I think that part of the cost inflation is so that intermediaries (pill brokers, insurance brokers, etc.) can show that they've negotiated great savings. On some of my insurance statements there is a column "Not Paid". While this is not explained anywhere, and the row math does not always add up, I'm sure that this is the most important column to someone along the line -- "look at what my negotiation skills saved". In many cases, this is the largest entry of the row.