer
confidence in generic drugs. We discuss these emerging challenges and propose
updates to the Hatch-Waxman Act to continue support for the timely emergence
of safe generic drugs.

.Aaron S. Kesselheim, M.D., J.D., M.P.H. is an Associate Professor of Medicine at Harvard

Medical School and Jonathan J. Darrow, S.J.D., J.D., M.B.A. a post-doctoral research fellow at
Harvard Medical School. Both are based at the Program On Regulation, Therapeutics, And Law
(PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's
Hospital. Dr. Kesselheim received a grant for this work from the Harvard Program in Therapeutic
Science, and Dr. Kesselheim's work is also supported by the Greenwall Faculty Scholars Program.
We are grateful for comments from colleagues, including Jerry Avorn, Ameet Sarpatwari, and
Kevin Outterson. Dr. Kesselheim reports serving as an expert witness in 2013 on behalf of a class
of individual plaintiffs against Wamer-Chilcott for anticompetitive conduct related to generic drug
marketing.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

TABLE OF CONTENTS

TABLE OF CONTENTS ....................................................................................... 294

INTRODUCTION ................................................................................................ 295

I. THE HATCH-WAXMAN ACT: BACKGROUND AND REGULATORY

FRAM EWORK ....................................................................................... 297

A. BACKGROUND AND ORIGINS OF THE HATCH-WAXMAN ACT ............ 297

B. BIOEQUIVALENCE PATHWAY FOR GENERIC DRUGS .......................... 301

C. GENERIC CHALLENGES TO BRAND-NAME MARKET EXCLUSIVITY ... 302
D. COMPETITION-FREE PERIODS FOR INNOVATIVE DRUG APPROVALS. 305
E. EXTENSIONS OF BRAND-NAME MARKET EXCLUSIVITY .................... 305

F . SUM M A RY ........................................................................................... 307

II. THE HATCH-WAXMAN LEGACY ................................................................ 307

A. INNOVATION BY BRAND-NAME DRUG MANUFACTURERS ................ 307

B. U SE OF G ENERIC D RUGS .................................................................... 309
C. IMPACT ON PATIENT OUTCOMES AND HEALTHCARE SPENDING ........ 314

D . SU MMAR Y .......................................................................................... 3 19
III. THIRTY YEARS AFTER HATCH-WAXMAN: CURRENT AND EMERGING
C HALLENGES ....................................................................................... 319
A. LIMITS OR DELAYS TO GENERIC DRUG AVAILABILITY UNDER HATCH-
WA X MAN ....................................................................................................... 3 19

1. PATENT ACCUM ULATION ................................................................ 320

2. REVERSE PAYMENT PARAGRAPH IV CHALLENGE SETTLEMENTS

("PA Y FO R D ELAY") .................................................................................. 328

3. A UTHORIZED G ENERICS .................................................................. 333

4. DOSE FORM OR OTHER CHANGES IN THE LISTED DRUG ................ 336

5. REFUSAL TO PROVIDE MATERIAL FOR PURPOSE OF ESTABLISHING
B IO EQU IV ALEN CE ...................................................................................... 340

B. ENSURING CONTINUED SAFETY OF GENERIC DRUGS ........................ 342

V . CONCLUSION ................................................................................................ 345

 HATCH-WAXMAN TURNS 30

INTRODUCTION

The last major piece of legislation that revolutionized the U.S. prescription
drug market was Drug Price Competition and Patent Term Restoration Act of
1984, which is more commonly known as the Hatch-Waxman Act.' Observing a
pharmaceutical marketplace dominated by expensive brand-name drugs despite
their patent protection having lapsed, while also hearing complaints from brand-
name manufacturers about the rising costs of innovative drug development,
legislators constructed the Hatch-Waxman Act to give brand-name
pharmaceutical manufacturers additional incentives to develop new drugs. At the
same time, the Hatch-Waxman Act reduced drug prices for unpatented drugs by
facilitating regulatory approval of low-cost, high-quality generic prescription
drugs. 2 Generic drugs are therapeutically equivalent to brand-name products
made by first-entry or pioneer manufacturers. The factors defining therapeutic
equivalence include both pharmaceutical equivalence and bioequivalence.
By nearly every measure, the Hatch-Waxman Act has been remarkably
impactful. 3 In 2012, generic drugs made up about eighty-four percent of all U.S.
prescriptions dispensed.4 Generic drugs are available in nearly every therapeutic
class, have become the standard of care for many common diseases, and are less
expensive in the United States than in most other countries. 5 The success of
generics translates into improved medication adherence6 and dramatically
reduced healthcare costs-more than a trillion dollars in the past decade,
according to the Government Accountability Office. 7 At the same time, Hatch-

1. Pub. L. No. 98-417, 98 Stat. 1585 (1984).

2. H.R. REP. No. 98-857(1), at 14-15 (1984), reprinted in 1984 U.S.C.C.A.N. 2647, 2647-48;
Alfred B. Engelberg, Special Patent Provisionsfor Pharmaceuticals: Have They Outlived Their
Usefulness?, 39 IDEA 389, 389 (1999).
3. See, e.g., Mark Metzke, Increasing Follow-on Biologics Competition with a New Biologics
Act, 39 AIPLA Q.J. 357, 371 (2011) ("From a utilitarian standpoint, the Hatch-Waxman Act
worked."). But see JEREMY A. GREENE, GENERIC: THE UNBRANDING OF MODERN MEDICINE 88
(2014) (arguing that "a single piece of legislation signed into law in 1984 did not create the modem
generic drug industry ... By the time the Hatch-Waxman Act was passed in 1984, the existence of
such an industry was no longer really in question, as it had been in the beginning of the 1960s").
4. Katie Thomas, U.S. Drug Costs Dropped in 2012, but Rises Loom, N.Y. TIMES, Mar. 19,
2013, at Al.
5. Patricia M. Danzon & Michael F. Furukawa, Prices and Availability of Pharmaceuticals:
Evidencefrom Nine Countries, HEALTH AFF. W3-52 1, W3-528 (2003).
6. William H. Shrank et al., The Implications of Choice: PrescribingGeneric or Preferred
PharmaceuticalsImproves Medication Adherence for Chronic Conditions, 166 ARCH. INTERNAL
MED. 332, 335 (2006) [hereinafter The Implications of Choice] (finding that the proportion of days
covered, a measure of adherence was 12.6% greater for patients initiated on generic versus non-
preferred medications).
7. U.S. GOV'T ACCOUNTABILITY OFFICE, GAO-12-371R, DRUG PRICING: RESEARCH ON
SAVINGS FROM GENERIC DRUG USE 4 (2012). See generally COUNCIL OF ECON. ADVISERS, EXEC.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

Waxman was also a boon to the brand-name drug industry by providing market
exclusivity extensions, which translated into billions of dollars in additional
revenue. Since Hatch-Waxman, transformative drugs brought to market based in
part on investment by brand-name drug companies have offered advances in
clinical care for infectious diseases like HIV, cardiovascular disease, 8 and
rheumatologic disease, as well as for numerous hereditary genetic disorders.
Thirty years later, however, the Hatch-Waxman Act has in some comers of
the prescription drug marketplace become a victim of its own success. Numerous
issues now affect patient access to generic drugs and prevent the generic drug
industry from having an even more substantial effect on U.S. healthcare
spending. Some of these issues, like business deals between brand-name and
generic manufacturers that serve to delay the introduction of bioequivalent
generic drugs, were spawned by the provisions of the Hatch-Waxman Act itself.
Other such issues were barely contemplated in the early 1980s when the statute
was designed, such as authorized generics, which emerged as a viable variation
on the concept of a generic drug only after traditional generic manufacturers
demonstrated the success of their business model under the Hatch-Waxman Act
and the resulting generic drug approval system advanced at the Food and Drug
Administration (FDA).
In light of the Hatch-Waxman Act's thirtieth anniversary in September 2014,
we sought to review the generic drug approval system. While the structure of the
legislation may have been appropriate in the context of the pharmaceutical
market in the late 1970s and early 1980s, a substantially different drug market in
the twenty-first century presents challenges that may not be readily addressed
under the current regulatory regime. Part I of this Article reviews the background
and origins of the Hatch-Waxman Act and explains the balanced incentive
system it created. Part II examines the beneficial legacy of the Hatch-Waxman
Act. Part III synthesizes criticisms and potential problems that have been created
or become evident over the past thirty years and identifies areas for potential
legislative amendment. Part IV concludes by summarizing the key areas that
could form the basis for reconsideration of the 1984 legislation: delays to generic
drug availability, tactics that reduce access to or raise the costs of generic drugs,
and oversight of evolving knowledge about safe and effective prescribing of
generic drugs.

OFFICE OF THE PRESIDENT, THE ECONOMIC CASE FOR HEALTH CARE REFORM 9-17 (2009),
http://www.whitehouse.gov/assets/documents/CEAHealthCareReport.pdf (discussing
inefficiencies within the United States healthcare system).
8. Aaron S. Kesselheim & Jerry Avom, The Most Transformative Drugs of the Past 25 Years:
A Survey of Physicians, 12 NATURE REVIEWS: DRUG DISCOVERY 425, 425 (2013) (describing the
most and second-most transformative drug and drug classes in fourteen fields of medicine).
 HATCH-WAXMAN TURNS 30

I. THE HATCH-WAXMAN ACT: BACKGROUND AND REGULATORY FRAMEWORK

A. Backgroundand Origins of the Hatch- Waxman Act

The Hatch-Waxman Act had its origins in policymakers' dissatisfaction with

the regulation of prescription drugs that hindered the ability of generic
manufacturers to market low-cost copies of brand-name drugs. Prior to 1984, the
most significant federal legislation affecting the pharmaceutical market was the
1962 Kefauver-Harris Amendments to the Food, Drug, and Cosmetic Act
(FDCA). The Kefauver-Harris Amendments gave the FDA the power to require
pharmaceutical manufacturers to prove that their drugs were safe and efficacious
before the drugs could be sold. 9 Premarket clinical (i.e., human) trials of the
drugs were needed to provide this proof of safety and efficacy. Following this
piece of legislation, in 1963 the FDA issued regulations requiring manufacturers
to file investigational new drug (IND) applications before commencing clinical
trials. 10 In these rules, the FDA laid out the expected progression of pre-approval
clinical trials, starting with Phase 1 trials, usually in a small number of healthy
volunteers, to determine a safe dosage range. The next step was Phase 2 dose-
determining studies in a limited number of patients with the disease intended to
be treated that also could provide some initial efficacy data. The final stage in the
pre-approval clinical trial process was larger Phase 3 studies, which were
described as adequate and well-controlled investigations providing efficacy and
safety data sufficient for approval.
Pursuant to the FDCA, the submission of a New Drug Application (NDA)
was the final step following a successful clinical trial process. An NDA
demonstrated the clinical circumstances in which a manufacturer's drug appeared
to be both useful and sufficiently safe, 1 and generally included reports of clinical
trials, as well as pharmacologic, preclinical, and other data compiled during a
drug's development. The FDA reviews the NDA to determine if there is "a lack
of substantial evidence that the drug will have the effect it purports or is
represented to have ... or [the drug's] labeling is false or misleading in any
particular."' 2 The statute also defines "substantial evidence" as "evidence
consisting of adequate and well-controlled investigations, including clinical
investigations... [showing] the drug will have the effect it ... is represented to
have."' 3 Thus, to have a drug approved by the FDA, a manufacturer needs to

9. S. REP. No. 87-1744 (1962), reprintedin 1962 U.S.C.C.A.N. 2884, 2886.

10. Part 130-New Drugs: Procedural and Interpretive Regulations; Investigational Use, 28
Fed. Reg. 179 (Jan. 8, 1963) (codified at 21 C.F.R. pt. 130.3).
11. Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 355(b) (2012).
12. § 355(d).
13. Id.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

show it is both safe and efficacious in clinical trials. Moreover, because

"adequate and well-controlled investigations" was written in the plural form, the
FDA interpreted the statute to prefer at least two separate
14
comparative clinical
trials, which usually were performed as Phase 3 trials.
By requiring the FDA to make an affirmative approval decision on an NDA
before a new prescription drug could be marketed, the Kefauver-Harris
Amendments thrust the FDA into a gatekeeper role in verifying how a
prescription drug worked.1 5 After the Amendments, it took substantial resources
for a drug company to sell a new prescription drug because developing a new
drug and completing the clinical trials necessary for FDA approval were
expensive endeavors. 1 6 Importantly, however, these responsibilities applied
equally to brand-name and generic manufacturers that were attempting to market
copies of post-1962 brand-name drugs after the expiration of the brand-name
manufacturer's essential patents on the underlying active ingredient. 7 In most
other industries, patent expiration means that competitors can join the market and
prices can fall, but generic manufacturers seeking to enter the pharmaceutical
marketplace with products for which the patent on the underlying active
ingredient had expired generally also had to conduct clinical trials to receive
approval from the FDA. 18 There were no provisions in the Kefauver-Harris
Amendments allowing expedited approval of drugs that were the same as
products already approved by the FDA. Instead, new clinical trials had to be
conducted even for generic drugs. 19 Prior to 1962, approval costs had not been as
substantial of an issue, since no drugs were required to affirmatively prove safety
and efficacy prior to FDA approval. While the FDA created an abbreviated new

14. Warner-Lambert Co. v. Heckler, 787 F.2d 147, 151 (3d Cir. 1986). The FDA did not view
the two-trial requirement rigidly, and subsequent amendments codified FDA practice to require
only one trial in certain circumstances.
15. Significant Dates in U.S. Food and Drug Law History, FOOD & DRUG ADMIN.,
http://www.fda.gov/AboutFDA/WhatWeDo/History/Milestones/ucml28305.htm (last visited Apr.
12, 2015).
16. DANIEL CARPENTER, REPUTATION AND POWER: ORGANIZATIONAL IMAGE AND
PHARMACEUTICAL REGULATION AT THE FDA 316 (2010) ("Yet they had also made drug
development more costly, at least in the nominal sense of additional time and money spent in
compliance with the regulations."); Pub. L. No. 87-781, § 102, 76 Stat. 780, 781 (1962).
17. H.R. REP. No. 98-857(11), at 4 (1984), reprintedin 1984 U.S.C.C.A.N. 2686, 2688 (noting
that the FDA would approve generic copies of pre-1962 drugs without the need for duplicative
clinical trials).
18. Richard G. Frank, The Ongoing Regulation of Generic Drugs, 357 NEW ENG. J. MED.
1993, 1993 (2007).
19. In 1978, the FDA started a "paper NDA" process to allow approval of generic copies of
new drugs introduced post-1962 based on published literature alone, but adequate literature able to
support a paper NDA was available for only a fraction of post-1962 drugs, so the impact of the
paper NDA process was extremely limited.
 HATCH-WAXMAN TURNS 30

drug application (ANDA) process in 1970 to handle "similar and related"

products that came on the market between 1938 and 1962, the absence of a legal
pathway for generics after 1962 dramatically raised the costs required to bring
generic copies of post-1962 drugs to market.2 ° Since generic drugs were at least
the second entrant into the market and would not be able to command the same
high prices as original brand-name drugs, 21 market economics also reduced the
incentive for manufacturers to create generic drugs.22
On the eve of the Hatch-Waxman Act, another substantial barrier to FDA
approval of generic drugs emerged and threatened to make entry into the market
even more difficult-the application of the experimental use defense to patent
liability infringement in the pharmaceutical space. In the 1960s and 1970s, it was
common practice for generic companies to experiment with brand-name drugs
before patent expiration in anticipation of FDA review.23 This experimentation
process allowed drug companies to prepare a dossier of trials showing that their
generic versions of the brand-name product were bioequivalent, or reached
similar blood concentration levels and generally worked the same way in the
human body. However, this changed in Roche Products, Inc. v. Bolar
PharmaceuticalCo., in which the newly created Court of Appeals for the Federal
Circuit was asked to decide whether generic companies could conduct testing on
patented products solely for the purpose of seeking FDA approval to make a
generic copy.24 The controversy arose in the context of a generic version of
flurazepam (Dalmene), a widely prescribed anxiolytic and sleeping pill. Before
the expiration of the patent on the active ingredient, Bolar, a generic
manufacturer, obtained a batch of the drug and began conducting basic
pharmacologic tests on it to prepare for its own NDA. 5 Roche, the brand-name
manufacturer of Dalmane, sued to enjoin Bolar from using its patented product
for any purpose whatsoever during the life of the patent. The Federal Circuit
agreed with Roche, holding that pre-expiration testing of patent-protected brand-

20. Frank, supra note 18, at 1993-94.

21. David Reiffen & Michael R. Ward, Generic Drug Industry Dynamics, 87 REV. EcON. &
STAT. 37, 37-38 (2005).
22. Richard G. Frank & David S. Salkever, Generic Entry and the Pricingof Pharmaceuticals,
6 J. ECON. & MGMT. STRATEGY 75, 83 (1997).
23. See Engelberg, supra note 2, at 396 ("[T]he weight of judicial authority and common
industry belief and practice supported the view that it was not an act of patent infringement to make
or use a patented drug solely for the purpose of seeking approval to market a generic copy of the
patented drug.").
24. 733 F.2d 858 (Fed. Cir. 1984), supersededby statute, Hatch-Waxman Act, Pub. L. No. 98-
417, 98 Stat. 1585 (1984).
25. Id. at 860; see also Pfizer, Inc. v. Int'l Rectifier Corp., 545 F. Supp. 486 (C.D. Cal. 1980)
(rejecting as improper the use within the United States of patented doxycycline tablets without
authorization of the patent holder, in order to gain FDA approval).
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

name drugs was not covered under any experimental use defense to liability for
infringement because of the substantial commercial implications of Bolar's
actions. 26 The court held it to be an act of patent infringement for a generic drug
manufacturer to perform tests on a patented product during the patent period
where those tests might lead to FDA approval. 27 A generic company could not
even begin the preclinical and clinical process needed for FDA approval of its
own version before all of the relevant patents on the brand-name drug expired.
Roche v. Bolar served to effectively extend product exclusivity periods and
threatened to dampen the market for generic products even further.
Even though the FDA worked to promote availability of generic entry for
post-1962 drugs, 28 by the late 1970s there were few substitutable generic drugs
on the market. About 150 brand-name drugs lacked generic versions despite
being off-patent, and generics accounted for only nineteen percent of all
prescriptions.29 In one study, only two of the top thirteen drugs between 1976 and 30
1982 were found to have had generic entry within one year of patent expiration.
As explained in more detail below, this created problems for patients and public
health outcomes. Naturally, patients benefit from the introduction of new brand-
name drugs, if those drugs offer substantial advantages in patient care. However,
patients also benefit from the low-cost generic drug market that is intended to
emerge after the brand-name drug patents expire. The high cost of brand-name
drugs can lead to reduced patient adherence to essential drug regimens and to
adverse patient outcomes from excessive spending on healthcare products. 3' The
healthcare system also benefits from reasonable drug price competition, which
permits payors to cover a greater range of healthcare interventions with the same

26. Roche v. Bolar, 733 F.2d at 863.

27. See Kristen E. Behrendt, The Hatch-Waxman Act: Balancing Competing Interests or
Survival of the Fittest, 57 FOOD & DRUG L.J. 247, 249 (2002) (discussing Roche v. Bolar).
28. See supranote 19 for discussion of the paper NDA process.
29. See Gerald J. Mossinghoff, Overview of the Hatch-Waxman Act and Its Impact on the
Drug Development Process, 54 FOOD & DRUG L.J. 187, 187 (1999); see also How Increased
Competitionfrom Generic Drugs Has Affected Pricesand Returns in the PharmaceuticalIndustry,
CONG. BUDGET OFF. at ix (July 1998), http://www.cbo.gov/ftpdocs/6xx/doc655/pharm.pdf (noting
generics accounted for 43% percent of prescription drugs sold in the United States in 1996, but
only 19% twelve years earlier). In 1970, only 8.9% of prescriptions were for generic drugs, a figure
that rose to 12.4% by 1977. Therapeutically Equivalent Drugs, 44 Fed. Reg. 2932 (proposed Jan.
12, 1979); Brian L. Strom et al., Antisubstitution Law Controversy: A Solution?, 81 ANNALS
INTERNAL MED. 254, 256 (1974) ("Between 1968 and 1970, generic prescriptions increased from
8.1% of all new prescriptions to 8.9%.").
30. Richard E. Caves et al., Patent Expiration, Entry, and Competition in the U.S.
PharmaceuticalIndustry, 1991 BROOKINGS PAPERS ON ECONOMIC ACTIVITY: MICROECONOMICS 1,
19 tbl.2.
31. Joshua J. Gagne et al., Comparative Effectiveness of Generic and Brand-Name Statins on
Patient Outcomes: A Cohort Study, 161 ANNALS INTERNAL MED. 400, 400 (2014).
 HATCH-WAXMAN TURNS 30

investment of resources.
It was in this environment that the Hatch-Waxman Act came into force. The
Hatch-Waxman Act was a combination of two separate pieces of legislation that
sought to bolster both the brand-name and generic drug industries.32 The Act was
intended to make low-cost generics more widely available while simultaneously
maintaining adequate incentives for innovation.3 3 To do so, it contained
provisions in four major subcategories: (1) creation of a separate abbreviated
FDA approval pathway for generic drugs proven to be pharmaceutically
equivalent and bioequivalent to their brand-name counterparts; (2) a system to
adjudicate generic manufacturers' challenges to brand-name drug manufacturers'
market exclusivity; (3) assurance of competition-free periods for innovative drug
approvals; and (4) extensions of brand-name market exclusivity. Each is
discussed in turn.

B. Bioequivalence Pathwayfor GenericDrugs

Title I of the Act established a formalized and expedited system for approval
of generic drug products to ensure a vibrant competitive market and lower prices
after the brand-name market exclusivity period ended.34 This system was the
ANDA pathway, which allowed a generic manufacturer to seek FDA approval by
submitting proof that the generic drug was both pharmaceutically equivalent and
bioequivalent to the brand-name version. 35 The statute implemented this pathway
by permitting applicants to "file with the Secretary an abbreviated application for
the approval of a new drug" and specified that such an abbreviated application
need only make a few certifications with respect to the drug product. First, the
applicant must demonstrate that the conditions of use recommended in the
labeling for the new drug are the same as those for a drug already approved by
the FDA as safe and effective. 36 Second, the applicant must provide "information
to show that the other active ingredients of the new drug are the same as the
active ingredients of the listed drug," that the "route of administration, the dosage

32. Mossinghoff, supra note 29, at 188.

33. Engelberg, supra note 2, at 389 (noting that it was "an unprecedented attempt to achieve
two seemingly contradictory objectives, namely, 1) to make lower-costing generic copies of
approved drugs more widely available and 2) to assure that there were adequate incentives to invest
in the development of new drugs").
34. Drug Price Competition and Patent Term Restoration Act, Pub. L. No. 98-417, § 101, 98
Stat. 1585, 1585-92 (1984) (codified as amended at 21 U.S.C. § 3550) (2012)).
35. This was in furtherance of the "Price Competition" aspect of the Hatch-Waxman Act.
Abbreviated New Drug Application (ANDA): Generics, FOOD & DRUG ADMIN. (Sept. 18, 2014),
http://www. fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved
/ApprovalApplications/AbbreviatedNewDrugApplicationANDAGenerics/.
36.21 U.S.C. § 355 (j)(2)(A)(i) (2012).
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

form, and the strength of the new drug are the same as those of the listed drug,"
and that the drug is "bioequivalent to the listed drug."' 37 Finally, the applicant
must certify that the labeling is the same. 38 The government is enjoined from
requiring additional scientific information. 39 Taken together, the criteria for
pharmaceutical equivalence and bioequivalence define therapeutic equivalence.
The FDA promulgated regulations 40 permitting bioequivalence to be
established based on several approaches, the principal one of which became
blood level crossover studies typically done in healthy male volunteers.
Bioequivalence measures drawn from these studies included time until maximum
serum (or plasma) concentration of the drug (Cmax) is reached, or the area under a
curve (AUC) defined by serum concentration as a function of time. The FDA
defined bioequivalence as sufficient demonstration that the ninety percent
confidence intervals for the ratio of pioneer-to-generic AUC and Cmax fall within
an acceptance interval of 0.80-1.25 (known as the "-20%/+25% rule"). 4' A
bioequivalent generic drug, therefore, was required to provide an acceptably
equivalent amount of the drug into the patient's blood stream over an equivalent
period of time.
The ANDA bioequivalence process permitted approval of generic drugs
scientifically proven to work similarly well to their brand-name versions without
subjecting those generic drugs to the same clinical trial requirements already
completed by the brand-name manufacturer.42 If the generic manufacturer could
show pharmaceutical equivalence and bioequivalence, additional Phase II and
Phase III clinical trials would not be necessary.43 Generic manufacturers could
thus focus on making their drugs as inexpensively and high-quality as possible.
Avoiding the costs of these clinical tests was intended to lead to lower drug
prices for consumers and for government payors.44

C. Generic Challenges to Brand-Name Market Exclusivity

In addition to the drug product-related certification required of generic drug

manufacturers in Title I, the Hatch-Waxman Act required a legal certification

37. § 355 (j)(2)(A)(ii)-(iii).

38. § 355 (j)(2)(A)(v).
39. § 355 (j)(2)(A)(viii).
40. Requirements for Submission of Bioavailability and Bioequivalence Data, 21 C.F.R. §
320.21 (2014).
41. Guidance for Industry: Bioavailability and Bioequivalence Studies for Orally-
Administered Drug Products-General Considerations, FOOD & DRUG ADMIN. 20 (2003),
http://www.fda.gov/ohrms/dockets/ac/3/briefing/3995BI-07-GFI-BioAvail-BioEquiv.pdf
42. Eli Lilly & Co. v. Medtronic, Inc., 496 U.S. 661, 676 (1990).
43. See Mutual Pharm. Co. v. Bartlett, 133 S. Ct. 2466, 2471 (2013).
44. H.R. REP. NO. 98-857(11), at 29-32 (1984), reprinted in 1984 U.S.C.C.A.N. 2686, 2713-16.
 HATCH-WAXMAN TURNS 30

regarding the status of the patents protecting the brand-name drug. A

manufacturer seeking to market a generic drug needed to certify to the FDA one
of the following: that no patents existed (Paragraph I); that previous relevant
patents were expired (Paragraph II); that they would wait until currently in-force
patents expired to market their versions (Paragraph III); or that their versions did
not infringe these patents or that the patents were invalid. 45 The final option,
contained in the fourth paragraph of the relevant section of the statute, became
known as a "Paragraph IV" certification.
To assist generic drug manufacturers in identifying patents that claimed the
brand-name drug, or its uses, the FDA required brand-name manufacturers to list
in the book of Approved Drug Products with Therapeutic Equivalence
Evaluations-also known as the Orange Book 46-all relevant patents protecting
their products. The Orange Book, first published in 1978, is a compendium of
FDA-approved products available for generic substitution.47 The two regulatory
criteria for listing a patent in the Orange Book are: (1) that the patent claim an
approved drug, its formulation, or a method of using the drug; and (2) that the
claim can be reasonably asserted in patent infringement litigation.4 8
When a generic manufacturer makes a Paragraph IV certification, it is
required to provide notice to the brand-name manufacturer. 49 An ANDA
submission containing such a certification would be deemed an act of patent
infringement by the statute, and the brand-name company would be given forty-
five days to initiate a lawsuit for alleged infringement. 50 The brand-name
manufacturer's lawsuit would generate an automatic thirty-month stay during
which the FDA could not approve the generic product, in order to allow some
time for the legal process to operate. 51 If patent litigation was not yet complete
after thirty months, generic companies were eligible to obtain final FDA approval

45. Generic Drug Entry Prior to Patent Expiration: An FTC Study, FED. TRADE COMM'N
(2002), https://www.ftc.gov/sites/default/files/documents/reports/generic-drug-entry-prior-patent-
expiration-ftc-study/genericdrugstudyO.pdf [hereinafter Generic Drug Entry Prior to Patent
Expiration].
46. Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations, FOOD
& DRUG ADMIN. (Dec. 21, 2010), http://www.accessdata.fda.gov/scripts/cder/ob/default.cf-n.
47. Id. The Orange Book was named for its orange cover, which was chosen because the
publication date of the first print edition in 1980 was around the time of Halloween. See Approved
Drug Products with Therapeutic Equivalence Evaluations (Orange Book): About the Orange Book,
FOOD & DRUG ADMIN. (Feb. 2015), www.fda.gov/Drugs/InformationOnDrugs/ucm129662.htm.
48. Submission of Patent Information, 21 C.F.R. § 314.53(b) (2014). One category of patents
that are not listable in the Orange Book, for example, is patents covering methods of manufacture.
49. Id. at § 314.52.
50. 35 U.S.C. § 271(e)(2) (2012).
51. 21 U.S.C. § 355(j)(5)(B)(iii) (2012).
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

and launch at risk.52 The Act afforded a six-month period of market exclusivity
to the first generic manufacturer to certify that the Orange Book-listed brand-
name manufacturer's patents were invalid or not infringed.5 3 Prices during that
period would remain higher than they would be in an openly competitive market
with multiple generic competitors, incentivizing generic manufacturers to assume
the legal fees and risks of challenging brand-name manufacturers' patents.54
The goal of creating the Paragraph IV challenge process was to provide a
mechanism through which generic manufacturers could challenge weak patents.
The pathway was necessary because brand-name drugs were (and are) rarely the
subject of a single patent on their underlying active ingredient. Rather, after a
successful molecule has been developed, brand-name drug manufacturers often
obtain numerous secondary patents on peripheral aspects of the product, such as
its coating, salt forms, alternative crystalline structures, and metabolites. 5' These
secondary patents, sometimes issued years after the original molecule's
discovery, can extend the effective market exclusivity of the drug beyond the life
of the first patent. Yet these secondary patented structures may not add to the
efficacy or safety of the original drug. Moreover, the patents themselves are more
likely to be invalid as lacking novelty or for being obvious improvements on
prior patented structures.56 Generic manufacturers seeking to make bioequivalent
versions of the underlying active ingredient could also more easily design around
secondary patents. Thus, there was a strong public policy rationale for building a
system through which generic manufacturers could challenge these patents and
obtain permission to market their approved generic versions as soon as possible
after expiration of the underlying active ingredient's patent. 57 Deputizing generic
manufacturers to break through the thicket of secondary patents surrounding the
original patented molecule would reduce inappropriate or excessive extensions in
market exclusivity by the brand-name manufacturer.

52. Id.
53. § 355(j)(5)(B)(iv).
54. See generally C. Scott Hemphill, Payingfor Delay: PharmaceuticalPatent Settlement as a
Regulatory Design Problem, 81 N.Y.U. L. REV. 1553 (2006) (discussing various aspects of the first-
filer "bounty").
55. Amy Kapczynski et al., Polymorphs and Prodrugs and Salts (Oh My!): An Empirical
Analysis of "Secondary" PharmaceuticalPatents,7 PLoS ONE e49470, at *1 (2012).
56. See Allison A. Schmitt, Competition Ahead? The Legal Landscapefor Reverse Payment
Settlements After Federal Trade Commission v. Actavis, Inc., 29 BERKELEY TECH. L.J. 493, 533
(2014) ("[S]econdary patents are invalidated at a much higher rate than active ingredient patents in
Hatch-Waxman litigation.").
57. Caraco Pharm. Labs. v. Novo Nordisk AIS, 132 S. Ct. 1670, 1678 (2012).
 HATCH-WAXMAN TURNS 30

D. Competition-FreePeriodsfor Innovative DrugApprovals

As it created a process for abbreviated approval of generic drugs, the Hatch-

Waxman Act provided assurance that brand-name manufacturers of innovative
products or uses of drugs would enjoy guaranteed minimum periods of
exclusivity. The legislation mandated that the ANDA process for new molecular
entities (NMEs) would not be allowed to start until five years after FDA approval
of the NME. 58 This guaranteed any manufacturer, even without a patent, at least
five years to earn revenues to recoup research and development (R&D) costs and
obtain monopoly profits. 59 A successful application for a new use or a new
formulation (e.g., immediate to modified delayed or extended release) of a
previously approved drug based on 60
original clinical investigations would receive
three years of market exclusivity.
Because of the thirty-month stay on Paragraph IV certifications, most
NMEs-unless they were not covered by a patent-would be expected to receive
a minimum of seven-and-a-half years of market exclusivity. 61 However, the Act
also superseded Roche v. Bolar, allowing generic manufacturers to experiment
with brand-name manufacturers' drugs to test their bioequivalent versions before
expiration of the patent so that ANDAs could be prepared and submitted to the
FDA without additional delay. 62

E. Extensions of Brand-Name Market Exclusivity

Title II of the Hatch-Waxman Act provided additional incentives for brand-

name drug manufacturers, who had argued that the 1962 Kefauver-Harris

58. 21 U.S.C. § 355(j)(5)(F)(ii) (2012). If the ANDA application contains a Paragraph IV

certification, this period is shortened to four years, but the thirty-month stay is extended so as to
ensure that 7.5 years elapses from the date of approval. Id.
59. § 355(c)(3)(E)(ii); see also Marc Kaufman, Generic Drugs Hit Backlog at FDA, WASH.
POST, Feb. 4, 2006,
http://www.washingtonpost.com/wp-dyn/content/article/2006/02/03/AR2006020302598.html
("The [Office of Generic Drugs] took [in 2005] an average of 20.5 months to review each
application....").
60. § 355 (j)(5)(F)(iii).
61. § 355 (j)(5)(F)(ii) (extending the 30-month period "by such amount of time (if any) which
is required for seven and one-half years to have elapsed from the date of approval of the subsection
(b) application"). Exclusivity could terminate prior to the conclusion of the 30-month period "if
before the expiration of such period the district court decides that the patent is invalid or not
infringed," or, if the district court finds infringement, "the date on which the court of appeals
decides that the patent is invalid or not infringed." § 355(j)(5)(B)(iii).
62. 35 U.S.C. § 271(e)(1) (2012); Pradip K. Sahu & K. Shannon Mrksich, The Hatch- Waxman
Act: When Is Research Exempt from Patent Infringement?, 22 ABA-IPL NEWSL. 23 (2004),
http://www.brinkshofer.coml/resource-center/85-the-hatch-waxman-act-research-exempt-from-
patent-infringement.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

Amendments unfairly shortened their effective exclusivity periods by requiring a

lengthy process of clinical testing and FDA review. 63 The seventeen-year patent
term in effect in 1984 began at the time the patent was granted, 64 which could
occur years prior to FDA approval. In cases in which development and approval
took especially long, brand-name manufacturers might find that little or no patent
term remained by the time the FDA approved the drug for marketing.
The Hatch-Waxman Act addressed this issue by granting brand-name
companies "patent term restoration," or additional time that would be added to
the seventeen-year patent term to compensate the patent holder for a portion of
the patent term that was lost during the clinical testing phases and FDA review
period. 65 For any first approval of a product subject to a regulatory review period,
the extension applied to any patents that claimed products, methods of using the
products, or methods of manufacturing the products as long as the patents were
still in force at the time of the extension application and had not been extended
before.66 If more than one patent were asserted as applying to a given drug
product, only one patent's term could be extended.67 The period of patent term
extension was calculated by adding one half of the time from the filing of the
IND to the filing of the NDA to the full time during which the FDA had reviewed
the NDA.68 Since some of the lost marketing time results from necessary
development effort rather than government delay, the extension was capped at
five years, and overall could not extend patent expiration past fourteen years
from the date of the drug's FDA approval. 69 The time extensions did not include
time before the issuance of the patent or periods in which the patent holder did
not act with "due diligence.., in seeking FDA approval. 7 °

63. B.P. Nagori et al., Generic Drug Approval: A U.S. Perspective, 27 CURRENT MED. RES. &
OPINION 541, 543 (2011).
64. The patent term now ends twenty years from the date of filing, 35 U.S.C. § 154(a) (2012),
creating an even greater lag between when the patent "clock" begins to run and FDA approval.
65. The issue was also addressed by the enactment of the Prescription Drug User Fee Act of
1992 (PDUFA), Pub. L. No. 102-571, 106 Stat. 4491, which authorized the FDA to collect "user
fees" from pharmaceutical manufacturers. These fees allowed the FDA to hire more employees,
which reduced the time needed for the FDA to review new drug applications. See Jonathan J.
Darrow et al., New FDA Breakthrough Drug Category: Implicationsfor Patients,370 NEw ENG. J.
MED. 1252, 1253 (2014).
66. 35 U.S.C. § 156(a)(l)-(2) (2012).
67. § 156(c)(4).
68. § 156(c)(2).
69. § 156(c)(3) & (g)(6).
70. A due diligence limitation could only be invoked by special petition from another party
filed within 180 days of the publication of the patent term extension determination. The FDA has
never received a petition charging lack of due diligence. Small Business Assistance: Frequently
Asked Questions on the Patent Term Restoration Program, FOOD & DRUG ADMIN.,
http://www.fda.gov/drugs/developmentapprovalprocess/smalibusinessassistance/ucm69959.htm
 HATCH-WAXMAN TURNS 30

F. Summary

Title II of the Hatch-Waxman Act provided additional incentives for brand-

name drug manufacturers, who had argued that the 1962 Kefauver-Harris
Amendments unfairly shortened their effective exclusivity periods by requiring a
lengthy process of clinical testing and FDA review. 7' The seventeen-year patent
term in effect in 1984 began at the time the patent was granted, 72 which could
occur years prior to FDA approval. In cases in which development and approval
took especially long, brand-name manufacturers might find that little or no patent
term remained by the time the FDA approved the drug for marketing.

11. THE HATCH-WAXMAN LEGACY

n the years after the Hatch-Waxman Act, hundreds of new generic drugs
were approved via the bioequivalence ANDA pathway. For seventeen major
drugs with patents expiring between 1990 and 1993, fourteen had generic entry
in just over one month following patent expiration. 73 State-level "Drug Product
Selection" (DPS) laws aided in the widespread use of these generics. In this
section, we discuss the various contributors to the legacy of the Hatch-Waxman
Act.

A. Innovation by Brand-Name Drug Manufacturers

There have been no direct studies of the success of the Hatch-Waxman Act
with respect to brand-name drug innovation, which was one of the two primary
goals of the legislation.74 Studies investigating the patent terms of new
prescription drugs before and after the legislation show an effect on lengthening
market exclusivity, as intended. One study found that after passage of the Hatch-

(last updated Mar. 31, 2009) ("At the present time no due diligence petition has been submitted to
FDA."). In addition, according to one report, no patent term extension has ever been limited by lack
of due diligence. Jeffrey S. Boone, Patent Term Extensions for Human Drugs Under the U.S.
Hatch- Waxman Act, 4 J. INTELL. PROP. L. & PRAC. 658, 659-60 (2009).
71. Nagori et al., supra note 63, at 543.
72. The patent term now ends twenty years from the date of filing, 35 U.S.C. § 154(a) (2012),
creating an even greater lag between when the patent "clock" begins to run and FDA approval.
73. CONG. BUDGET OFFICE, How INCREASED COMPETITION FROM GENERIC DRUGS HAS
AFFECTED PRICES AND RETURNS IN THE PHARMACEUTICAL INDUSTRY 67 app. (1998),
http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/6xx/doc655/pharm.pdf.
74. Examining a broader context, one author uncovered evidence suggesting that
overaggressive intellectual property law and enforcement may stifle innovation. See Michael A.
Carrier, Copyright and Innovation: The Untold Story, 2012 Wis. L. REV. 891 (using survey data
from thirty-one CEOs, company founders, and vice-presidents from technology companies, the
recording industry, and venture capital firms).
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

Waxman Act, the market exclusivity period for brand-name drugs introduced
between 1990 and 1995 was 11.7 years as a result of the patent term restoration
process, compared to 8.1 years for drugs approved between 1980 and 1984. 75
More recent studies have generally been consistent with the earlier studies,
finding that actual average pharmaceutical market exclusivity periods (i.e., the
76
time between approval and first generic entry) are approximately twelve years.
Other studies have looked at the number of new drug introductions. Since
the Hatch-Waxman Act was enacted, the number of new drugs approved each
year has generally reflected the continued upward trend that has characterized the
market since the 1950s. 77 Studies have also shown an increase in the average
R&D expenditures per drug approval.78 According to one report, pharmaceutical
R&D spending has increased by nine percent annually in real terms.79 There does
not appear to be a relationship between the cost of innovative drug R&D and the
Hatch-Waxman Act.
By contrast, there may be a relationship between the existence of vigorous
and timely generic competition and brand-name manufacturers' willingness to
invest in innovative drug development. Low-cost generic drugs advance
innovation in the pharmaceutical marketplace by forcing innovator

75. Henry G. Grabowski & John M. Vernon, Effective Patent Life in Pharmaceuticals, 19
INT'L J. TECH. MGMT. 98, 103, 109 (2000) (finding a mean 11.7 years); Henry G. Grabowski &
John Vernon, Longer Patents for Increased Generic Competition in the U.S., 10
PHARMACOECONOMICS 110, 118 (1996) (finding a mean of 8.1 years); Henry G. Grabowski & John
M. Vernon, Returns to R&D on New Drug Introductions in the 1980s, 13 J. HEALTH ECON. 383,
389 (1994) (finding a mean of 9-13 years).
76. Henry G. Grabowski & Margaret Kyle, Generic Competition and Market Exclusivity
Periods in Pharmaceuticals,28 MANAGERIAL & DECISION EcON. 491, 493 (2007) (reporting 10.5 to
12.5 years for market size categories above $100 million); C. Scott Hemphill & Bhaven N. Sampat,
Evergreening, Patent Challenges, and Effective Market Life in Pharmaceuticals,31 J. HEALTH
ECON. 327, 330 tbl.1 (2012) (finding a mean of 12.15 years).
77. See Bernard Munos, Lessons from 60 Years of PharmaceuticalInnovation, 8 NATURE
REVIEWS: DRUG DISCOVERY 959, 959 (2009); see also Jonathan J. Darrow & Aaron S. Kesselheim,
Trends in Drug Development and Approval, 1987-2013, 370 NEW ENG. J. MED. e39 (2014). The
number of new molecular entities (NMEs) approved during the twenty years following Hatch-
Waxman (1985-2004; 602 NMEs) was 79% greater than during the twenty years prior to Hatch
Waxman (1965-1984; 336 NMEs). Id.
78. See, e.g., Fabio Pammolli et al., The Productivity Crisis in PharmaceuticalR&D, 10
NATURE REVIEWS: DRUG DISCOVERY 428, 428 (2011) (noting that "although investment in
pharmaceutical research and development (R&D) has increased substantially in this time, the lack
of a corresponding increase in the output in terms of new drugs being approved indicates that
therapeutic innovation has become more challenging"); Jack W. Scannell et al., Diagnosing the
Decline in PharmaceuticalR&D Efficiency, 11 NATURE REVIEWS: DRUG DISCOVERY 191, 191
(2012).
79. WENDY H. SCHACHT & JOHN R. THOMAS, CONG. RESEARCH SERV., CRS-7-5700, THE
HATCH-WAXMAN ACT: A QUARTER CENTURY LATER 16 (2012).
 HATCH-WAXMAN TURNS 30

pharmaceutical companies to develop new products that will contribute to the

next generation of therapies and medical progress, rather than simply re-investing
in their current drug product lines. 80 Graham and Higgins studied 308
pharmaceutical companies with one FDA-approved product between 1985 and
2001 and found that loss of market exclusivity protection was the "most
important predictor" of the arrival of a new product and the number of new
product introductions. They concluded that pharmaceutical companies act
strategically with respect to new product introductions, timing the introduction
according to when exclusivity is expiring on their other products and in particular
"targeting the three-year window around the loss of exclusivity to introduce new
products." 81
Thus, data show that the Hatch-Waxman Act increased market exclusivity
periods for brand-name drugs, but there is no clear evidence that these longer
periods had any impact on rates of brand-name drug innovation. Circumstantial
evidence suggests that the vigorous generic substitution market organized by the
legislation may help provide a stimulus for brand-name drug innovation. Further,
many new products are not genuinely innovative and there has been much
consolidation in the pioneer industry with consequent reduction in pipelines for
new drug development.

B. Use of Generic Drugs

While the relationship between the passage of the Hatch-Waxman Act and
brand-name drug innovation has not been firmly established, the legislation
indisputably helped galvanize increases in the overall dispensing of generic drugs
in the United States. The less expensive Hatch-Waxman ANDA regulatory
approval process was a major factor in allowing generic drugs to reach the
market expeditiously and with less up-front investment. As a consequence,
generic drugs could be offered at substantially lower prices than their

80. See United States v. Aluminum Co. of Am., 148 F.2d 416, 427 (2d Cir. 1945) ("Many
people believe that possession of unchallenged economic power deadens initiative, discourages
thrift and depresses energy; that immunity from competition is a narcotic, and rivalry is a stimulant,
to industrial progress; that the spur of constant stress is necessary to counteract an inevitable
disposition to let well enough alone."). See generally Kenneth J. Arrow, Economic Welfare and the
Allocation of Resourcesfor Invention, in ESSAYS INTHE THEORY OF RISK-BEARING 144, 157 (3d ed.
1976) (declaring "the incentive to invent is less under monopolistic than under competitive
conditions"); Joseph E.Stiglitz, Economic Foundations of Intellectual Property Rights, 57 DUKE
L.J. 1693, 1696 (2008) (arguing that that an excessively strong intellectual property regime can
impede innovation).
81. Stuart J. Graham & Matthew J. Higgins, The Impact of Patenting on New Product
Introductions in the Pharmaceutical Industry, MUNICH PERS. REPEc ARCH. 2 (2007),
http://mpra.ub.uni-muenchen.de/4574/l/MPRA-paper_4574.pdf.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

corresponding brand-name products, which quickly reduced drug costs for

patients and payors. 82 One study showed a more than five-fold increase in the
percentage of brand-name prescriptions being filled with generics from 1980 to
1989.83 By 2002, the Federal Trade Commission (FTC) could confidently state
that "[b]eyond any doubt, Hatch-Waxman has increased generic drug entry,"
noting that the generic drug prescription fill rate had increased to forty-seven
percent. 84 Based on market and other incentives, generic usage continued to
increase dramatically to sixty percent in 2005, seventy-four percent in 200985 and
eighty-four percent in 2012.86
In addition to spurring the creation of a competitive market with numerous
generic drug entrants after patent expiration, the Hatch-Waxman Act successfully
created a pathway that stimulated generic drug manufacturers to initiate lawsuits
challenging existing brand-name drug patents. Generic manufacturer-led
Paragraph IV challenges as a fraction of contributions to all new generic drug
approvals increased from two percent in the 1980s to approximately twenty
percent by 2000.87 As the statute intended, studies have shown that Paragraph IV
challenges commonly addressed secondary patents covering peripheral
components of the drug, rather than the patent on the underlying active
ingredient.88 Indeed, these same studies show that the patents subject to
Paragraph IV challenges also tended to be lower "quality," defined as being in
retrospect much more likely to have been improperly granted by the United

82. See generally How Increased Competition from Generic Drugs has Affected Prices and
Returns in the Pharmaceutical Industry, CONG. BUDGET OFF. (1998),
http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/6xx/doc655/pharm.pdf (explaining the
impact of generic drugs on brand-name drug revenues).
83. Caves et al., supra note 30, at 7 ("[G]eneric substitution for brand-written multisource
prescriptions is relatively infrequent, confined to 29 percent of these prescriptions in 1989 ...[as
compared to] 5 percent of brand-written multisource prescriptions in 1980.").
84. Generic Drug Entry Priorto Patent Expiration,supra note 45, at i.
85. Ernst R. Berndt & Murray Aitken, Brand Loyalty, Generic Entry and Price Competition in
Pharmaceuticalsin the Quarter Century After the Waxman-Hatch Legislation, 18 INT'L J. ECON.
Bus. 177, 181 fig.2, 183 tbl.l, 186 (2011).
86. Thomas, supra note 4, at Al. IMS is a leading provider of data regarding drug prices and
sales. See also All Together Now: Liberalisation and the Quest for Scale are Pushing Generic-
Drug Firms to Merge, ECONOMIST, July 24, 2008 ("Generics make up nearly two-thirds of the
American drugs market by volume, but only thirteen percent by value.").
87. Generic Drug Entry Prior to Patent Expiration, supra note 45, at 10 ("According to the
data provided by the FDA, during the 1980s (1984-89), only 2 percent of ANDAs contained
paragraph IV certifications. This share increased to approximately 12 percent for the 1990s, and it
has increased substantially in the last few years: from 1998-2000, approximately 20 percent of
ANDAs contained paragraph IV certifications.").
88. C. Scott Hemphill & Bhaven N. Sampat, When Do Generics Challenge Drug Patents?, 8
J. EMPIRICAL LEGAL STUD. 613 (2011).
 HATCH-WAXMAN TURNS 30

States Patent and Trademark Office (USPTO). 89

In the late 1970s and early 1980s, the growth of DPS laws in each of the
fifty states bolstered the impact of the Hatch-Waxman Act's generic approval
and challenge pathways in helping set an environment in which generic
competition for brand-name drugs could flourish after their market exclusivity
terms expired. 90 For much of the early twentieth century, generic drug
manufacturers were less reputable 9' and many physicians and pharmacists
worried about the safety of drugs made by these companies.9 2 By the 1960s,
nearly every state had "anti-substitution laws" that required pharmacists to fill
physicians' prescriptions exactly as written and not to substitute a similarly
named product made by a different manufacturer. 93 Generic drugs, because of
these barriers, did not present an effective competitive 94alternative to brand-name
drugs, even when they were therapeutically equivalent.
However, after the Kefauver-Harris Amendments introduced assurance of
safety and efficacy for new products, 95 many states started repealing their anti-
substitution statutes, replacing them with laws that allowed prescriptions to be
filled with FDA-approved generic drugs. 96 If the FDA certified a generic drug as
safe and efficacious for its intended use, there was no clinical or public health
reason to prevent it from being substituted at the pharmacy for a prescription
written for a bioequivalent brand-name drug. The publication of the Orange Book
contributed to the increase in demand for generic drugs occasioned by the repeal

89. Id.
90. Allan I. Wertheimer, The Irony of Drug Product Selection, 70 AM. J. PUB. HEALTH 473
(1980).
91. DOMINIQUE A. TOBBELL, PILLS, POWER, AND POLICY: THE STRUGGLE FOR DRUG REFORM IN
COLD WAR AMERICA AND ITS CONSEQUENCES 165 (2012).
92. Joint Statement on Antisubstitution Laws and Regulations, 225 JAMA 142 (1973).
93. Tony Burton et al., A History of Antisubstitution Laws and Their Replacement by Drug
Product Substitution Laws, in GENERIC DRUG LAWS: A DECADE OF TRIAL-A PRESCRIPTION FOR
PROGRESS (Theodore Goldberg et al. eds., 1986); Peter Allen Younkin, A Healthy Business: The
Evolution of the U.S. Market for Prescription Drugs 45-72 (2010) (unpublished Ph.D. dissertation,
Univ. of Calif., Berkeley), http://escholarship.org/uc/item/7zx4c6l f.pdf.
94. Henry G. Grabowski & John M. Vernon, Brand Loyalty, Entry, and Price Competition in
PharmaceuticalsAfter the 1984 Drug Act, 35 J.L. & ECON. 331 (1992).
95. Daniel P. Carpenter & Dominique A. Tobbell, Bioequivalence: The Regulatory History of
a Scientific Concept, 85 BULL. HIST. MED. 93 (2011).
96. William H. Shrank et al., State GenericSubstitution Laws Can Lower Drug Outlays Under
Medicaid, 29 HEALTH AFF. 1383 (2010) [hereinafter Substitution Laws]. Model state Drug Product
Selection legislation was developed by the Department of Health and Human Services (HHS) and
the Federal Trade Commission (FTC), which set up a structure for state-based drug formularies that
would list equivalent drug products, potentially including all drug products determined by the FDA
to be therapeutically equivalent. Therapeutically Equivalent Drugs; Availability of List, 45 Fed.
Reg. 72,582, 72,583 (Oct. 31, 1980) (codified at 21 C.F.R. pt. 20).
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

of anti-substitution laws and the enactment of DPS laws. 97 With its central listing
of all FDA-approved generic products,98 the Orange Book allowed healthcare
decision makers to easily determine which generic products were both
bioequivalent and pharmaceutically equivalent (meaning they had the same
dosage strength and form, e.g., tablet to tablet, capsule to capsule), to the
reference-listed brand-name drug. 99 A key purpose of developing this list of
bioequivalent drugs was to make drugs products 100 "sufficiently interchangeable so
that price can be a major factor in their selection.1
By the mid-1980s, all fifty states had repealed their anti-substitution laws
and replaced them with laws encouraging substitution, at the level of the
pharmacy, of less-expensive generic drugs approved by the FDA as being
pharmaceutically equivalent and bioequivalent to the brand-name version. Some
state boards of pharmacy adopted mandatory generic substitution laws. 101 These
required pharmacists to substitute a less-expensive generic for a brand-name
medication unless the prescriber specified that only the brand-name drug should
be dispensed. More permissive DPS laws enacted in other states give pharmacists
more discretion by allowing, but not requiring, pharmacists to substitute less-
expensive generics.10 2 In addition, some states 1require
03
patient consent before
substitution of a generic, while other states do not.
The new state DPS laws allowed the Hatch-Waxman Act generic drug
approval pathway to flourish' 4 because of the unique relationship of the patient,

97. See Substitution Laws, supra note 96.

98. Orange Book Preface,APPROVED DRUG PRODUCTS WITH THERAPEUTIC EQUIVALENTS (34th
ed. 2014), http://www.fda.gov/Drugs/DevelopmentApprovalProcess/ucm079068.htm (last updated
Mar. 14, 2014).
99. Id. One of the goals of the Orange Book was to create a list of therapeutically equivalent
drugs, and it was believed that "publication of the List will lend to increased consumer awareness
of less expensive therapeutically equivalent prescription drug products." Therapeutically
Equivalent Drugs, 45 Fed. Reg. 72,582, 72,583 (Oct. 31, 1980) (codified at 21 C.F.R. pt. 20). This
"increased awareness should stimulate greater consumer demand for less expensive therapeutic
equivalents, and physicians and pharmacists should be influenced to respond to that demand by
prescribing and dispensing such less expensive drug products." Id.
100. OFFICE OF TECH. ASSESSMENT, U.S. CONG., DRUG BIOEQUIVALENCE: A REPORT OF THE
OFFICE OF TECHNOLOGY ASSESSMENT DRUG BIOEQUIVALENCY STUDY PANEL 57 (1974).
101. Jesse C. Vivian, Generic-Substitution Laws, U.S. PHARMACIST, June 2008, at 30.
102. Shrank et al., supra note 96, at 1384.
103. Id.
104. Other policies, such as the introduction of tiered formularies by insurance companies,
have also incentivized the use of generic medicines. See, e.g., Haiden A. Huskamp et al., The Effect
of Incentive-Based Formularieson Prescription-DrugUtilization and Spending, 349 NEW ENG. J.
MED. 2224, 2231 (2003) ("[A] sizeable minority of patients did change to less expensive tier-I [i.e.
generic] or tier-2 [i.e. preferred non-generic] alternatives [following implementation of a three-tier
formulary] .... ").
 HATCH-WAXMAN TURNS 30

prescriber, and payor in the pharmaceutical marketplace: the physician writes the
prescription for the medication, the pharmacist dispenses and sells the medication
(provided it has the same non-proprietary name), and the patient (or patient's
insurer) pays for the medication. The separation of the prescription-writing act
from the prescription-paying act caused a disconnect between medication use and
payment in ways that hindered or prevented effective price competition. In 1979,
an FTC report observed, "the forces of competition do not work well in a market
where the consumer who pays does not choose and the physician who chooses
does not pay."' 0 5 The FTC report lamented the ability of FDA-approved
therapeutically equivalent products to lead to reduced prices because physicians
were not involved in paying for drugs and were largely unaware of drug prices.
Physicians' lack of awareness of drug prices and spending by patients on drugs
persists to the present day. 1 06 Importantly, as the 1979 FTC report recognized, the
price disconnect could be bridged by the pharmacist. 107 The report noted that
pharmacists

have both the power and the incentive to respond to lower prices. That is
the role envisioned for the drug product selection laws: to transfer some of
this power to pharmacists. Consumers are the ones most interested in a
lower price, and pharmacists must respond to consumer demand because of
direct competition with other pharmacies on prescription prices. 108
09
With the Hatch-Waxman Act, the number of AB-rated generic versions of

105. Alison Masson & Robert L. Steiner, Generic Substitution and PrescriptionDrug Prices:
Economic Effects of Drug Product Selection Laws, FED. TRADE COMM'N 2 n.4 (1985),
https://www.ftc.gov/sites/default/files/documents/reports/generic-substitution-prescription-drug-
prices-economic-effects-state-drug-product-selection-laws/massonsteiner.pdf, see also 22
LEGISLATIVE HISTORY OF THE FOOD, DRUG & COSMETIC ACT AND ITS AMENDMENTS 17,368 (1962)
(highlighting the absence of prescription drug price competition: "[H]e who orders does not buy
and he who buys does not order"); Brief for FTC as Amicus Curiae, Mylan Pharm., Inc. v. Warner
Chilcott Pub. Ltd. Co., Civ. No. 12-3824, 2013 WL 6145117 (E.D. Pa. Nov. 20, 2013), 2012 WL
7649225, at *11 ("The physician, who selects the drug product but does not pay for it-has little
incentive to consider price when deciding which drug to prescribe.").
106. See G. Michael Allan et al., Physician Awareness of Drug Cost: A Systematic Review, 4
PLoS MED. 1486, 1493 (2007); Fiona M. Scott Morton, Barriers to Entry, Brand Advertising, and
Generic Entry in the U.S. PharmaceuticalIndustry, 18 INT'L J. INDUS. ORG. 1086, 1088 (2000); Ya-
Chen Tina Shih & Betsy L. Sleath, Health Care ProviderKnowledge of Drug Formulary Status in
Ambulatory Care Settings, 61 AM. J. HEALTH-SYSTEM PHARMACISTS 2657, 2662 (2004); William
H. Shrank et al., Physicians' Perceived Knowledge of and Responsibility for Managing Patients'
Out-of-Pocket Costsfor PrescriptionDrugs, 40 ANNALS PHARMACOTHERAPY 1534, 1538 (2006).
107. BUREAU OF CONSUMER PROT., FED. TRADE COMM'N, DRUG PRODUCT SELECTION: STAFF
REPORT TO THE FEDERAL TRADE COMMISSION 168 (1979).
108. Masson & Steiner, supra note 105, at 7.
109. "Multisource drug products listed under the same heading (i.e., identical active
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

reference brand-name products listed in the Orange Book grew as more generic
manufacturers took advantage of the ANDA bioequivalence pathway and, later,
Paragraph IV challenges. The state DPS laws helped lead to rapid uptake of
bioequivalent generic drugs in practice without the time and expense needed to
encourage physicians to change their prescribing practices. After the relevant
brand-name manufacturers' exclusivity periods expired, generic manufacturers
could compete purely on the basis of price, leading to rapid consumer savings." 0
Indeed, early studies showed rapid improvement in consumer access to generic
drugs. ' Shortly after the Hatch-Waxman Act came into effect, the end of a
brand-name drug's market exclusivity period became synonymous with the
manufacturer's loss of revenue and the onset of significant generic price
competition for that drug. As a result of the Hatch-Waxman Act and pro-
substitution DPS laws in each state supporting automatic substitution by the
pharmacist," 2 generic drugs generally now sell for between twenty and seventy
percent of the original price of the drug and 3take up to ninety percent of the
brand's sales within a year after generic entry. "1

C. Impact on Patient Outcomes and HealthcareSpending

Since the Hatch-Waxman Act, studies and substantial clinical experience

ingredient[s], dosage form, and route(s) of administration) and having the same strength...
generally will be coded AB if a study is submitted demonstrating bioequivalence." FOOD & DRUG
ADMIN., APPROVED DRUG PRODUCTS WITH THERAPEUTIC EQUIVALENCE EVALUATIONS xvi (35th ed.
2015).
110. See generally Allen M. Sokal & Bart A. Gerstenblith, The Hatch-Waxman Act:
Encouraging Innovation and Generic Drug Competition, 10 CURRENT ToPICs MED. CHEM. 1950
(2010) (discussing the intended purposes of the Hatch-Waxman Act).
111. See, e.g., Norman V. Carroll et al., The Effects of Differences in State Drug Product
Selection Laws on Pharmacists' Substitution Behavior, 25 MED. CARE 1069, 1076 (1987);
Theodore Goldberg et al., Evaluation of Economic Effects of Drug Product Selection Legislation,
17 MED. CARE 411,415-17 (1979).
112. Masson & Steiner, supra note 105. See generally Shrank et al., supra note 96 (discussing
the potential cost savings of generic substitution laws).
113. Ann Martin et al., Recession Contributes to Slowest Annual Rate of Increase in Health
Spending in Five Decades, 30 HEALTH AFF. 11, 18 (2011) (noting that generic drugs cost "30-80
percent less than their brand-name counterparts"); Pay-for-Delay: How Drug Company Pay-Offs
Cost Consumers Billions, FED. TRADE COMM'N: 8 (2010),
http://www.ftc.gov/os/2010/01/100112payfordelayrpt.pdf. The variability in the discounts generic
drugs can offer over the brand-name version depends on many factors, including the cost of
production, but is primarily related to the number of direct generic competitors. See Generic
Competition and Drug Prices, FOOD & DRUG ADMIN. (Mar. 1, 2010),
http://www.fda.gov/AboutFDA/CentersOffices/OfficeofvedicalProductsandTobacco/CDER/ucm 1
29385.htm (revealing that generic drug prices reach about 55% of the brand-name price when two
competitors are in the market, 33% when there are five competitors, and 13% when there are
fifteen).
 HATCH-WAXMAN TURNS 30

have supported the bioequivalence standard as a means of ensuring the efficacy

and safety of generic drugs for patients. 114 Patients who receive a generic drug
have experienced the same beneficial clinical outcomes and risks of side effects
as patients taking brand-name drugs. On a pharmacologic level, a review by the
FDA of bioequivalence studies conducted between 1996 and 2007 found that the
average difference in bioequivalence measures between generic and innovator
products was about four percent, and that in nearly ninety-eight percent of the
bioequivalence studies, the pharmacodynamics (i.e., the effect of the drug in the
human body) of the generic product differed from that of the innovator product
by less than ten percent. 115 The FDA standard for bioequivalence requires that
the bioequivalence measures be within 80-125%, a standard that also applies to
the variability between lots of branded drugs." 6 This review therefore
demonstrated that generics were produced at a level of pharmaceutical quality
consistently well within FDA standards.
Thus, as approved, generic drugs have produced the same clinical effects for
patients as their brand-name counterparts.1 7 No prospective randomized
controlled trials comparing brand-name and AB-rated generic drugs have shown
any clinically significant variations in outcomes between brand-name and generic
drugs. Two systematic reviews of studies comparing clinical outcomes from the
use of brand-name and generic drugs in all types of cardiovascular disease" 8 and
for epilepsy" 9 found no evidence of worse clinical outcomes from the use of
generic drugs for these conditions. Other well-controlled studies of individual

114. Therapeutic Equivalence of Generic Drugs: Letter to Health Practitioners, FOOD &
DRUG ADMIN. (Jan. 28, 1998),
http://www.fda.gov/Drugs/DevelopmentApprova]Process/HowDrugsareDevelopedandApproved/A
pprovalApplications/AbbreviatedNewDrugApplicationANDAGenerics/ucm073182.htm.
115. Barbara M. Davit et al., Comparing Generic and Innovator Drugs: A Review of 12 Years
of Bioequivalence Data from the United States Food and Drug Administration, 43 ANNALS
PHARMACOTHERAPY 1583, 1588 (2009).
116. 21 C.F.R. § 210.3(b)(2) & (10) (2014); Guidancefor Industry: Process Validation, FOOD
& DRUG ADMIN. 6 (Jan. 2011), http://www.fda.gov/downloads/Drugs/GuidancesUCM070336.pdf
[hereinafter Process Validaton]; Letter from Roger L. Williams, M.D., U.S. Food & Drug Admin.,
to Carmen A. Catizone, Nat'l Ass'n of Bds. of Pharmacy 2-4 (Apr. 16, 1997),
http://www.fda.gov/ohrms/dockets/dailys/04/JuneO4/060804/03p-0 I26-supOO06-Attachment
-H-vol3.pdf [hereinafter Letter from Roger L. Williams to Carmen A. Catizone] (discussing the
range of 80-125%).
117. Aaron S. Kesselheim et al., The Clinical Equivalenceof Generic and Brand-Name Drugs
Used in CardiovascularDisease: A Systematic Review and Meta-Analysis, 300 JAMA 2514, 2524
(2009) (concluding that "generic and brand-name cardiovascular drugs are similar in nearly all
clinical outcomes").
118. Id. at 2514.
119. Aaron S. Kesselheim et al., Seizure Outcomes Following Use of Generic vs. Brand-Name
Antiepileptic Drugs:A Systematic Review and Meta-Analysis, 70 DRUGS 605, 619 (2010).
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

drugs or drug classes have also concluded that generic substitution

12
does not
events.
exacerbate disease or increase drug-related adverse
120 1

The increased availability of therapeutically equivalent generic drugs

approved via the Hatch-Waxman ANDA pathway has had an important and
positive effect on patient care. Low-cost generic drugs have been shown to
promote adherence to medication regimens,' 22 enhance access to drugs for lower-
income patients, 123 and reduce financial strain caused by illness. 24 With these
improvements, more patients experience the benefits from essential prescription 25
drug therapies, which translates into better patient health outcomes.
Medication non-adherence, which occurs when patients do not take medications
as prescribed by their healthcare providers, is a key public health issue.126 A
study of patients with hypertension, hyperlipidemia, and diabetes found that one
in four patients failed to adhere to their medication regimen. 127 Non-adherence
has been linked to adverse health effects including stroke in hypertensive
patients, higher viral load in patients with H1V, and hospitalization and mortality
in patients with heart failure. 128 Overall, approximately 125,000 lives are lost
annually from non-adherence. 129 The cost to the U.S. healthcare system may
exceed $100 billion per year due to complications that could have been prevented

120. Scott T. Devine et al., Acute Epilepsy Exacerbations in Patients Switched Between A-
Rated Anti-Epileptic Drugs, 26 CURRENT MED. RES. & OPINION 455, 463 (2010).
121. Meytal A. Tsadok et al., Amiodarone-Induced Thyroid Dysfunction: Brand-Name Versus
Generic Formulations, 183 CANADIAN MED. Ass'N J. E817, E823 (2011).
122. The Implications of Choice, supra note 6, at 335.
123. See Yuting Zhang et al., Access to and Use of $4 Generic Programs in Medicare, 27 J.
GEN. INTERNAL MED. 1251, 1256 (2012) (noting that only 16.3% used a $4 program in 2007).
124. See Vicki Fung et al., Responses to Medicare Drug Costs Among Near-Poor Versus
Subsidized Beneficiaries,48 HEALTH SERVS. RES. 1653, 1661-62 (2013).
125. See Gagne et al., supra note 31, at 405.
126. Joyce A. Cramer et al., Medication Compliance and Persistence: Terminology and
Definitions, 11 VALUE HEALTH 44, 46 (2008); Lars Osterberg & Terrence Blaschke, Adherence to
Medication, 353 NEw ENG. J. MED. 487,487 (2005).
127. Michael A. Fischer et al., Primary Medication Non-Adherence: Analysis of 195,930
Electronic Prescriptions, 25 J. GEN. INTERNAL MED. 284, 288 tbl.4 (2010) (finding that patients
over 18 years of age filled 76.5% of their e-prescriptions).
128. Ashley A. Fitzgerald et al., Impact of Medication Nonadherenceon Hospitalizationsand
Mortality in Heart Failure, 17 J. CARDIAC FAILURE 664, 668 (2011); Marcia McDonnell Holstad et
al., Adherence, Sexual Risk, and Viral Load in HIV-Infected Women Prescribed Antiretroviral
Therapy, 25 AIDS PATIENT CARE & STDs 431, 437 (2011); Paul Muntner et al., Low Medication
Adherence and the Incidence of Stroke Symptoms Among Individuals with Hypertension: The
REGARDS Study, 13 J. CLrNICAL HYPERTENSION 479, 484 (2011) (concluding that "a graded
association was present between worse medication adherence and a higher risk for developing new
stroke symptoms").
129. Gary E. Applebaum, Cut Drug Copayments to Bolster "Adherence," BALT. SUN, June 16,
2009, http://articles.baltimoresun.com/2009-06-16/news/0906150027 1 non-adherence-health-
care-system-improve-patient-adherence.
 HATCH-WAXMAN TURNS 30

if patients had taken their medications as prescribed. 130

One of the key contributors to medication non-adherence is the high cost of
prescription drugs. 131 In one survey, one-third of elderly patients reported not
filling a prescription or taking a reduced dose as a result of the drug's high out-
of-pocket costs. 132 By contrast, generic drugs' lower prices promote patient
adherence to essential medications. 33 This can be particularly important for
patients with limited income and public insurance programs with constrained
budgets. Thus, increasing availability of generic drugs has contributed to
substantial improvements in public health outcomes.
The increased availability of generic drugs also has financial benefits for
United States taxpayers. As healthcare costs rise, the cost of medications
purchased by government programs becomes an important health policy issue. 134
Within Medicaid-the federal- and state-funded healthcare insurance program
for the poor-annual spending on prescription drugs increased from $22.3 billion
in 2007 to $25.4 billion in 2009. This accounted for 6.6 percent of total Medicaid
spending on all services during those years and ten percent of total prescription
drug spending in the United States.1 35 High spending on healthcare can be
damaging to the economy, 136 and as a result of high costs, payors have cut
benefits or increased co-payments, and public insurers have raised their
thresholds for eligibility. 37 Reducing drug costs thus allows the benefits of all
healthcare services to be spread more widely throughout society. 138 The

130. Osterberg & Blaschke, supra note 126, at 488.

131. See Dana P. Goldman et al., Prescription Drug Cost Sharing: Associations with
Medication and Medical Utilization and Spending and Health, 298 JAMA 61, 65 (2007); Osterberg
& Blaschke, supra note 126, at 491 tbl.2.
132. Thomas S. Rector & Patricia J. Venus, Do Drug Benefits Help Medicare Beneficiaries
Afford PrescribedDrugs?, 23 HEALTH AFF. 213, 219 (2004).
133. The Implicationsof Choice, supra note 6, at 335.
134. Kelly Kennedy, States Scramble to Drive Down Medicaid Drug Costs, USA TODAY,
Aug. 12, 2013, http://www.usatoday.com/story/news/politics/2013/08/1 I/medicaid-drug-
benefit/2636891 /("The increase in spending for Medicaid, the federal-state health care program for
low-income Americans, has bedeviled states for decades.").
135. Medicaid Payment for Outpatient Prescription Drugs, KAISER FAM. FOUND. 1 fig. 1
(2011), http://kaiserfamilyfoundation.files.wordpress.com/2013/01/1609-04.pdf
136. Council of Econ. Advisers, The Economic Casefor Health Care Reform, EXEC. OFF. OF
THE PRESIDENT 23, 29 (2009),
http://www.whitehouse.gov/assets/documents/CEAHealthCareReport.pdf.
137. Kevin Sack & Robert Pear, States Consider Medicaid Cuts as Use Grows, N.Y. TIMES,
Feb. 18, 2010, atAl.
138. Andrew Pollack, Cutting Dosage of a Costly Drug Spurs Debate, N.Y. TIMES, Mar. 16,
2008, http://www.nytimes.com/2008/03/16/business/16gaucher.html. See generally Aaron S.
Kesselheim et al., Extensions of Intellectual Property Rights and Delayed Adoption of Generic
Drugs: Effects on Medicaid Spending, 25 HEALTH AFF. 1637 (2006) (discussing the burden placed
on Medicaid by rising prescription drug costs).
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

availability of bioequivalent generic drugs and state DPS laws have reduced
pharmaceutical spending and helped rein in healthcare costs., 39 Indeed, in 2012,
pharmaceutical spending fell one percent, the first decrease in nearly two
decades, a trend attributed to more widespread generic drug availability. 140

C. Impact on PatientOutcomes and Healthcare Spending

Since the Hatch-Waxman Act, studies and substantial clinical experience

have supported the bioequivalence standard as a means of ensuring the efficacy
and safety of generic drugs for patients. 141 Patients who receive a generic drug
have experienced the same beneficial clinical outcomes and risks of side effects
as patients taking brand-name drugs. On a pharmacologic level, a review by the
FDA of bioequivalence studies conducted between 1996 and 2007 found that the
average difference in bioequivalence measures between generic and innovator
products was about four percent, and that in nearly ninety-eight percent of the
bioequivalence studies, the pharmacodynamics (i.e., the effect of the drug in the
human body) of the generic product differed from that of the innovator product
by less than ten percent. 142 The FDA standard for bioequivalence requires that
the bioequivalence measures be within 80-125%, a standard that also applies to
the variability between lots of branded drugs. 143 This review therefore
demonstrated that generics were produced at a level of pharmaceutical quality
consistently well within FDA standards.

139. See generally U.S. GOV'T ACCOUNTABILITY OFFICE, GAO-12-371R, DRUG PRICING:
RESEARCH ON SAVINGS FROM GENERIC DRUG USE (2012) (discussing cost savings from the use of
generic drugs).
140. Thomas, supra note 4. It is notable that generic drug usage has increased from nineteen
percent to eighty-four percent in the thirty years since the Hatch-Waxman Act, yet overall drug
spending largely increased steadily over the same period. Explanations for this trend include an
aging of the population, greater use of pharmaceuticals in medical care, and higher prices over time
for brand-name prescription drugs. See Panos Kanavos et al., Higher U.S. Branded Drug Prices
and Spending Compared to Other Countries May Stem Partlyfrom Quick Uptake of New Drugs, 32
HEALTH AFF. 753, 756-57 (2013); Glen T. Schumock et al., National Trends in PrescriptionDrug
Expenditures and Projectionsfor 2014, 71 AM. J. HEALTH SYS. PHARMACY 482, 483 (2014).
141. Therapeutic Equivalence of Generic Drugs: Letter to Health Practitioners, FOOD &
DRUG ADMIN. (Jan. 28, 1998),
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/A
pprovalApplications/AbbreviatedNewDrugApplicationANDAGenerics/ucm073182.htm.
142. Barbara M. Davit et al., ComparingGeneric and Innovator Drugs: A Review of 12 Years
of Bioequivalence Data from the United States Food and Drug Administration, 43 ANNALS
PHARMACOTHERAPY 1583, 1588 (2009).
143. 21 C.F.R. § 210.3(b)(2) & (10) (2014); Process Validation, supra note 116, at 6; Letter
from Roger L. Williams to Carmen A. Catizone, supra note 116, at 2-4.
 HATCH-WAXMAN TURNS 30

D. Summary

In the past thirty years, the Hatch-Waxman Act has directly contributed to a
revolution in the United States therapeutic marketplace from an environment in
the early 1980s in which most prescriptions were filled by brand-name drugs to
the present day when most prescriptions are filled are by generic drugs. Pro-
substitution DPS laws have led to numerous health, social, and economic benefits
to U.S. patients and the healthcare system. The impact of this major shift in the
generic marketplace on brand-name drug innovation is less clear. While the
Hatch-Waxman Act led to longer market exclusivity periods for brand-name
drugs, the rate of increase in the number of NMEs approved per year has not
measurably changed since the legislation, while the cost of drug development has
increased.

III. THIRTY YEARS AFTER HATCH-WAXMAN: CURRENT AND EMERGING

CHALLENGES

Despite revolutionary changes in the generic drug market since the Hatch-
Waxman Act, the past decade has seen a number of challenges arise that threaten
the continued success of the generic drug market. First, despite the systems set up
by the Hatch-Waxman Act, market entry of generic drugs has been delayed
beyond the point at which they should have been available. This has reduced 44
drug availability and increased unnecessary spending by patients and payors.1
Delay strategies have been growing in type and scope and can generally be traced
to unintended consequences of the legislation or features of the Hatch-Waxman
Act that were sensible thirty years ago but have no place in the modem
prescription drug market. A second major challenge involves the Supreme
Court's recent interpretation of the Hatch-Waxman Act in a way that limits the
liability of generic drug companies when patients are harmed by their drugs,
which may disincentivize future generic drug use. We review these challenges to
the Hatch-Waxman regime in turn and assess whether changes to the legislation
are necessary to address these shortcomings.

A. Limits or Delays to Generic DrugAvailability Under Hatch-Waxman

In this section, we detail how Hatch-Waxman generic drug approval

pathway has evolved in certain ways to support inappropriate extensions in
market exclusivity of brand-name drugs.

144. Shirley S. Wang, TriCor Case May Illuminate Patent Limits, WALL ST. J., June 2, 2008,
http://www.wsj.com/articles/SB 121236509655436509.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

1. PatentAccumulation

The patent-related provisions of the Hatch-Waxman Act provide one

mechanism for delaying the availability of generic drugs. Pharmaceutical
manufacturers had long relied on patents to protect the intellectual property in
their products, given the relative ease with which small-molecule pharmaceutical
products can be reverse-engineered. The Hatch-Waxman Act set a floor of five
years of guaranteed market exclusivity for all new molecules. Following this
five-year period, any additional brand-name drug exclusivity was to be
determined by reference to relevant patents that covered the pharmaceutical
product, which under the terms of the Hatch-Waxman Act had to be listed in the
Orange Book. 145 Expiration of these Orange Book-listed patents marks the
initiation of the competitive generic drug market, and it is these patents that are
the primary subjects of the Paragraph IV challenge process.
Patents listed in the Orange Book by the brand-name manufacturer provide
automatic thirty-month extensions of the guaranteed market exclusivity period if
they are challenged through the Paragraph IV litigation process. This thirty-
month stay effectively increases the guaranteed minimum market exclusivity
period for every new drug that lists patents in the Orange Book from five years to
seven years and six months. 146 Importantly, this thirty-month stay is available no
matter how weak the patent is or how peripheral the protected feature is to the
underlying active ingredient, product, or use. 147 For example, in the case of the
proton-pump inhibitor omeprazole (Prilosec), used to treat gastroesophageal
reflux disease, the Orange Book-listed patents covering the coating of the pill
served as the basis for litigation between the brand-name manufacturer and
generic competitors seeking to enter the market. 148 Generic competition emerged
only after litigation revealed that the coating by one of the potential generic
entrants did not infringe the brand-name product's coating patent. By enabling
companies to obtain an automatic thirty-month stay even for secondary patents
associated with pharmaceutical products, Hatch-Waxman rewarded brand-name
pharmaceutical manufacturers for seeking such patents.
The centrality of patents to the Hatch-Waxman Act's balancing of brand-
name and generic drug availability has had numerous consequences for the
pharmaceutical market. Chief among these is that the Act reinforced the pursuit

145. Pub. L. No. 98-417, § 102(a)(1), 98 Stat. 1585, 1592 (1984) (codified as amended at 21
U.S.C. § 355(b)(1) (2012)).
146. § 103, 98 Stat. at 1596 (codified as amended at 21 U.S.C. § 355(j)(5)(F)(ii) (2012)).
147. As explained below, it is possible this thirty-month stay could terminate early if patent
litigation is resolved prior to the end of the thirty-month period. See supra note 61.
148. See, e.g., In re Omeprazole Patent Litig., 536 F.3d 1361 (Fed. Cir. 2008).
 HATCH-WAXMAN TURNS 30

of multiple secondary patents, on features such as small changes to formulation,

variation in the inactive salt component, or other crystalline structures. Since the
early 1980s, there has been substantial growth in the overall number of patents
covering pharmaceutical products. Experts have noted that, for example, "the
number of patents per new drug has increased dramatically" since the early
1980s. 149 From 1992 to 2012, the combined number of patents granted in classes
424 and 514 (both listed as "Drug, Bio-Affecting and Body Treating
Composition") increased 256 percent-from 3,596 to 9,210."50 It is not
uncommon for marketed drugs to be covered by dozens of unique patents,' 5'
although only a small fraction of these are listed in the Orange Book. 152 For
example, a patent map of the HIV protease inhibitors ritonavir and lopinavir-
which are marketed together in the United States as a fixed-dose combination
product called Kaletra for treatment of HIV infection-found 108 patents and
patent applications, all but two of which53 covered secondary chemical structures
or processes for manufacturing the pill.1
As the overall number of patents relating to pharmaceutical products has
increased, so has the number of Orange Book-listed patents. The total number of
Orange Book-listed patents increased by approximately 300 percent from 1992 to
2012. 154 One review found that the number of patents per drug listed in the
Orange Book increased over time from around 1.9 in a cohort of drugs approved
between 1985-87 to nearly 3.9 in a comparable 2000-02 cohort. 55 Blockbuster
drugs tended to have the highest numbers of patents listed in the Orange Book,
with an average of over five per drug. Another group of authors examined the
1,261 Orange Book-listed patents related to 528 NMEs approved by the FDA
from 1988 to 2005.156 Of the 432 drugs that were protected by at least one patent,
about two-thirds were protected by claims for the chemical compound, meaning
that over a third of patented drugs had no chemical compound claims at all.

149. Kapczynski et al., supra note 55, at *1.

150. See Patent Counts by Class by Year: January 1977-December 2014, U.S. PATENT &
TRADEMARK OFF. (Mar. 18, 2015), http://www.uspto.gov/web/offices/ac/ido/oeip/taf/cbcby.htm.
151. Ron A. Bouchard et al., EmpiricalAnalysis of Drug Approval-Drug Patenting Linkage
for High Value Pharmaceuticals,8 Nw. J. TECH. & INTELL. PROP. 174,202 & fig.6d, 203 (2010).
152. Ruben Jacobo-Rubio et al., Pharmaceutical Patent Litigation: Measuring the Value of
Generic Entry Rights and Brand Deterrence (June 2013) (unpublished manuscript) (on file with
authors) (noting that the average branded drug product has five listed patents).
153. Tahir Amin & Aaron S. Kesselheim, Secondary Patenting Could Extend U.S. Market
Exclusivity of HIV Drugs Norvir and Kaletra Through 2028, 31 HEALTH AFF. 2286, 2288 (2012).
154. Jacobo-Rubio et al., supra note 152, at 13 fig.1.
155. Hemphill & Sampat, supra note 88, at 619 ("Drugs in the first cohort, approved between
1985 and 1987, have an average of 1.9 patents per drug. In the final (2000 to 2002) cohort, the
mean slightly more than doubles to 3.9 patents per drug.").
156. Kapczynski et al., supra note 55, at *2-3.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

Eighty-one percent were protected by formulation claims, eighty-three percent by

method-of-use claims, and fifty-one percent by claims relating to alternative
structures of the product including polymorphs, isomers, prodrugs, esters, and
salts. On average these secondary patents were more likely to be found listed in
high-sales drugs, and had expiration dates that were six to seven years after the
expiration date of the last expiring chemical compound patent.
The growth of secondary pharmaceutical patents, as well as Orange Book
patent listings, slows approval of generic drugs and raises the cost of market
entry. Prospective generic entrants must expend effort evaluating the thicket of
patents surrounding a particular drug product to determine which of them may
serve as potential barriers to entry. Some patents can delay competitors and force
generic manufacturers to design around certain features of the drug product. In
addition, the brand-name manufacturer may make slight changes to the marketed
molecule and obtain one or more secondary patents on the slightly altered
molecule or its formulation, which has implications for the bioequivalence
testing process that the generic manufacturer needs to pursue. Since these patents
are generally all issued in the years following the patent on the underlying active
ingredient, they can help to extend the market dominance of the brand
manufacturer, which can introduce slightly modified products that delay or
reduce competition without contributing substantial new therapeutic benefit.' 57
For example, the anti-cancer drug imatinib (Gleevec) has been protected by two
key patents: the initial patent dating back to 1993, which covers the basic active
ingredient (imatinib); and a subsequent patent (dating back to 1998) that covers
the product as formulated and marketed for use by patients (the beta crystalline
form of imatinib mesylate). The 1993 patent is for the active ingredient, while the
1998 patent is for the end-formulated version as sold. 5 8 There is no evidence that
the beta crystalline form provides relevant clinical improvement over the original
version, but it does offer the possibility of extended market exclusivity. In the
case of Kaletra, Abbott's secondary patents nominally extend its exclusivity from
2016 to 2028 and beyond in the United States, 5 9 although some empirical work
suggests that weak, late-expiring patents are the most likely to be challenged and
subsequently overturned. 160 Though it may be possible to market the older

157. See Jonathan J. Darrow, Debunking the "Evergreening" Patents Myth, HARV. L. REC.,
Dec. 8, 2010, at 6.
158. See Rajshree Chandra, The Role of National Laws in Reconciling ConstitutionalRight to
Health with TRIPS Obligations: An Examination of the Glivec Patent Case in India, in GLOBAL
PUBLIC HEALTH 381, 391 (Thomas Pogge et al. eds., 2010) (describing Novartis's filing of patents
on two formulations of imatinib mesylate in 1993 and 1998).
159. Amin & Kesselheim, supra note 153, at 2290.
160. Hemphill & Sampat, supra note 88, at 644.
 HATCH-WAXMAN TURNS 30

version of Kaletra once its patent and regulatory exclusivities expire in 2020,161 it
is likely that these older versions would not be considered interchangeable with
the current formulation of the drug. A generic manufacturer would therefore need
to separately market their drug product, cutting into prospective cost-savings.
Instead of serving as a means to prevent generic substitution, an improved
formulation of the listed drug should ideally lead to the removal of the predicate
version and should occur in a timely way based on public health considerations.
Of course, it is difficult to parse the impact of Hatch-Waxman from general
patenting trends over the past three decades, including the overall rise in the
annual number of patents issued in the United States. Other laws such as the
1980 Bayh-Dole Act,1 62 which encouraged university patenting, may also have
played a role in the proliferation of drug patents. The total number of United
States patents issued (excluding design patents and plant patents) increased
dramatically from 1981 to 2014-from 65,771 to 300,678-an increase of 357
percent. 163 While the number of pharmaceutical patents has certainly increased, it
is difficult to say whether pharmaceutical innovation has increased equally (or at
all) in magnitude. It is even more difficult to determine whether this innovation,
however significant from a technical perspective, has been translated into the
types of therapeutic advances that matter to patients. What can be said with
greater certainty is that many of the patents protecting pharmaceuticals are
"weak" (i.e., likely to be found invalid if challenged in court), that the cost of
proving patent invalidity is high, and that these weak patents delay generic entry.
One study found that generic firms prevailed in seventy-eight (forty-nine percent)
of 159 Paragraph IV cases that were litigated to decision,' 64 a figure that climbs
to seventy-six percent if settlements (which conclude about half of all Paragraph
IV challenges) are included.165 A 2012 study found that more than fifty percent
of Paragraph IV lawsuits involved disputes over secondary patents, rather than

161. See Approved Drug Products with Therapeutic Equivalence Evaluations Patent and
Exclusivity Search Results, App/. No. 021226, FOOD & DRUG ADMIN.,
http://www.accessdata.fda.gov/scripts/cder/ob/docs/patexclnew.cfm?Appl_No=021226&Product_
No=001&tablel=OB Rx (last visited Mar. 29, 2015) (listing Nov. 22, 2020 as the expiration date
of the latest expiring patent on Kaletra, including a six-month pediatric extension).
162. Pub. L. No. 96-517, 94 Stat. 3015 (1980) (codified as amended at 35 U.S.C. §§ 200-12
(2012)).
163. See U.S. Patent Activity Calendar Years 1790 to the Present, U.S. PATENT & TRADEMARK
OFF., http://www.uspto.gov/web/offices/ac/ido/oeip/taf/h-counts.htm (last visited Apr. 18, 2015).
164. Jacobo-Rubio et al., supra note 152, at 15 tbl. 1; see also Generic Drug Entry Prior to
Patent Expiration, supra note 45, at 16 (finding that generic applicants prevailed in twenty-two
(73%) of thirty cases in which a court had resolved the drug patent dispute).
165. Adam Greene & D. Dewey Steadman, Pharmaceuticals: Analyzing Litigation Success
Rates, RBC CAPITAL MKTS. 4 (2010), http://amlawdaily.typepad.com/pharmareport.pdf.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

those covering the drug compound. 166 Patent litigation can nevertheless be 167
lengthy and expensive, costing the generic applicant as much as $10 million.
One study found the average time to a district court decision was 2.3 years, with
an additional 1.2 years to reach an appellate court decision.69
168 The average cost
of patent litigation may be $4.5 million per party or more.'
Reforms to patent law or alterations to the Hatch-Waxman Act can
counteract excessive and wasteful accumulation of low-value pharmaceutical
patents. Some have advocated raising the obviousness, novelty, or utility
standards, in order to make pharmaceutical patents more difficult to obtain.' 70 In
2007, the U.S. Supreme Court revisited the obviousness criterion in its case of
KSR v. Teleflex, 17 1 setting down a new higher standard for determining
obviousness of combinations of two pieces of existing technologies. Societal
concern over low-value patents is also reflected in the growing trend among other
countries to statutorily raise the bar for obtaining pharmaceutical patents. While
current U.S. practice evaluates the appropriateness of pharmaceutical patent
applications by focusing primarily on molecular form-asking whether the
particular crystalline structure sought to be protected is sufficiently different from
a previously described structure--other countries have developed
pharmaceutical-specific patent laws that explicitly tie novelty and non-
obviousness to the effectiveness of the drug. India, for example, has refined its
law to prevent patents on drug products created through minor modifications 72
to
previously existing products that do not demonstrate enhanced efficacy. 1
A second avenue of patent reform that could address the problem of low-
value secondary drug patents would be to facilitate patent challenges after they
are granted. For example, some have proposed streamlining post-grant opposition

166. Jacobo-Rubio et al., supra note 152, at 7.

167. Michael R. Herman, Note, The Stay Dilemma: Examining Brand and Generic Incentives
for Delaying the Resolution of PharmaceuticalPatent Litigation, Ill COLUM. L. REV. 1788, 1795
n.41 (2011) (citing MARC GOODMAN ET AL., MORGAN STANLEY EQUITY RESEARCH, QUANTIFYING
THE IMPACT FROM AUTHORIZED GENERICS 9 (2004)).
168. Jacobo-Rubio et al., supra note 152, at 14.
169. Hemphill, supra note 54, at 1574 & n.89 (citing AM. INTELLECTUAL PROP. LAW ASS'N,
REPORT OF THE ECONOMIC SURVEY 2005, at 22 (2005)) (median expenses on patent litigation with
more than $25 million at risk is $4.5 million). The outcomes of pharmaceutical patent cases can
implicate far more than $25 million, so even $4.5 million may be a conservative estimate.
170. FREDERICK M. ABBOIr & GRAHAM DUKES, GLOBAL PHARMACEUTICAL POLICY: ENSURING
MEDICINES FOR TOMORROW'S WORLD 34-37 (2009); Jerry Avorn, Sending Pharma Better Signals,
309 SCIENCE 669, 669 (2005); John H. Barton, Reforming the Patent System, 287 SCIENCE 1933,
1933-34 (2000); Matthew Rimmer, The Alchemy of Junk: Patent Law and Non-Coding DNA, 3
OTTAWA L. & TECH. J. 539, 582 (2006).
171. KSR Int'l Co. v. Teleflex Inc., 550 U.S. 398 (2007).
172. See Rahul Rajkumar & Aaron S. Kesselheim, Balancing Access and Innovation: India's
Supreme Court Rules on Imatinib, 310 JAMA 263, 263 (2013).
 HATCH-WAXMAN TURNS 30

procedures in order to both encourage and reduce the cost of challenges to weak
patents. 73 In general, this approach may be preferable if the percentage of
patents that are subject to litigation or licensing is low, because it defers costly
examination and limits it to those patents that matter most. Placing yet greater
emphasis on post-grant oppositions would continue a trend Congress started in
1980 and significantly expanded in 1999 and 2011.14 The 2011 Leahy-Smith
America Invents Act established new post-grant opposition proceedings through
which third parties could challenge the existence of a patent by submitting
additional information bearing on patentability of the claimed invention to the
USPTO. 175 The presumption of patent validity does not apply in these
proceedings.' 76 This is in contrast to ordinary judicial proceedings in which a
patent is presumed valid and the challenger must prove invalidity by clear and
convincing evidence. 177 Post-grant opposition proceedings have the potential for
weeding out bad pharmaceutical patents without the protracted time and cost of
litigation, though the America Invents Act only permits the broadest type of 78
post-
grant opposition proceedings for nine months after issuance of the patent.
While patent reform proposals have merit and are consistent with current
trends, U.S. lawmakers have been resistant to making market-specific exclusions
or changes to patent law. Proposals to change the statutory definition of criteria
such as novelty or non-obviousness across the board would be politically
challenging. Therefore, a more viable approach could be to revisit the Hatch-
Waxman Act and adjust the patent-listing process. For example, the Hatch-
Waxman Act could be amended such that the listing of a patent in the Orange
Book automatically reopened a post-grant review window of nine months, which
would make it symmetric with the America Invents Act. 17 9 At that point, the
patent's invalidity could be administratively reconsidered by the USPTO based
on details offered by the generic manufacturers or other interested parties.

173. See, e.g., Michael A. Carrier, Post-Grant Opposition: A Proposaland a Comparison to

the America Invents Act, 45 U.C. DAVIS. L. REV. 103 (2011); Bronwyn H. Hall & Dietmar Harhoff,
Post-GrantReviews in the U.S. Patent System: Design Choices and Expected Impact, 19 BERKELEY
TECH. L.J. 989 (2004).
174. See Mark A. Lemley, Why Do Juries Decide If PatentsAre Valid?, 99 VA. L. REV. 1673,
1722 (2013).
175. Pub. L. No. 112-29, 125 Stat. 284 (2011) (codified as amended in scattered sections of 35
U.S.C.).
176. See 35 U.S.C. § 316(e) (2012) ("Evidentiary Standards. In an inter partes review ... the
petitioner shall have the burden of proving a proposition of unpatentability by a preponderance of
the evidence.").
177.35 U.S.C. § 282 (2012).
178. Pub. L. No. 112-29, § 6(d), 125 Stat. 284, 306 (2011) (codified at 35 U.S.C. § 32 1(c)
(2012)).
179. Id.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

Resolving patent disputes outside of judicial proceedings would increase

efficiency. Indeed, the 180-day generic exclusivity period was originally inserted
into the Hatch-Waxman Act because of the concern that the patent challenge and
litigation process may be too time-consuming and costly for many generic
manufacturers without some sort of bonus.' 80 Streamlining the patent-challenge
process by adopting the USPTO-based pathway for administrative
reconsideration of the patent would reduce the need to grant the generic
manufacturer 180 days of market exclusivity.. The goal of such a pathway would
be to reduce the number of weak secondary patents that now populate the Orange
Book without the need for a costly-and time-intensive-litigation process that
necessarily involves a thirty-month extension of guaranteed exclusivity. 7 2 If
challenging potentially invalid patents could be made less costly, incentivizing
the generic manufacturer with a 180-day period of higher prices would become
less necessary. Hence, robust generic competition could begin immediately after
expiration of any remaining patents. In addition, by minimizing the cost of
challenging weak patents, expanded post-grant review could reduce the overall
risk of anticompetitive settlements.
More radically, the Hatch-Waxman Act could be altered to permit listing of
only original drug compound patents in the Orange Book, as opposed to other
drug formulations or methods of use. This avenue would reduce the market
impact of all secondary patents, whether strong or weak. '81 One positive outcome
would be to reduce uncertainty. Brand-name manufacturers would bear less risk
of weak patents being invalidated during the regulatory exclusivity period.
Generic manufacturers would have a clear date on which they could enter the
market at a lower risk.182 Although secondary patents might still be asserted at

180. See Janssen Pharmaceutica, N.V. v. Apotex, Inc., 540 F.3d 1353, 1361 (Fed. Cir. 2008)
("The 180-day exclusivity period is important to generic pharmaceutical companies as it promotes
patent challenges by enabling a generic company a period to recover its investment in [challenges
to Orange Book listed patents].").
181. This proposed solution draws a bright line, which makes it easier to implement, but also
risks reducing the incentives for incremental innovations on drug products that actually do lead to
improved clinical benefits. For example, if a different crystalline structure of a drug is discovered
after approval that improves its bioavailability or potency in a clinically meaningful way, the patent
covering this new formulation would not qualify, reducing the drug company's motivation to
identify such better-acting compounds. But real-life examples of this sequence of events occurring
are relatively rare. Most examples of incremental or follow-on innovations in the pharmaceutical
market that are clinically meaningful involve major alterations in a drug's chemical structure that
allow it to be taken less often (e.g., once instead of multiple times per day as in the case of
metoprolol and extended release metoprolol), or that isolate the more active isomer (e.g.,
omeprazole and esomeprazole). Changes of this sort are typically filed as under their own NDAs,
so our proposal would not affect incentives to innovate these products.
182. See generally James Bessen & Michael J. Meurer, Lessons for Patent Policy from
EmpiricalResearch on Patent Litigation,9 LEWIS &CLARK L. REV. 1 (2005) (expressing concerns
 HATCH-WAXMAN TURNS 30

any point prior to expiration, the threat of thirty-month stays would largely be
eliminated, in part because, as indicated above, most Paragraph IV challenges are
brought against secondary patents. The reduction in the number of Paragraph IV
challenges would also reduce the prevalence ofl80-day generic exclusivity
periods. Transaction costs arising from litigation and patent searching might
decline as incentives to file for patent term extensions and obtain thirty-month
stays become less important.183
Since the combination of five-year data exclusivity and the thirty-month
stays arising from Paragraph IV challenges essentially provide pioneer
manufacturers with 7.5 years of guaranteed market exclusivity, this proposal
threatens to reduce that number to closer to five years.' 8 4 Five years of
exclusivity is often sufficient time for most brand-name manufacturers to earn
back their investment on a drug and earn a substantial profit. In the case of
sofosbuvir (Sovaldi), the transformative oral antiviral agent to treat hepatitis C
virus, the brand-name manufacturer paid $11 billion for the small company
making the drug at a late stage, and earned back that investment in the first year
the drug was on the market. However, not all drugs have the immediate success
of sofosbuvir. 185 Thus, it might be necessary to assure brand-name drug
manufacturers that they will benefit from slightly longer market exclusivity
periods, since most new drugs will not be brought to market until six to ten years
after the original patent on their underlying active ingredient is granted. 186 A two-

about patent quality and the high cost and uncertainty of litigation).
183. In the field of taxation, the use of the standard deduction serves a similar role by
encouraging the substitution of numerous small, high-transaction-cost deductions with a single,
low-transaction-cost standard deduction. These small, high-transaction-cost deductions are
analogous to the numerous secondary patents that could be replaced by a lengthened regulatory
exclusivity period.
184. Under Hatch-Waxman, a generic drug manufacturer's application cannot be filed until
five years have passed. This means that an application to market a generic drug must await review
by the FDA's Office of Generic Drugs. Delays at the FDA due to lack of resources have caused a
backlog and, as a result, the application review process can take more than three years. The backlog
at the Office of Generic Drugs has shortened considerably since 2012, when the FDA Safety and
Innovation Act created a generic drug user fee system to enhance FDA resources for generic drug
application reviews. So even without the Paragraph IV challenge process, the actual exclusivity
period for most products will likely remain between 6 and 8 years.
185. For example, one economist has estimated that the overall break-even point for a
"representative portfolio" of approved biologic drugs is approximately 12.9 years, although the
estimate includes assumptions highly favorable to originator biotechnology companies, such as
$1.2 billion in capitalized research and development costs. See Henry Grabowski et al., Data
Exclusivityfor Biologics, 10 NATURE REVIEWS: DRUG DISCOVERY 15, 15-16 (2011).
186. See Matthew J. Higgins & Stuart J.H. Graham, Balancing Innovation and Access: Patent
Challenges Tip the Scales, 326 SCIENCE 370, 370-71 (2009). Europe, Canada, and Japan provide
around ten years of drug regulatory exclusivity. In 2009, Congress provided twelve years of
exclusivity to new biologics in the United States. Biologics Price Competition and Innovation Act
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

or three-year longer guaranteed exclusivity period would not necessarily delay

generic entry for many drugs already protected by the original patent on the
underlying active ingredient, since FDA exclusivity periods (other than six-
month pediatric exclusivities) run concurrently with the patent period.

2. Reverse Payment ParagraphIV Challenge Settlements ("Pay for Delay ")

Few aspects of Hatch-Waxman have generated as much controversy or

confusion as the settlement of patent litigation between brand-name and generic
manufacturers. In general, nearly all civil lawsuits are resolved by settlement-
more than ninety-eight percent, according to some estimates 1 7-although this
figure can vary substantially by type of litigation. Settlement is a more amicable
means of resolving disputes that not only reduces litigation expenses, but can
also resolve issues more quickly and reduce the burden on the judiciary."' 8
Naturally, litigation that arises in the Hatch-Waxman context may culminate in
settlement when a potential generic competitor challenges a brand-name
manufacturer's Orange Book-listed patent. These settlements may result from
reasoned decision-making on behalf of the parties, taking into account the risks
of litigation, the strengths of the patents being challenged, and other aspects of
the market. However, they have become a source of controversy in recent years
in cases with arguably anticompetitive settlement terms. Of particular concern

of 2009, Pub. L. No. 111-148, §§ 7001-03, 124 Stat. 119, 804-21 (2010) (codified at 42 U.S.C. §
262 (2012)). Such a move would be consistent with a recent scholarly proposal to tailor invention
protection to the cost and risk of the invention (pharmaceuticals tend to have high cost and risk
compared to other inventions). See Benjamin N. Roin, The Case for Tailoring Patent Awards
Based on the Time-to-Market of Inventions, 61 UCLA L. REV. 672 (2014) (see especially Part VI).
187. E.g., STEVEN SHAVELL, FOUNDATIONS OF ECONOMIC ANALYSIS OF LAW 410 (2004) (noting
a state court civil settlement rate of 96% and a federal court civil settlement rate of 98%, and
explaining why these figures may be either under- or over-inclusive); Marc Galanter, The
Vanishing Trial: An Examination of Trials and Related Matters in Federal and State Courts, I J.
EMPIRICAL LEGAL STUD. 459, 463 tbl.1 (2004) (indicating that 1.8% of civil cases in U.S. District
Courts are resolved by trial, and that 2.4% of intellectual property cases are resolved by trial).
188. In re Ciprofloxacin Hydrochloride Antitrust Litig., 544 F.3d 1323, 1333 (Fed. Cir. 2008)
("[T]here is a long-standing [judicial] policy in the law in favor of settlements, and this policy
extends to patent infringement litigation."); Schering Plough Corp. v. FTC, 402 F.3d 1056, 1073
(11 th Cir. 2005) ("The importance of encouraging settlement of patent-infringement litigation ...
cannot be overstated." (internal quotation marks and citation omitted)); Doe v. Delie, 257 F.3d 309,
322 (3d Cir. 2001) ("The law favors settlement, particularly in class actions and other complex
cases, to conserve judicial resources and reduce parties' costs."); Stewart v. M.D.F. Inc., 83 F.3d
247, 252 (8th Cir. 1996) ("The judicial policy favoring settlement.., rests on the opportunity to
conserve judicial resources .... "); In re Androgel Antitrust Litig., 687 F. Supp. 2d 1371, 1378
(N.D. Ga. 2010) (quoting Valley Drug Co. v. Geneva Pharm., Inc., 344 F.3d 1294, 1309 (11th Cir.
2003)) ("[L]itigation is a much more costly mechanism to achieve exclusion, both to the parties and
to the public, than is settlement.").
 HATCH-WAXMAN TURNS 30

are settlements that include substantial payments from a brand-name

manufacturer to a potential generic competitor, with the generic manufacturer
agreeing to drop its challenge or to introduce its generic only at (or close to) the
original patent's expiration date. In such cases, the generic manufacturer appears
to be accepting a short-term guaranteed payment instead of pursuing the
challenge envisioned under the Hatch-Waxman Act, while the brand-name
manufacturer appears to be propping up potentially weak or invalid patents by
providing a large enough payment to generic manufacturers to fend off their
challenges. Settlements with these terms have been called "reverse payment" (or,
more pejoratively, "pay-for-delay" settlements), because unlike most patent
settlements in which the alleged infringer agrees to pay a reasonable royalty to
end litigation, payments in the Hatch-Waxman context run from brand-name
manufacturer to the prospective generic competitor. '
Commentators have often viewed the delay in generic competition that may
accompany such settlements (hence the term "pay-for-delay") as running counter
to the intent of Hatch-Waxman, which provides the 180-day exclusivity bounty
for the purpose of motivating patent challenges that lead to earlier generic
entry. 9' Numerous commentators 9' and legislators 92 have expressed concern

189. See FTC v. Actavis, 133 S. Ct. 2223, 2235 (2013) ("[W]here only one party owns a
patent, it is virtually unheard of outside of pharmaceuticals for that party to pay an accused
infringer to settle the lawsuit.").
190. In addition to the use of authorized generics to diminish the value of the 180-day bounty,
brand-name companies in the 1990s simply declined to bring suit against the Paragraph IV filer,
thus depriving it of the trigger for 180-day exclusivity. This practice ended with Mova
Pharmaceutical Corp. v. Shalala, 140 F.3d 1060 (D.C. Cir. 1998), which held that the first
Paragraph IV ANDA filer was entitled to 180-day exclusivity even if it was not sued.
191. E.g., Roger D. Blair & Thomas F. Cotter, Are Settlements of Patent Disputes Illegal Per
Se?, 47 ANTITRUST BULL. 491, 534 (2002) (suggesting that reverse-payment settlements should be
subject to a rebuttable presumption of illegality); Marcia M. Boumil & Gregory D. Curfman, On
Access and Accountability: Two Supreme Court Rulings on Generic Drugs, 369 NEw ENG. J. MED.
696, 697 (2013) (noting that "[t]he Actavis ruling favors consumers"); Thomas F. Cotter, Antitrust
Implications of Patent Settlements Involving Reverse Payments: Defending a Rebuttable
Presumption of Illegality in Light of Some Recent Scholarship, 71 ANTITRUST L.J. 1069, 1094
(2004) ("[A] rebuttable presumption of illegality still seems to be the most sensible approach");
Joshua P. Davis, Applying Litigation Economics to Patent Settlements: Why Reverse Payments
Should Be Per Se Illegal, 41 RUTGERS L.J. 255, 260 (2009) (concluding that the use of a rule-of-
reason approach would entail substantial transaction costs); Herbert Hovenkamp et al.,
Anticompetitive Settlement of Intellectual Property Disputes, 87 MINN. L. REV. 1719, 1759 (2003)
(suggesting that reverse payment settlements that exceed litigation costs be "presumptively
unlawful, shifting the burden of proof to the infringement plaintiff'); Aaron S. Kesselheirn et al.,
"Payfor Delay" Settlement of Disputes over PharmaceuticalPatents, 365 NEW ENG. J. MED. 1439,
1443-44 (2011) (generally favoring restrictions on settlements, but suggesting that an enhanced
post-grant review process would be even better); Robert Kneuper, Four Economic Principles
Underlying the FTC's Position Against Payments in Patent Settlement Agreements, 5 ANTITRUST
SOURCE I, 2-4 (Jan. 2006) (explaining that (1)the patent holder has market power; (2) the
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

with reverse payment settlements, although a number have also defended them as
legitimate.'93 The FTC, an independent, bipartisan agency with a declared

possibility of shared monopoly profits creates an incentive to settle; (3) patents confer are
probabilistic rights (i.e., they may be invalid); and (4) consumer welfare losses from delay are
large); Erica J. Hemphill Kraus, A Shift on Payfor Delay: Reopening Doorsfor Pharmaceutical
Competition?, 367 NEW ENG. J. MED. 1681, 1683 (2012) ("[A]llowing these agreements frustrates
the Act's central precompetitive purpose .... "); Pier Luigi Parcu & Maria Alessandra Rossi,
Reverse Payment Settlements in the PharmaceuticalSector: A European Perspective, 2 EUR. J.
RISK REG. 260 (2011) ("[P]otential benefits associated with settlements are of an order of
magnitude insufficient to outweigh the certain drawbacks .... ); Carl Shapiro, Antitrust Limits to
Patent Settlements, 34 RAND J. ECON. 391, 408 (2003) (arguing that "a naked cash payment
flowing from the patentholder to the challenger (in excess of avoided litigation costs) is a clear
signal that the settlement is likely to be anticompetitive" but acknowledging that other factors such
as risk aversion and asymmetric information can come into play). Many other commentators have
discussed reverse payments without taking a strong position in favor or against them. See, e.g.,
Henry N. Butler & Jeffrey Paul Jarosh, Policy Reversal on Reverse Payments: Why Courts Should
Not Follow the New DOJ Position on Reverse-Payment Settlements of PharmaceuticalPatent
Litigation, 96 IOWA L. REv. 57, 114 (2010) (recommending use of the rule of reason); John E.
Lopatka, A Comment on the Antitrust Analysis of Reverse Payment Settlements: Through the Lens
of the Hand Formula, 79 TUL. L. REV. 235, 264 (2004) (recommending use of the Hand formula);
Amanda P. Reeves, Muddying the Settlement Waters: Open Questions and Unintended
Consequences Following FTC v. Actavis, 28 ANTITRUST 9, 14 (Fall 2013) (explaining how
companies and their attorneys should respond to Actavis); Miriam Shuchman, Delaying Generic
Competition: CorporatePayoffs and the Future of Plavix, 355(13) NEW ENG. J. MED. 1297, 1297-
1300 (2006) (summarizing several high profile pay-for-delay deals).
192. Preserve Access to Affordable Generics Act, S. 214, 113th Cong. (1st Sess. 2013)
(describing reverse payments as "subvert[ing]" the intent of Hatch Waxman); Preserve Access to
Affordable Generics Act, S. 3582, 109th Cong. (2d Sess. 2006) (defining reverse payment
settlements as an unfair method of competition under § 5 of the Federal Trade Commission Act).
Similar bills were proposed in 2007, 2009, and 2011.
193. Hatch-Waxman Act: Reverse-Payment Settlements: FTC v. Actavis, 127 HARV. L. REV.
358, 367 (2013) ("[T]he Court should have prioritized judicial administrability by protecting
settlement agreements within the scope of the relevant patent."); Daniel A. Crane, Per Se Illegality
for Reverse Payment Settlements?, 61 ALA. L. REV. 575, 576 (2010) [hereinafter Per Se Illegality]
(arguing that a ban on reverse payments would be futile because "creative lawyers are capable of
crafting settlement agreements that have the same effects as the most pernicious reverse payment
cases but would pass unscathed under a rule focusing on reverse payments"); Ronald W. Davis,
Reverse Payment Settlements: A View into the Abyss, and a Modest Proposal,21 ANTITRUST 26, 30
(Fall 2006) (arguing that if the patentee is more likely than not to prevail in litigation "then the
patentee and the challenger should enjoy an unqualified right to agree to restrain trade"); Kevin
McDonald, Hatch- Waxman Patent Settlements and Antitrust: On "Probabilistic" Patent Rights
and False Positives, 17 ANTITRUST 68, 75 (Spring 2003) (approving of reverse payments "if the
patent is valid and the exclusion of competition no broader than that inherent in the patent"); Stuart
N. Senator & Rohit K. Singla, FTC v. Actavis: Antitrust Litigation over "Reverse-Payment"
PharmaceuticalPatent Settlements, 22 COMPETITION: J. ANTITRUST & UNFAIR COMP. L. SEC. ST. B.
CAL. 153, 163 (2013) (noting that under the Supreme Court's reasoning in Actavis, "a reverse
payment may be explained-that is, justified-based upon the value of the drug at issue");
Elizabeth Stanley, An Ounce of Prevention: Analysis of Drug Patent Settlements Under the Hatch-
Waxman Act, 10 GEO. MASON L. REV. 345, 358 (2002) (expressing concern that too harsh a view of
 HATCH-WAXMAN TURNS 30

mission to "protect consumers and promote competition,"' 94 has condemned

reverse payment settlements since 1999. '9 Both Senator Orrin Hatch and
Representative Henry Waxman, the co-sponsors of the original 1984 Act, have
spoken out against reverse payment settlements.' 96 Nonetheless, they have been
popular,'97 with a growing number of Paragraph IV cases settling with reverse
payments or other terms.'98 These terms invoke the specter of the brand-name
manufacturer sharing its monopoly rents in return for a promise to discontinue
challenging what may be a weak patent.'99 Reflecting concern about possible
consumer harm from anticompetitive settlement agreements, the Medicare
Prescription Drug, Improvement, and Modernization Act (MMA) of 2003

settlements could adversely affect innovation).

194. What We Do, FED. TRADE COMM'N, www.ftc.gov/about-ftc/what-we-do (last visited Apr.
9,2015).
195. Pay-for-Delay: How Drug Company Pay-Offs Cost Consumers Billions, FED. TRADE
COMM'N 1 (2010), https://www.ftc.gov/sites/defaultlfiles/documents/reports/pay-delay-how-drug-
company-pay-offs-cost-consumers-billions-federal-trade-commission-staff-
study/100112payfordelayrpt.pdf; Generic Drug Entry Prior to Patent Expiration, supra note 45 at
63.
196. 148 CONG. REC. 14,437 (2002) (statement of Sen. Hatch) ("It was and is very clear that
the [Hatch-Waxman Act] was not designed to allow deals between brand and generic companies to
delay competition."); 146 CONG. REC. 18,774 (2000) (statement of Rep. Waxman) (introducing bill
to deter companies from "strik[ing] collusive agreements to trade multimillion dollar payoffs by the
brand company for delays in the introduction of lower cost, generic alternatives"); see also Brief
for Representative Henry A. Waxman as Amicus Curiae Supporting Petitioner, at 2, FTC v. Watson
Pharm. Inc., 113 S. Ct. 2223 (2013) (No. 12-416), 2013 WL 417736, at *2 (calling the shielding of
reverse payment settlements from antitrust scrutiny "a significant obstacle to the fulfillment of the
important public policies embodied in the Hatch-Waxman [Act]").
197. See Shuchman, supra note 191, at 1297-1300 (discussing several such settlements).
198. See Agreements Filed with the Federal Trade Commission Under the Medicare
PrescriptionDrug, Improvement, and ModernizationAct of 2003:Overview of Agreements Filed in
FY 2013: A Report by the Bureau of Competition, FED. TRADE COMM'N 4 (2013),
https://www.ftc.gov/system/files/documents/reports/agreements-filled-federal-trade-commission-
under-medicare-prescription-drug-improvement/I 41222mmafyl 3rpt- I.pdf [hereinafter Overview of
Agreements Filed in FY 2013].
199. Agreements Filed with the Federal Trade Commission Under the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003: Overview ofAgreements Filed in FY 2012: A
Report by the Bureau of Competition, FED. TRADE COMM'N, 1-2 (2013),
https://www.ftc.gov/sites/default/files/documents/reports/agreements-filed-federal-trade-
commission-under-medicare-prescription-drug-improvement-and/13011 7mmareport.pdf
[hereinafter Overview of Agreements Filed in FY 2012]. The most recent year for which a report
has been issued is 2012. Hatch-Waxman did not restrict the patents listed in the Orange Book to
those covering the active ingredient itself. For purposes of Paragraph IV litigation, a patent on the
underlying active ingredient is treated the same as a patent on a peripheral feature of the drug, such
as its coating or heat stability, or a metabolite or other derivative crystalline structure. In addition,
the FDA was not given authority to evaluate the patents listed by the brand-name company to
determine their validity or relevance to the potential generic competitors.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

requires that settlement agreements between Paragraph IV filers and brand-name

companies be reported to the FTC. 00
In 2013, the Supreme Court weighed in, holding in FTC v. Actavis that
reverse payment settlement agreements can sometimes violate antitrust laws. 20 1
The Court rejected the view of a growing number of U.S. Courts of Appeals that
defendants would be immune from antitrust scrutiny so long as any
anticompetitive effects of the settlement fell "within scope of the exclusionary
potential of the patent, ' 92 noting that the patent at issue "may or may not be
valid [and infringed].""2 2 The Court also disposed of the argument that patentees
would find it too expensive to "buy off' other patent challengers by pointing out
that if the first-to-file applicant forfeits its 180-day exclusivity right (which could
occur following a reverse-payment settlement), no other generic can obtain it,
dampening the likelihood of subsequent challenges.2 3 In holding that reverse
payment settlements are subject to analysis under the rule of reason standard, the
Court provided a useful guide to future cases, indicating that the excess of the
reverse payment beyond what could be justified by litigation savings or other
legitimate explanations could provide a workable surrogate for a patent's
weakness as well as insight into the ultimate question of antitrust violation. The
Actavis case may slow the number of settlement agreements with reverse
payments or other anticompetitive terms, or it may merely influence the content
of those agreements; it is too early to tell. While a number of pending cases have
been affected by the Actavis decision,0 4 its impact is not yet clear.
If reverse payment settlement agreements continue to prove problematic, a
number of reforms could address this unintended consequence of the Hatch-
Waxman Act. Currently, the FTC must be notified of reverse payment settlement
agreements, but it does not prospectively approve or disapprove them as it does
for proposed mergers under the Hart-Scott-Rodino Act. 2" The absence of FTC
approval means that brand-name and generic manufacturers may proceed

200. Pub. L. No. 108-173, §§ 1111-18,117 Stat. 2066,2461-63.

201. 133 S. Ct. 2223 (2013).
202. Id. at 2231.
203. Id. at 2229.
204. See, e.g., Merck & Co. v. La. Wholesale Drug Co., 133 S. Ct. 2849 (2013) (K-Dur
(potassium chloride)); In re Lipitor Antitrust Litig., 46 F. Supp. 3d 523 (D.N.J. 2014) (atorvastatin;
dismissing case for failure to meet pleading standards); In re Nexium (esomeprazole) Antitrust
Litig., 968 F. Supp. 2d 367 (D. Mass. 2013); King Drug Co. of Florence, Inc. v. Cephalon, Inc.,
702 F. Supp. 2d 514 (E.D. Pa. 2013) (Provigil (modafinil)). See generally Brian Sodikoff et al.,
Reverse Payments After Actavis: 15 Cases to Follow, 12 PHARMACEUTICAL L. & INDUS. REP. 999,
1008 (2014) (discussing fifteen cases applying, or soon to apply, the Actavis standard and noting
that "the contours of post-Actavis reverse payment analysis are not definitively established, creating
uncertainty").
205. Pub. L. No. 94-435, 90 Stat. 1383 (1976) (current version at 15 U.S.C. § 18a (2012)).
 HATCH-WAXMAN TURNS 30

according to the terms of their agreements without waiting any particular period
of time. They also need not negotiate with the FTC prior to entering into the
settlement agreement. Legislative amendments to Hatch-Waxman might confer
approval power to the FTC and impose a waiting period during which time the
FTC could evaluate a proposed settlement. The power to disapprove could help
reduce or at least diminish the litigation burden on the FTC, as well as provide an
opportunity to negotiate concessions with respect to the terms of any proposed
settlement agreement. In addition, under the MMA amendments, failure to file
with the FTC can result in civil penalties of up to $11,000 per day ($4 million per
year).20 6 However, given that the forty potential reverse payment settlements filed
with the FTC in 2012 concerned products that averaged $268 million in sales per
year,2" 7 these penalties may be too small. Finally, the MMA amendments to the
Hatch-Waxman Act required filing of only settlement agreements between
brand-name and Paragraph IV generic ANDA filers, but not those between
brand-name and generic manufacturers that might later have filed a Paragraph IV
challenge if not for an earlier agreement. Agreements entered into before the
filing of Paragraph IV challenges might not be settlement agreements, but the
FTC should be attentive to possible shifts in concerted practices that could result
from stricter settlement agreement legislation and decisions.2 8

3. Authorized Generics

In recent years, the rise of a new category of drugs called "authorized

generics ' 20 9 has threatened the balance between brand-name drug exclusivity
periods and generic drug competition established by the Hatch-Waxman Act.
Authorized generics are products that are marketed as generics but sold by a
brand-name manufacturer or its licensee. Because authorized generics
administratively fall under the brand-name company's original NDA approval,
they can be introduced at the brand-name company's discretion. In most cases,
they are sold just prior to the beginning of the 180-day generic exclusivity period

206. Pub. L. No. 108-173, § 1115(a), 117 Stat. 2066, 2463 (2003).
207. Overview of Agreements Filed in FY 2012, supra note 198, at I (noting thirty-one
different branded products with combined annual U.S. sales of $8.3 billion).
208. See Per Se Illegality, supra note 193, at 576 ("[C]reative lawyers are capable of crafting
settlement agreements that have the same effects as the most pernicious reverse payment cases but
would pass unscathed under a rule focusing on reverse payments.").
209. See Aidan Hollis & Bryan A. Liang, An Assessment of the Effect ofAuthorized Generics
on Consumer Prices GENERIC PHARM. MFR. ASS'N 2 n. 1 (2006),
http://emmanuelcombe.org/hollisliang.pdf (defining "authorized generic" as "the actual brand-
name drug product, manufactured by the brand company, but sold as a generic, competing with
independent generics"); see also SCHACHT & THOMAS, supra note 79, at II ("[l]n 2007, 9.3% of
prescriptions filled by generic drugs were filled by branded generics.").
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

that occurs when the first traditional generic drug enters the market after a
successful Paragraph IV challenge. As a result, authorized generics have been
criticized as a deliberate attempt to undermine the incentive structure of Hatch-
Waxman, as they disincentivize the initiation of Paragraph IV challenges against
weak Orange Book-listed patents protecting brand-name products. 210 The
presence of an authorized generic reduces the potential profits available to
generic manufacturers by introducing a competitor to the generic during the
exclusivity period. A 2009 FTC Report confirmed that authorized generics
reduce prices by increasing competition during the 180-day period. 2 " Average
retail prices were found to be 4.2 percent lower if an authorized generic entered
the market than if it did not.2 12 The Report also confirmed the concern that entry
by an authorized generic "significantly decreases the revenues" 21 3 of the first-
filing generic manufacturer by approximately fifty percent.2 14
Brand-name manufacturers have hinted that consumers benefit from the
lower drug prices that authorized generics offer during the 180-day duopoly
period. 215 However, such positive outcomes come at a significant cost if they
deter generic manufacturers' willingness to bring Paragraph IV challenges in the
first place. There is not yet conclusive evidence as to whether authorized generics
deter the initiation of Paragraph IV challenges. 21 6 Some commentators have
concluded that authorized generics are unlikely to have a significant deterrent
effect. Indeed, Paragraph IV certifications have been frequent despite existing
situations in which multiple generic manufacturers might enter the market, such
as might result from same-day filings 217 or filings that pertain to different doses

210. See Beth Understahl, Authorized Generics: Careful Balance Undone, 16 FORDHAM
INTELL. PROP. MEDIA & ENT. L.J. 355,392-93 (2005).
211. Authorized Generics: An Interim Report, FED. TRADE COMM'N 1, 2 (2009),
https://www.ftc.gov/sites/default/files/documents/reports/authorized-generics-interim-report-
federal-trade-commission/p062 105 authorizedgenericsreport.pdf [hereinafter Authorized Generics].
212. Id. at 6-7; see also Aaron Barkoff, PhRMA Study Finds Authorized Generics Lead to
Lower Drug Prices, ORANGEBooKBLOG (June 27, 2006),
http://www.orangebookblog.com/2006/06/phrma-study-fin.html ("[W]ith an authorized generic on
the market during the exclusivity period, discounts to brand medicines were greater-on average
15.8 percentage points greater-than instances when a generic company did not face competition
from an authorized generic.").
213. Authorized Generics, supra note 211, at 16.
214. Id. at 3.
215. Barkoff, supra note 212.
216. Hollis & Liang, supra note 209, at 2.
217. Guidancefor Industry: 180-Day Exclusivity When Multiple ANDAs Are Submitted on the
Same Day, FOOD & DRUG ADMIN. 4-5 (2003),
www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm07285 I.p
df.
 HATCH-WAXMAN TURNS 30

of the same drug. 218 Notwithstanding the possibility of entry by authorized

generics, the number of Paragraph IV challenges increased dramatically from 35
in 2001 to 242 in 2011,219 although it fell to 204 in 2012.220 That challenges are
frequent despite the disincentive created by the introduction of authorized
generics can be explained in part by the fact that Paragraph IV challenges can be
averted only if all generics are deterred from filing under Paragraph IV. Generic
manufacturers, however, may each have different business risk tolerance levels,
assessments of likely litigation outcome, or thresholds for required return-on-
investment. Given this variation, all generic manufacturers are likely to be
deterred only when the relevant patents are perceived to be relatively strong or
when expected profits are relatively small.221
While the impact of authorized generics on initiation of Paragraph IV
challenges by generic manufacturers is not fully known, authorized generics do
appear to exert a strong effect on reverse payment settlements. Indeed, in many
reverse payment cases, major settlement terms include the brand-name
manufacturer's promise either not to market an authorized generic or to allow the
generic challenger to market the authorized generic.222 Thus, the existence of
authorized generics as a key negotiating tool in reverse payment settlement cases
potentiates the anticompetitive effects and public health complications of those
agreements.
Despite their potential to suppress Paragraph IV filings and clear impact in
providing a vehicle for settlements in reverse payment cases, authorized generics
appear to be a permanent fixture of the pharmaceutical market. Recognizing the
potential chilling effect of authorized generics, generic manufacturers have
petitioned the FDA to prevent their sale during the 180-day exclusivity period.223
These petitions have not been successful, as the FDA does not have authority to

218. Ernst R. Berndt et al., Authorized Generic Drugs, Price Competition, and Consumers'
Welfare, 26 HEALTH AFF. 790, 793 (2007).
219. Gregory Glass, The Paragraph Four Report: January 2013 1 (2013),
http://www.paragraphfour.com/forums/uploads/qn/QN 113.pdf
220. Id.
221. Berndt et al., supra note 218, at 794.
222. C. Scott Hemphill, An Aggregate Approach to Antitrust: Using Data and Rulemaking to
Preserve Drug Competition, 109 COLUM. L. REv. 629 (2009).
223. See Letter from Mylan Pharm., Inc., to FDA. (Feb. 17, 2004) Prohibitthe Marketing and
Distribution of Authorized Generics Until the Expiration of the First Generic Applicant's
Exclusivity Period, Docket No. 2004P-0075,
www.fda.gov/ohrms/dockets/dailys/04/feb04/021804/04p-0075-cpOO00 -vol I .pdf, Letter from
Teva Pharm., USA, Inc., to FDA (June 9, 2004) Prevent Pfizer Inc. from Marketing a Generic
Version of Accupril Until After the Expiration of Teva's 180-day Exclusivity Period, Docket No.
2004P-0261, www.fda.gov/ohrms/dockets/dailys/04/JuneO4/061004/04p-0261 -cpO0001 -01 -
voll.pdf.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

challenge brand-name manufacturers' actions with respect to drug pricing (as

opposed to actions that change the formulation of the drugs being sold). Courts
have affirmed the ability for authorized generics to compete with ANDA-
approved generic products during the 180-day exclusivity period.224
Further study on the use and prevalence of authorized generics would help
determine whether the public health benefits arising from the decrement in price
that they offer during the 180-day exclusivity period is outweighed by the risks
that they pose to the efficient functioning of the Hatch-Waxman Paragraph IV
challenge process. Even without such evidence, it is clear that their existence
undermines the deliberately crafted incentive structure in the Hatch-Waxman Act
that intends to reward generic manufacturers for challenging weak or invalid
brand-name patents. Since the FDA will not be able to act on authorized generics
without additional authority, Congress should consider amending the Act to
prohibit the introduction of authorized generics until after the conclusion of the
180-day period.

4. Dose Form or Other Changes in the Listed Drug

One central purpose of the Hatch-Waxman Act was to guarantee a sufficient

exclusivity period to the innovator while facilitating generic entry at the end of
the exclusivity period. The balance can be tipped in favor of the innovator by the
brand-name manufacturer's strategic introduction of a slightly modified form of
the product just prior to patent expiration. A common strategy is to introduce the
new version while the patent on the old version still prevents competition. Then,
before the old patent expires, the brand-name manufacturer engages in intensive
marketing to convince physicians to prescribe the new product. The push to
switch can be reinforced by discontinuing promotion of the old product, or even
taking it off the market altogether, thereby preventing substitution at the
pharmacy counter. 25 While such dose formulation or other changes in the listed
drug2 26 can generally only succeed if the market can be convinced that the new

224. See, e.g., Teva Pharm. Indus. Ltd. v. FDA, 355 F. Supp. 2d Ill (D.D.C. 2004), affd sub
nom. Teva Pharm. Indus. Ltd. v. Crawford, 410 F.3d 51 (D.C. Cir. 2005) (holding that Pfizer may
sell its own authorized generic version of its epilepsy drug gabapentin (Neurontin) during a 180-
day exclusivity period granted to Teva Pharmaceuticals).
225. Michael A. Carrier, A Real- World Analysis of PharmaceuticalSettlements: The Missing
Dimension of Product Hopping, 62 FLA. L. REV. 1009, 1021-29 (2010); Seth C. Silber & Kara
Kuritz, Product Switching in the PharmaceuticalIndustry: Ripe for Antitrust Scrutiny?, 7 J.
GENERIC MEDICINES 119 (2012) ("[T]he market for [the old] product may be greatly depleted.").
226. This process is sometimes referred to by the derogatory term "product hopping" in the
literature. See, e.g., Jessie Cheng, An Antitrust Analysis of Product Hopping in the Pharmaceutical
Industry, 108 COLUM. L. REV. 1471 (2008); Mark Metzke, Targeting EnantiomerProduct Hopping
with a New "Obviousness" Standard, 14 UCLA J. L. & TECH. 1 (2010).
 HATCH-WAXMAN TURNS 30

version is superior, marketing has long proven successful at making new drugs
appear more desirable than justified by their therapeutic value. 227 For example, in
the case of the antibiotic doxycycline hyclate extended release (Doryx), which
was available in a capsule and nearing the date of expected generic competition,
the manufacturer introduced a tablet version at the same dosage strength and
withdrew the capsule from the market.22 8
To support a change, the original product may also be delisted from
pharmaceutical pricing guides, which are used by insurers and hospitals to
determine which drugs are available in which forms, and whether they are
produced by brand-name or generic manufacturers. For example, in the case of
the cholesterol-lowering drug fenofibrate (Tricor), Abbott moved from a 67mg
capsule to a 54mg tablet and then to a 48mg tablet. Abbott successfully mitigated
competition for more than five years before a coalition of generics
manufacturers, retail pharmacies, and class action plaintiffs convinced a court
that the manufacturer's behavior had likely violated antitrust laws.229
Only after consumers become familiar with the new version will the patent
expire and competition for the old product begin. By then, however, switching
costs have already taken hold in the form of familiarity with the new product. If
providers are writing prescriptions for the new drug, the generic version of the
old drug cannot be automatically substituted because it will not be AB-rated vis-
Ai-vis the new drug. Substitution of non-AB-rated generics, even if bioequivalent,
is generally not permitted under state substitution regimes without express
authorization from the prescriber. This means that the physician has to be
contacted and the prescription rewritten in order for a generic drug to be
dispensed.2 30 The strategy is comparable to predatory pricing in that it lures
consumers with a price that is initially the lowest available. Soon thereafter,
when generic competition emerges for the older product, it becomes more
expensive than other options. This is different from predatory pricing insofar as
consumers could switch a second time to the newly-introduced generic. But
generic manufacturers do not engage in sufficient marketing of their products to

227. See generally Jonathan J. Darrow, Pharmaceutical Gatekeepers, 47 IND. L. REV. 363
(2014) (explaining why patients, physicians, insurance companies, government regulators, and
courts do not effectively screen out drugs with poor therapeutic value).
228. Brief for FTC as Amicus Curiae, Mylan Pharm. v. Warner Chilcott Pub. Ltd. Co., 2:12-
cv-03824-PD (No. 12-3824) (E.D. Pa., Nov. 21, 2012).
229. Abbott Labs. v. Teva Pharm. USA, Inc., 432 F. Supp. 2d 408, 434 (D. Del. 2006)
(denying a motion to dismiss).
230. State Regulations on Generic Substitution, 22 PHARMACIST'S LETTER/PRESCRIBER'S
LETTER 220901 (2006) (updated Apr. 2009),
http://pharmacistsletter.therapeuticresearch.com/(X(I)S(ngouagz3ngdjz5qkl vti2045))/pl/ArticlePD
F.aspx?cs=yml&s=PL&DocumentFilelD=1499&DetaillD=220901&SegmentlD= 1186.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

promote such a switchback, although there may be financial pressures from

insurers or other payors once they become savvy to the stratagem and if the new
version's use cannot be justified by additional benefits.
Dose formulation or other changes in the listed drug are distinct from similar
strategies in other industries in that they can entitle the patent holder to a second
thirty-month stay of generic competition if a Paragraph IV challenge is brought
against the new product. In the 1990s, brand-name manufacturers began to obtain
multiple thirty-month stays on a single product before Congress generally barred
that practice with the MMA of 2003.23 1 The provisions of the MMA, however, do
not extend to an altered dosage, dosage form, or method of administration, since
those are considered to result in a "new drug," as is combining two existing drugs
into a single dosage form or altering the proportions of those drugs as compared.
to an existing combination.232 A drug for which the labeling is revised to indicate
use for a different disease--or for the same disease in a different part of the
body-could also be considered a "new drug" under FDA regulations.233
Even absent an additional thirty-month stay, a shift to a new version will
create delay by forcing the generic manufacturer to submit a second ANDA for
the new product.234 Under the 2012 Generic Drug User Fee goals, the FDA will
seek to act on ninety percent of ANDAs within ten months by the year 2017.235
But reformulation and ANDA preparation time must be added to this figure.
While it is possible for the generic firm to market its copy of the old product
under its own brand and encourage doctors to prescribe it directly, this is not a
role that generics are well-equipped to undertake. In cases in which the brand-
name manufacturer voluntarily withdraws the original drug from the U.S. market,
the ANDA applicant will have to petition the FDA for a determination that the

231. Pub. L. No. 108-173, § 1101(a)(2)(A)(ii)(1), 117 Stat. 2066, 2449 (codified at2l U.S.C. §
355(j)(5)(B)(iii) (2012)); id. § l101(b)(2)(B)(i), 117 Stat. 2453 (codified at 21 U.S.C. §
355(c)(3)(C) (2012)); see also Draft Guidancefor Industry: Listed Drugs, 30-Month Stays, and
Approval of ANDAs and 505(b)(2) Applications Under Hatch-Waxman, as Amended by the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003: Questions and
Answers, FOOD & DRUG ADMIN. 8 (2004),
http://www.fda.gov/ohrms/dockets/dockets/04d0460/04d-0460-gd10001.pdf [hereinafter Questions
and Answers] (noting that "in most cases.., no more than one 30-month stay" is permitted).
232.21 C.F.R. § 310.3(h) (2014).
233. Id.; see also 21 C.F.R. § 314.92(a)(1) (2014) ("For determining the suitability of an
abbreviated new drug application, the term 'same as' means identical in active ingredient(s),
dosage form, strength, route of administration, and conditions of use .... ").
234. In some cases, the generic applicant may submit an amendment or supplement, such as
where the ANDA seeks approval for different strengths of the same listed drug. Questions and
Answers, supra note 231, at 3.
235. 158 CONG. REC. S8291 (daily ed. Dec. 20, 2012).
 HATCH-WAXMAN TURNS 30

drug was not withdrawn for safety or effectiveness reasons,236 which may result
in delay237 or even litigation to sort out the issue.238
A number of commentators have taken a permissive view of changing dose
formulations or other pharmaceutically relevant features of the listed drug, often
on the theoretically plausible (but largely unsubstantiated) basis that new
versions could possess advantages that their predecessors do not. 239 One
suggested that the practice be allowed so long as the old drug is left on the
market or the new one offers significant improvement. 240 Another went further,
suggesting that the practice be deemed per se legal so long as a valid patent
supports the new product.24 1One pair of antitrust attorneys pointed out that this is
merely one form of life-cycle management, which firms have undertaken for
decades and which is a normal part of development and innovation.2 42 They note
that, in practice, courts have tended to find violations of the antitrust laws only
where consumers are coerced into a choice, such as where the old version is
removed from the market. 243
The patent laws are intended to lay the groundwork for vigorous competition
after the expiration of the patent term, and patentable product changes are
therefore expected to create a new period of exclusivity for the modified form.
The Hatch-Waxman Act, however, grew out of a special need in the

236. E.g., 21 C.F.R. § 314.92(a)(1) (2014) ("If a listed drug has been voluntarily
withdrawn... sale by its manufacturer, a person who wishes to submit an abbreviated new drug
application for the drug shall comply with § 314.122."); 21 C.F.R. § 314.122(a) (2014) (requiring
submission of a petition to determine whether listed drug was withdrawn for safety or effectiveness
reasons).
237. See 21 C.F.R. § 314.93(e)(l)(v) (2014) (noting that the petition may be disapproved if the
agency has not yet determined whether the voluntary withdrawal from sale is for safety or
effectiveness reasons); Michael A. Carrier & Daryl Wander, Citizen Petitions: An EmpiricalStudy,
34 CARDOZO L. REV. 249, 262-63 (2012) (discussing delays in the petition process that culminated
in a 2007 law requiring the FDA to respond within 180 days).
238. Cumberland Pharm. Inc. v. FDA, 981 F. Supp. 2d 38 (D.D.C. 2013). Moreover,
withdrawal of the older branded drug may lead the FDA to designate a generic company as the
RLD holder, which one court has held subjects the generic company to failure-to-wam liability
normally borne only by brand manufacturers. In re Reglan/Metoclopramide Litig., 81 A.3d 80, 96
(Pa. Super. Ct. 2013), appealdenied, 99 A.3d 926 (Pa. 2014).
239. See, e.g., Daniel A. Crane, Provigil: A Commentary, 3 HASTINGS SCI. & TECH. L.J. 453,
455 (2011).
240. Alan Devlin, Exclusionary Strategies in the Hatch- Waxman Act, 2007 MICH. ST. L. REV.
631, 681 (2007).
241. Michelle L. Ethier, Permissible Product Hopping: Why a Per Se Legal Rule Barring
Antitrust Liability is Necessary to Protect Future Innovation in the PharmaceuticalIndustry, 3
AKRON INTELL. PROP. J. 323, 324 (2009). To obtain a new 30-month stay for the new drug, at least
one Orange Book-listed patent must exist in order to create a basis for a Paragraph IV certification.
242. Silber & Kuritz, supra note 225, at 3.
243. Id.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

pharmaceutical market stemming from the fact that the expiration of the patent
period alone could not adequately promote generic competition due to the high
transaction costs associated with pharmaceutical introductions. While the ANDA
process reduces these costs substantially, costs remain high, both in terms of
dollar value and months of delay. For this reason, changes in dose formulations
or other similar changes in the listed drug should be viewed skeptically. This will
ensure that generic drugs can freely compete at the expiration of both patent and
regulatory exclusivity periods, and will thwart what the FTC recently described
as techniques used to "game the regulatory structure ' , 244 on the part of brand-
name manufacturers. Courts, the FTC, and even the FDA should closely
scrutinize practices for which the primary purpose is to frustrate generic
competition as generic competition for that product nears. These practices
include voluntarily withdrawing a brand-name drug for reasons other than safety
or efficacy or changing the number of milligrams of active ingredient in a
formulation in ways that do not correspond to therapeutic demands. While
discerning a company's "purpose" in taking some action may be difficult, timing
can provide an important clue. In light of the dramatic success and increasing
market share of generics, scrutiny by the FTC and courts rather than statutory
amendment should be sufficient to effectuate the purposes of the Hatch-Waxman
Act with respect to this business practice. Should trends reverse and a clear
pattern of abuse go uncorrected by the courts, statutory amendment might be a
better means of reform.

5. Refusal to Provide Materialfor Purpose ofEstablishingBioequivalence

Unintended consequences of legislation are not limited to oddities like

"reverse" payments, well-timed switching of the dose formulation, or slight
changes to other pharmaceutically relevant components of the listed drug.
Another strategy brand-name manufacturers recently used to protect their market
share was to take deliberate steps to prevent generic firms from obtaining
samples of their branded products to conduct the bioequivalence testing
envisioned under the Hatch-Waxman Act. Although the FDA takes a flexible
approach to the determination of bioequivalence, generic approval as an AB-
rated bioequivalent drug generally requires comparative testing of the generic
against the innovator drug. 245 The acquisition of a certain amount of brand-name

244. Brief for FTC as Amicus Curiae, Mylan Pharm. Inc. v. Warner Chilcott Pub. Ltd. Co.,
No. 12-3824 (E.D. Pa. Nov. 21, 2012); see also I HERBERT HOVENKAMP ET AL., IP AND ANTITRUST
§ 15.3 (2d ed. Supps. 2010-2013) (discussing reverse payment settlements, authorized generics,
conduct designed to eliminate 180-day exclusivity, misrepresentations to the FDA, sham FDA
citizen petitions, and product hopping).
245. See, e.g., Complaint at 9-10, Mylan Pharm. Inc. v. Celgene Corp., No. 2:14-cv-02094
 HATCH-WAXMAN TURNS 30

product is therefore usually a prerequisite to generic approval.246

However, over the past several years, the FTC has been investigating
allegations by some generic manufacturers that brand-name firms are deliberately
withholding access to their products for the purpose of preventing bioequivalence
testing.24 7 In 2009, generic firms reported that Celgene refused to sell them
samples of thalidomide (Thalomid), the infamous drug associated with birth
defects in the 1950s, which was approved in 1998 and 2006 to treat leprosy and a
form of cancer called multiple myeloma, respectively. 248 Gilead has been accused
of including provisions in its supply chain contracts that restrict the distribution
of ambrisentan (Letairis), a pulmonary artery hypertension drug, to generic
manufacturers. 249 Similar practices were challenged in court under the antitrust
laws against Actelion, the company that manufacturers bosentan (Tracleer),
another pulmonary artery hypertension product, and miglustat (Zavesca), a
treatment for a form of the rare genetic deficiency Gaucher disease. 250 The FTC
filed an amicus brief supporting the position of the generic manufacturers, 25' but
the case recently settled with an undisclosed outcome.
There are sometimes legitimate safety reasons to restrict sales of patented

(D.N.J. Apr. 3, 2014) ("In order to perform the necessary bioequivalence testing between a
proposed generic product and the RLD, the generic manufacturer needs to obtain samples of the
RLD."); Draft Guidancefor Industry on Bioequivalence Studies with PharmacokineticEndpoints
for Drugs Submitted Under an Abbreviated New Drug Application; Availability, FOOD & DRUG
ADMIN. 3 (2013),
http://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm3 7
7465.pdf ("[FDA] recommend[s] that applicants perform a two-period, two-sequence, two-
treatment, single-dose, crossover study .... In this design, each study subject should receive each
treatment (test, and RLD [i.e., reference listed drug]) in random order."); see also id. at 6 ("[FDA]
usually recommend[s] a ... two-treatment ... crossover study for fed BE [i.e., bioequivalence]
studies."); Guidance for Industry on Bioavailability and Bioequivalence Studies for Orally
Administered Drug Products-General Considerations, FOOD & DRUG ADMIN. 6 (2003),
http://www.fda.gov/downloads/Drugs/Guidances/ucm070124.pdf ("A typical [bioequivalence]
study is conducted as a crossover study."); Guidance for Industry: Statistical Approaches to
Establishing Bioequivalence, FOOD & DRUG ADMIN. 7 (2001),
http://www.fda.gov/downloads/Drugs/Guidances/ucm070244.pdf (referring to "the standard two-
formulation ... crossover design").
246. Even if the branded drug is covered by a patent, a special provision provides an
exemption from patent infringement litigation for otherwise infringing uses that are "reasonably
related to the development of information" for FDA approval, therefore allowing bioequivalence
testing prior to patent expiration. 35 U.S.C. § 271 (e)(l) (2012).
247. Brief for FTC as Amicus Curiae, Actelion Pharm. Ltd. v. Apotex Inc., No. I:12-cv-
05743-NLH-AMD, at 2 (D.N.J. Mar. 11,2013).
248. Katie Thomas, Game Plan Against Generics, N.Y. TIMES, Apr. 15, 2013, at B 1.
249. Id.
250. Actelion Pharm. Ltd. v. Apotex Inc., No. 1:12-cv-05743-NLH-AMD, 2013 WL 5524078
(D.N.J. Sept. 6, 2013).
251. Brief for FTC as Amicus Curiae, supra note 228, at 2.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

pharmaceuticals. In 2007, the Food and Drug Administration Amendments Act

(FDAAA) gave the FDA power to require drugs to be distributed through
controlled channels as part of its Risk Evaluation and Mitigation Strategies
(REMS) provision. 2552 Foreseeing the potential to use this provision to frustrate
generic entry, Congress specifically prohibited companies from using REMS to
"block or delay approval" of an ANDA. 25' However, the legislation did not
address restrictions on distribution unrelated to REMS, nor did it affirmatively
require brand-name companies to sell their products to generics. Nevertheless,
deliberate attempts to frustrate the operation of the Hatch-Waxman Act's
bioequivalence provisions are likely to be viewed skeptically by courts. If the
judiciary does not restrain this tactic, amending the Hatch-Waxman Act to ensure
access may be a reasonable solution. The FDA recently issued guidance intended
to assist the generic industry in obtaining samples of brand products subject to
restricted distribution systems.254 It is too early to determine whether this
guidance will have any positive impact.

B. Ensuring Continued Safety of GenericDrugs

A second major challenge to the Hatch-Waxman regime involves

interpretation of the statute by the Supreme Court in a way that fundamentally, if
unintentionally, has altered the interchangeability of generics and brands. Both
Hatch-Waxman and state generic substitution laws depend on the assumption that
generic products are medically equivalent to their brand-name versions. As
discussed above, decades of evidence demonstrate that the safety and efficacy
profiles of generic and branded drugs are equivalent. In 2011, however, the
Supreme Court held in Pliva, Inc. v. Mensing that patients injured by a generic
drug could not bring suit against the manufacturer for failing to include an
adequate warning on the label.255 This was because the FDA interpreted the
Hatch-Waxman Act to require generic manufacturers to display a label that is the
same as the brand name label at all times.256 The FDA's goal may have been to

252. Pub. L. 110-85, 121 Stat. 823, 926 (codified as amended at 21 U.S.C. § 355-1 (2012)).
253.21 U.S.C § 355-1(f)(8) (2012).
254. Draft Guidance: How to Obtain a Letterfrom FDA Stating that Bioequivalence Study
Protocols Contain Safety Protections Comparable to Applicable REMS for RLD, FOOD & DRUG
ADMIN. (2014),
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UC
M425662.pdf.
255. 131 S. Ct. 2567, 2582 (2011). Mensing's holding was reinforced in another Supreme
Court case in 2013, Mutual Pharm. Co. v. Bartlett, 133 S. Ct. 2466 (2013).
256. 21 U.S.C. § 355(J)(2)(A)(v) (2012); Supplemental Applications Proposing Labeling
Changes for Approved Drugs and Biological Products, 78 Fed. Reg. 67,985 (proposed Nov. 13,
2013) (to be codified at 21 C.F.R. pts. 314, 601).
 HATCH-WAXMAN TURNS 30

ensure that the drugs were as interchangeable as possible. Because the Court
found that the Hatch-Waxman Act did not provide a clear pathway for generic
manufacturers to independently change their label, generic manufacturers could
not be liable under state law for failing to change it. Brand-name drug
manufacturers, by contrast, could be liable for failing to conform to their state-
law duties to provide adequate labeling and update their labeling proactively,
because the FDA had provided a pathway to do that under the FDCA 7
The practical impact of the Mensing holding, however, is a reduction in
safety oversight for, and an increased threat to, the interchangeability of generic
drugs. Post-Mensing, there is little incentive for generic manufacturers to
undertake pharmacovigilance or other programs intended to promote learning
about the adverse effects of generic drugs. In the past, serious new safety issues
have been identified after generic versions of a drug become available. A recent
review led by Public Citizen identified dozens of drugs that had black box
warnings-the most prominent sort of warning that the FDA can impose on a
product-added after the generic version of the product was available.2 58 But
many of these new warnings have been identified fortuitously by government-
funded observational research or years of litigation led by injured plaintiffs. 219 If
generic manufacturers are not subject to lawsuit by virtue of their label not being
updated to reflect ongoing learning about safe use of a drug, then they have no
incentive to lead the studies that might contribute to such learning and uncover
late-arising safety hazards. Because only brand-name manufacturers bear this
responsibility, active learning about prescription drugs under the Mensing regime
essentially stops after generics hit the market and brand-name manufacturers'
market penetration drops precipitously (or they exit the market altogether).26°
In addition to its negative effects on public health, Mensing gave patients
reason to be wary of accepting low-cost generic drugs that were pharmaceutically
and clinically equivalent: if they were injured by side effects that were
inadequately described in the label, they would find it more difficult to obtain
compensation from the manufacturer. Mensing also undermines
interchangeability in a second, complementary fashion. After 2011, physicians

257. Wyeth v. Levine, 555 U.S. 555 (2009).

258. Generic Drug Labeling: A Report on Serious Warnings Added to Approved Drugs and on
Generic Drugs Marketed Without a Brand-Name Equivalent, PUB. CITIZEN 4 (2013),
http://www.citizen.org/documents/2138.pdf.
259. Aaron S. Kesselheim et al., Risk, Responsibility, and Generic Drugs, 367(18) NEw ENG.
J. MED. 1679, 1680 (2012) [hereinafter Risk, Responsibility, and Generic Drugs].
260. See Henry Grabowski et al., Recent Trends in Brand-Name and Generic Drug
Competition, J. MED. ETHICS 1, 6 (2013) (After only a single year of generic competition, "brands
retained an average of only 16%" of unit sales.); see also id. at 7 fig.4 (illustrating that both the
speed and extent of market share loss to generic entrants has increased between 1999 and 2012).
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

deciding whether to prescribe brand-name or generic drugs for their patients now
faced an ethical conundrum. Should they prescribe the generic (or allow
substitution), on the basis that most patients will appreciate the lower price and
that they have an ethical responsibility to be prudent stewards of healthcare
resources, or should they prescribe the brand-name drug so as to preserve a
patient's ability to obtain compensation should injury result? Or, would the
physician be obligated to make a case-by-case determination, taking into account
factors such as the likelihood and magnitude of potential harm and the patient's
financial position, including insurance coverage? Even more disconcerting,
Mensing questions the ethics of generic substitution laws, threatening to erode
the prodigious gains in generic market share over the past thirty years. Mensing
was met with stunned bewilderment in the press 6' and elicited pleas for reform
by commentators.262
Recognizing the oddity created by the Mensing holding, the Supreme Court
offered that "Congress and the FDA retain the authority to change the law and
regulations if they so desire. 2 63 Lawmakers responded by introducing
legislation,264 but it has not passed. The FDA also acted on the Supreme Court's
invitation, issuing proposed regulations in late 2013 that would permit ANDA
holders to distribute revised product labeling that differs, temporarily, from the
brand-name version's labeling.265 However, a dispersed community of generic
manufacturers may not be well positioned to monitor and respond to safety
concerns. 266 Even brand-name manufacturers channel resources away from
pharmacovigilance of their products once the products go off-patent. A more
promising approach would be to centralize the collection and analysis of safety
data about generic drugs at the FDA, which would coordinate the creation of a
consensus label. Injured plaintiffs could be compensated out of a fund generated
from a small tax on generic drug sales, 267 using the National Childhood Vaccine
Injury Act's provision for the establishment of a National Vaccine Injury

261. See e.g., Katie Thomas, Generic Drugs Prove Resistant to Damage Suits, N.Y. TIMES,
Mar. 20, 2012, at Al.
262. See e.g., Leonard H. Glantz & George J. Annas, Impossible? Outlawing State Safety
Laws for Generic Drugs, 365 NEW ENG. J. MED. 681 (2011); Citizen Petition of August 29, 2011
PUB. CITIZEN (2011), http://www.citizen.org/documents/1965.pdf.
263. Pliva, Inc. v. Mensing, 131 S. Ct. 2567, 2582 (2011).
264. Risk, Responsibility, and Generic Drugs, supra note 259, at 1679.
265. Supplemental Applications Proposing Labeling Changes for Approved Drugs and
Biological Products, 78 Fed. Reg. 67,985 (Nov. 13, 2013) (to be codified at 21 C.F.R. pts. 314,
601).
266. Risk, Responsibility, and Generic Drugs, supra note 259, at 1680.
267. Aaron S. Kesselheim et al., Who Is Now Responsiblefor Discovering and WarningAbout
Adverse Effects of Generic Drugs?, 310 JAMA 1023, 1024 (2013).
 HATCH-WAXMAN TURNS 30

Compensation Program 268 as a model. These steps would help to ensure adequate
patient warnings, provide compensation to injured plaintiffs, and, most
importantly for present purposes, restore both medical equivalence and ethical
equipoise to the choice between brand-name products and their generic
equivalents.

V. CONCLUSION

In the robust generic drug market in the United States, generics make up a
dominant and rising share of prescriptions, and generic prices are low in the
United States when compared with prices in other developed countries. 269 This
success is attributable to a number of features of the Hatch-Waxman Act that
facilitate and encourage the introduction of new generic drugs and help to
promote price competition once those drugs are approved. The 180-day generic
exclusivity period offered to the first generic to challenge a pharmaceutical
patent creates a financial incentive to bring generic drugs to market as early as
possible, and potentially clears away weak patents so that other generic firms can
enter the market at the end of the exclusivity period. By statutorily deeming the
act of filing with the FDA to constitute constructive patent infringement, the
Paragraph IV system provides a means to obtain a judicial determination of
patent validity at relatively low risk, avoiding the need to "bet the farm, 270 by
entering the market and risking treble damages for intentional infringement. The
bioequivalence pathway created by the Hatch-Waxman Act allows generic firms
to obtain approval by showing acceptable serum concentrations based on data
from a few dozen subjects, avoiding the need to conduct duplicative and costly
full-scale clinical trials of hundreds or even thousands of subjects. Finally, DPS
laws facilitate the dispensing of the generic drugs that are approved, providing a
needed element in a system where insurance might otherwise inappropriately
dampen price competition. As a result, scores of generic drugs are widely
available for as little as $4 for a thirty-day supply at stores such as Wal-Mart and
Target, 2 7 and dozens of new generics are approved each month.

268. Pub. L. No. 99-660, Title Ill, § 311 (a), 100 Stat. 3755, 3758 (1986) (codified as amended
at 42 U.S.C. § 300aa-10 (2012)).
269. Danzon & Furukawa, supra note 5, at 528.
270. See Medimmune, Inc. v. Genentech, Inc., 549 U.S. 118, 129 (2007) (noting the
importance to potential defendants of being able to obtain judicial resolution of patent matters
without having to "bet the farm" by actually infringing the patent and risking treble damages).
271. See Save Big on Hundreds of Generic Drugs, TARGET,
http://www.target.com/pharmacy/generics-alphabetic (last visited Apr. 18, 2015); Retail
Prescription Program Drug List, WALMART (2013),
http://i.walmart.com/i/if/hmp/fusion/genericdruglist.pdf.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)

Despite this generally positive record of success, a number of challenges to

the continued effectiveness of the Hatch-Waxman Act have emerged that require
legislative, regulatory, or judicial attention. Some of these developments consist
of the deliberate reactions of industry players that are attempting to maximize
profitability within the constraints of the Hatch-Waxman Act, while others have
been technological or legal developments that have threatened to render the Act
less effective or less relevant. Much like taxpaying entities alter their behavior in
response to new tax laws, players in the brand-name and generic drug industries
have rationally responded to the Hatch-Waxman legislation in a number of ways
that may not be socially productive. Such responses include: amassing large
numbers of patents that can be used to trigger a thirty-month stay; using the
threat of authorized generics as a potentially anti-competitive lever to settle
Paragraph IV challenges; and hopping to new products without a substantial
clinical justification in order to obtain additional thirty-month stays. At the same
time, the Supreme Court decision in Pliva v. Mensing has called into question the
future clinical and ethical interchangeability of generic and brand-name drugs.
With three decades of experience to guide the way, numerous policy
refinements could address these challenges and thereby help to fulfill the Hatch-
Waxman Act's original purpose. Congress should consider amending the Act to
prohibit the introduction of authorized generics during the 180-day period.
Courts and the FTC should scrutinize attempts by brand-name firms to engage in
formulation changes or to prevent generic companies from obtaining needed test
products unless it can be shown that these actions have a genuine clinical
justification. Clinical equivalence and ethical equipoise should be restored by
abrogating Pliva v. Mensing either via legislation or regulation, 272 and
considering whether compensation for harms might better be provided by a
government-funded program analogous to that available for vaccine injuries.
Additional funding may be needed to educate patients and healthcare
professionals regarding generic equivalence and to generate additional data in
those areas where evidence of equivalence is not sufficiently robust.
The Hatch-Waxman Act has transformed the pharmaceutical marketplace

272. Following Mensing, the FDA proposed regulations that would permit ANDA holders to
revise their product labels such that they differ in certain respects, on a temporary basis, from the
label in the RLD. See Supplemental Application Proposing Labeling Changes for Approved Drugs
and Biological Products, 78 Fed. Reg. 67,985 (proposed Nov. 13, 2013) (to be codified at 21 C.F.R.
pts. 314, 601). Although this would likely preserve the ability of patients to bring failure-to-warn
claims against generic manufacturers and thereby help to restore clinical and ethical equipoise, the
proposed regulation has been criticized for its potential to lead to reduced generic drug availability
due to liability costs and uncertainties. See Erin M. Bosman et al., FDA Proposed Rule in Flux?,
MORRISON & FOERSTER LLP (2015),
http://www.mofo.com/-/media/Files/ClientAlert/2015/02/150218FDAProposedRule.pdf.
 HATCH-WAXMAN TURNS 30

over the last thirty years, and its influence around the world will only increase as
trade agreements are developed and similar legislation is enacted in other
countries. The importance of the law to setting the appropriate balance between
pioneering innovation and a vibrant generic drugs market warrants continued
vigilance in light of evolving circumstances. With attention to the issues raised in
this Article, modest reshaping of the law can help assure the continued success of
the Hatch-Waxman Act for decades to come.
YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS 15:2 (2015)