Why is the pharmaceutical industry investing in targeted therapies? The emergence of “premium pharma”

Recent decades have witnessed a major transformation in biomedical knowledge production, framed as the rise of personalized, precision, or stratified medicine. While social scientists have explored the implications for disease classification, patienthood, datafication and governance, the central role of the pharmaceutical industry in shaping this new biomedical paradigm remains under-examined. This paper addresses this gap by analyzing the industry's strategic shift since the 1990s from mass market "blockbuster" drugs to high-priced, targeted therapies for niche and stratified markets. Employing a mixed-methods approach-including regulatory data analysis, examination of industry business models and pipelines, and observation at international conferences-we chart the contours and drivers of this transition. Our findings reveal that targeted therapies, such as orphan drugs and precision cancer treatments, now dominate pharmaceutical pipelines, enabled by regulatory incentives (e.g., the Orphan Drug Act), expedited review pathways, and monopolistic practices like patent thickets and indication stacking. These therapies are cheaper to develop, yet command extremely high prices. We conceptualize this shift as the emergence of "premium pharma," a new sociotechnical regime characterized by intellectual monopoly capitalism, neoliberal deregulation, and financialization. Integrating Geels' Multi-Level Perspective with theories of intellectual monopoly, we identify a series of parallel regulatory, cognitive, and normative changes that have made this possible. We argue that premium pharma entrenches innovation for high-income markets and prioritizes rent extraction over public health, exacerbating global inequalities. This analysis offers a novel framework for understanding the political economy of contemporary biomedicine and its implications for therapeutic innovation and access.