An alternative hypothesis is that the pharmaceutical industry has become cartelized and formed a bureaucratic oligopoly, resulting in reduced innovation and efficiency. As of 2022, approximately 20 Big Pharma companies control the majority of global branded drug sales (on the scale of ±$1 trillion annually). Critics point out that Big Pharma has reduced investment in R&D, spending double on marketing, and have focused on elevating drug prices instead of risk-taking.