Just a few weeks after President Donald Trump’s December promise that prescription drug prices would plummet “fast and furious,” Patricia Brown checked into a California clinic for an infusion of Merck & Co.’s blockbuster cancer drug, Keytruda.
When the bill arrived, the clinic’s charge for a 400 mg dose dominated the page: $162,567.74.
Brown, an accomplished cook battling lung cancer, owed about $2,000.
But the six-figure charges to Brown and her insurance company show how quickly prices for cutting-edge medical treatments can balloon in the U.S. health care system. Someone has to pay: An employer, taxpayers, or regular people whose insurance premiums go up and up.
The price of Keytruda for Americans starts high and often heads higher. Merck lists Brown’s dose at an already steep $24,000. Then, depending on the insurer, the health-care provider and any number of middlemen, prices can rise.
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Merck CEO and Chairman Robert M. Davis lined up behind Trump in December alongside the pharmaceutical leaders at a White House press conference. He declared 100% support for the president’s actions and vowed Merck would drop prices on a diabetes drug and a cardiovascular pill.
He didn’t say anything about cutting the cost of Keytruda, which accounted for $31.7 billion in worldwide sales in 2025, nearly half of Merck’s revenue.
The drug has become a lifeline for a growing number of cancer patients around the world. But a joint investigation by the International Consortium of Investigative Journalists and USA TODAY found that Merck has employed several tactics to keep Keytruda’s price high – along with its profits.
Merck protects the drug from generic competition behind a growing wall of patents. The company lobbies to avoid negotiating the price of the drug with Medicare. And though studies have said lower doses based on weight are effective and would save money, the company has not moved to change dosing.
In some other countries, ICIJ found, such tactics have priced Keytruda out of reach of cancer patients who need it. In the U.S., where Merck tallies about 60% of the drug’s sales, the prices generally begin with what Merck charges. Costs for the life-saving drug then increase as middlemen and health providers tack on charges.
In a statement, Merck spokeswoman Julie Cunningham blamed high prices in the U.S. on pharmacy benefit managers and health insurers, middle players who extract rebates and fees, driving up costs for patients.
“America is the only country in the world where entities that don’t make medicines take half of every dollar spent on brand medicines,” she said.
Merck’s tactics with Keytruda are common – and legal – in the pharmaceutical industry. Once a drug company discovers an effective medicine that the public and the medical community demand, the company pulls legal levers to maintain that advantage for as long as it can.
“Squeezing as much life out of an original patent is par for the course” in the drug industry, said Antonio Ciaccia, president of 3 Axis Advisors and an expert in drug pricing. “You get a breadwinner, you want to hold onto that breadwinner as long as you can.”
Scott Brown, a 63-year-old grocery store employee, has been caring for his wife, Patricia Brown, at their home in Rancho Cordova, California, for nearly a year as she fights advanced lung cancer that has spread to her brain and spine.
The couple, who have been together for 40 years, briefly turned to Keytruda in November 2025 alongside chemotherapy and radiation. Patricia Brown received the drug every six weeks until side effects on her thyroid forced her to stop. Looking at the bills, including the $162,000 bill for one Keytruda treatment from UC Davis Health, Scott Brown doubts prices for cancer treatment will ever fall.
“I would love for them to understand what the little guy’s going through,” he said of politicians and pharmaceutical executives, “but I’m also a realist.”
How Merck protects Keytruda’s price
Merck, either alone or jointly through partners, has employed the patent system to build a fortress around Keytruda of 50 active patents in the United States. Citing data from the initiative for Medicines, Access, and Knowledge, or I-MAK, ICIJ tracked more than 1,200 patent applications filed by Merck and other cancer research businesses. These applications related to the drug were in 53 countries, regions and territories. These patents could help Merck fend off competition and maintain high prices – and billions of dollars in revenue – for 14 years after its original patents expire in 2028, ICIJ found.
In a statement, Merck’s Cunningham disputed those findings.
Cunningham said it’s a “common myth” that drug companies game the patent system with overlapping patents to delay competition. “It has been repeatedly shown that patent counts do not predict timing of generic entry.”
Patents are a critical part of the U.S. drug development system. In exchange for encouraging research and development of new drugs, patents allow drug companies an exclusive window to sell a brand name drug without competition from a less-expensive generic or biosimilar. U.S. patents, which generally last 20 years from the application date, allow companies to enjoy a dominance in the market, charge higher prices, recover research and development costs and earn profits to fund future research.
Drug pricing experts say using patents to delay competition from companies offering less expensive versions is a common strategy.
“This scenario where a drug company obtains dozens of patents protecting different aspects of a blockbuster drug in order to ward off competition is quite common,” said Dr. Benjamin Rome, a Harvard Medical School professor. “Just the existence of this patent thicket can scare away companies who would otherwise seek to make biosimilar versions of Keytruda, as the biosimilar makers need to spend exorbitant amounts of money to fight these patents in court.”
Merck is rolling out a new version of the medication – an injectable version called Keytruda Qlex. Merck expects many Keytruda users will switch to the new injectable version before Keytruda’s original patent expires in 2028.
“We expect to see between 30 to 40 percent adoption as we approach 2028,” Cunningham said.
If enough customers switch to the injectable version from the original infused Keytruda, it could delay competition until the 2030s, ICIJ reported, citing three industry experts.
While the Food and Drug Administration has approved Keytruda’s dosing of 200 mg every three weeks or 400 mg every six weeks, some cancer researchers contend Merck promotes a higher dosage of Keytruda than is necessary. The excess dosing could cost each patient an extra $75,000 over the course of their treatment, researchers at the World Health Organization say, totaling an estimated $5 billion that could be saved through 2040 just among lung cancer patients.
And like other drug companies, Merck has lobbied and sued to prevent Medicare from negotiating lower drug prices. The Inflation Reduction Act empowered Medicare, the federal insurance program for adults 65 and older, to negotiate lower prices on some of the federal insurer’s costliest drugs. But President Donald Trump’s tax cut and spending legislation in 2025 delayed Medicare price negotiations for some drugs, including Keytruda, by at least one year.
Merck senior vice president Johanna Herrmann defended the company’s pricing practices, saying that Keytruda’s price “reflects its value to patients and health-care systems.”
“We have a long history of responsibly pricing our medicines to reflect their value to patients, payers and society,” she said in a letter to ICIJ.
Herrmann acknowledged in a separate letter that Merck faces “increasing political and business pressures” over access and pricing in emerging markets. But she said the company is working to ensure health care is “affordable, efficient, equitable and sustainable on a global scale.”
Rates for Keytruda vary by tens of thousands of dollars
Beyond Merck’s list price of $12,031 per 200 mg treatment of Keytruda, the amount Americans pay for the immunotherapy is a spin of the wheel, depending on where they live, where they get it and what their insurance covers.
Middlemen such as drug wholesalers and pharmacy benefit managers each take a piece of a blockbuster drug’s profits.
Interviews with patients and a review of drug price transparency data show the actual rates billed vary by tens of thousands of dollars per treatment, depending on the patient’s home state, type of treatment, health care provider and insurer.
Patients interviewed by USA TODAY shared hospital bills ranging from about $15,000 for a standard 200 mg treatment to more than $162,000 for Patricia Brown’s double dose, almost seven times costlier than Merck’s list price.
Brown’s insurance company paid more than $110,000 to UC Davis Health, which administered her double dose. The insurer, UnitedHealthcare, also discounted the bill more than $57,000, a hospital invoice shows.
A spokesman for UC Davis Health said hospital pricing is complex and reflects the full cost of safely delivering care, and not just the cost of the medication.
Serif Health, a San Francisco firm that compiles records monthly from more than 200 commercial insurers, shared data with USA TODAY showing negotiated in-network rates for a standard 200 mg Keytruda treatment range broadly depending on where the patient lives, which insurance company and medical provider they use, and how it’s billed.
USA TODAY’s review of records from March and April shows some states, such as Maine and Rhode Island, have a very narrow window of in-network rates that insurers have negotiated with health care providers. Most Keytruda patients there will be charged within just a few hundred dollars of each other.
Other states, like Alaska, Idaho and Utah, show much wider variation in the negotiated rates. One Keytruda patient could easily get billed thousands of dollars more than a patient with different insurance or at a healthcare system across town.
Overall, Serif Health’s records show the majority of negotiated prices across the country fall between $8,600 and $22,200 for a single treatment, with a handful of extreme prices reported above $100,000 per dose.
Most American Keytruda patients insured through their employers or Medicare will pay just a sliver of that price, until they hit the out-of-pocket maximum set by their insurance plan. For uninsured cancer patients, some hospital systems, nonprofit organizations and Merck offer financial assistance programs that can knock down the cost.
Hospitals charge higher prices
On a narrow suburban street lined with modest, single-story homes outside Cincinnati, Ohio, 64-year-old Barbara Thornton presided over tables filled with neat rows of homemade baked goods one recent Saturday morning.
Surrounded by family in her yard, Thornton hawked her famous lemon bars, pound cake and twice-baked potatoes to friends, neighbors and the mail carrier, who all stopped by and helped her raise about $3,000 for pancreatic cancer research.
“Just this past December, I finally rang the bell,” Thornton said, referring to a common ritual when survivors complete treatment. “100% cancer-free in remission.”
Every three weeks for more than two years, Thornton had been driving just a few streets over to a hospital outpatient clinic where she got Keytruda treatments.
“Basically, that day at the infusion center was $42,000, and I was getting that every three weeks,” Thornton said. “But I was lucky. I had insurance.”
Plenty of other Keytruda patients share Thornton’s experience of receiving bills with staggeringly high figures. In fact, billed prices can nearly double when the drug is administered in a hospital outpatient setting instead of a doctor’s office, according to the Health Care Cost Institute.
This nonprofit group, which analyzes employer-sponsored insurance claims in the U.S., reviewed U.S. Keytruda treatment cost data for this project. They found the median price for a dose of Keytruda at hospital systems to be about $21,600 in 2022. At doctor’s offices that year, the same treatment cost $11,500.
“Whether it is drug administration, lab testing or imaging, the care provided is often identical, but as we saw with Keytruda, the price tag depends entirely on the building you’re treated in,” John Hargraves, HCCI’s managing director of data strategy and analytics, told ICIJ. “While it’s not unusual for specialty drugs like Keytruda to carry very high per-patient costs, the scale of spending we’re seeing here is remarkable and raises important questions about affordability for employers and patients alike.”
A hospital is usually the costliest place to get care. Hospitals must support round-the-clock staffing. Hospitals are legally required to assess and stabilize any patient who comes to an emergency room – even if they don’t have the means to pay the bill. Most U.S. hospitals are tax exempt and must provide community benefit, often in the form of free or reduced-price care for low-income families.
It’s one reason why medications typically cost more when administered by hospitals. But how much a consumer and their insurance plan is billed varies greatly.
For a three-week regimen of Keytruda, 372 hospitals in 49 states charge more than 11,000 different prices for the same medication, according to an analysis by 3 Axis Advisors and Patient Rights Advocate.
Even in the same hospital, prices vary significantly.
Depending on their insurance card, a patient who gets Keytruda at a hospital in Sullivan, Missouri, may pay as little as $11,747 or as much as $42,498, according to the 3 Axis analysis.
“The negotiated prices are all over the map,” Ciaccia said. “Drug pricing in the United States is not as simple as what a manufacturer (charges). There are challenges and distortions in the drug distribution system that can also result in significantly inflated costs.”
Some hospitals cash in on Keytruda discounts
Former North Carolina Treasurer Dale Folwell sought to get to the bottom of the Tar Heel State’s sky-high costs for cancer drugs.
At stake was North Carolina’s ability to provide benefits to state workers and their families.
So when he was still in office in 2024, Folwell commissioned a report to examine why the cost of cancer drugs and other specialty drugs soared 75% from 2018 through 2022.
North Carolina zeroed in on a federal program designed to bolster safety net hospitals.
Created in 1992 and expanded in 2010 with the Affordable Care Act, the “340B” program mandates pharmaceutical companies sell drugs at a discount to hospitals and clinics that care for a large share of low income and rural patients. Once they buy drugs at a discount, hospitals can charge market prices to health insurers and patients.
The study found North Carolina hospitals charged significantly more for cancer drugs they bought at a discount. On average, these hospitals charged prices that were 5.4 times more than what they paid for the cancer drugs, the report said.
For a single treatment with Keytruda, hospitals collected an average payment of about $21,000 for medication they acquired for an estimated $8,000. That represented an average profit of more than $13,000 per treatment, the report said.
“We could easily talk billions,” said Folwell. “But the fact is any one dollar stolen from any North Carolina taxpayer or citizen is one dollar too much.”
The 340B program has also drawn scrutiny. While hospitals contend the program is critical for bolstering the finances of safety-net locations that serve the poor and vulnerable, a lack of disclosures can make it difficult to tell whether that’s happening, said William Smith, a senior fellow at Pioneer Institute, a Boston-based think tank.
For one, hospitals don’t have to report how much of a discount they get under the 340B program.
Collectively, hospitals, clinics and other entities spent nearly $8.2 billion on Keytruda in 2024, according to the U.S. Health Resources & Services Administration. It was by far the top-grossing drug in the federal program. Hospitals spent nearly twice as much on Keytruda compared to the No. 2 drug, the HIV medication Biktarvy.
Groups that have scrutinized how hospitals use the federal program say there’s some evidence hospitals are extending the program to wealthier communities. So, while hospitals can buy discounted drugs, they can sell the medications to patients in wealthier communities who are more likely to have robust insurance coverage.
“They’re trying to bring people with good insurance and wealthier people into the program,” Smith said. “They can get a generous reimbursement when they buy the drug” at a deep discount.
‘Everyone is fighting for their life’
Brett Shoopman has spent years walking golf courses in his hometown of Palm Springs, California, one of the most sun-drenched cities in the country. Even still, the golf professional was surprised when doctors told him a mole on his belly turned out to be Stage 4 melanoma.
When his skin cancer returned after surgery, Shoopman began heading to the nearby Eisenhower Medical Center for a year’s worth of Keytruda treatment. He said it cost about $15,000 per infusion every three weeks.
“For a golf pro, that’s a lot of golf lessons!” Shoopman said. “Obviously, you don’t really know the costs right up front because you’re going to get their help because you have no alternative.”
Like Patty Brown near Sacramento and Barbara Thornton in Cincinnati, Shoopman’s insurance covered most of his Keytruda costs. Many patients won’t pay the full amount out of pocket, but costs are borne by consumers, employers and taxpayers who must absorb ever-rising health insurance bills that are based on the nation’s more than $5 trillion in health care spending.
Shoopman declined his oncologist’s suggestion to apply for disability, but a friend created a GoFundMe campaign to help cover his portion of the treatment.
As a skin cancer survivor, Shoopman organizes an annual golf tournament to benefit the hospital that cared for him. Now in its 13th year, the golf tournament has raised over $400,000 and funded free skin cancer screenings that have saved at least 15 lives, Shoopman said. He plans to spread his tournament to additional cities in the future to raise awareness and prevent others from needing to make regular visits to infusion clinics.
“When you’re in a room like that, everyone is fighting for their life. It’s the saddest place to be,” Shoopman said. “Golf’s a challenge, but it’s nowhere near what cancer is.”
Ken Alltucker is a consumer health reporter at USA TODAY; reach him at alltuck@usatoday.com.
Austin Fast is an investigative data reporter at USA TODAY; reach him at afast@usatoday.com.
Sydney P. Freedberg is ICIJ’s chief reporter; reach her at sfreedberg@icij.org.
The International Consortium of Investigative Journalists, a nonprofit news outlet based in Washington, D.C., and a global network of investigative reporters, organized and led this project.
Editor’s Note: Some ICIJ funders advocate for reform of the pharmaceutical industry to make it more transparent and its products more affordable and accessible for patients. Funders have no involvement in ICIJ’s editorial decisions.