Waldmann/Ginn don't describe the FDA's complaints about the competitors, but it's probably: (1) a failure to validate claims or (2) insufficient design/manufacturing controls. IMO it's very unlikely that the FDA is engaged in protectionism of the sole manufacturer of this product.
> Most definitely, the solution is not more government controls through regulation.
I agree that we likely don't need any more regulation in this space. But it seems obvious to me that this issue is related to the overall shift lately. Employers are offering high-deductible insurance plans and employees are bearing a greater burden. The outrage over EpiPens is just another symptom of the US public clamoring for what they see as something that should be an entitlement. I don't know that I prefer it but it seems pretty clear to me that it's coming (within another generation or two at max).
The point about patent protection is pretty huge. I wonder: what net effects would there be to removing patents entirely? Would we end up with less ambitious products and services because designs would just get copied by the cheapest production centers? Could we/should we restrict patents among different industries?
It is not made at all clear if the government is truly granting that monopoly (and if they are, did Mylan bribe the government for that privilege somehow?) or if the competing products were truly not deemed safe or effective enough. Anyone have expert knowledge in that area?
The rest of the Forbes Articles seems like the usual delusional libertarian nonsense were they point out well known and obvious downsides of regulation while pretending no such downsides exist in deregulated markets
(i.e., poor people would still die, even as prices drop, because some prices can only drop so much, and dangerous drugs brought to market by unscrupulous companies which are always common)
Also I like to remind the HackerNews community, that everything you use every day (transistors, integrated circuits, information theory, communications satellites) were invented in whole or part at a government mandated monopoly (Bell Labs). Of course there were conditions on that mandate, like not patenting what they invented.
There's generic versions of a different auto-injector available, so the monopoly is very narrow, on prescriptions that say "Epipen". Patients can ask their doctor to prescribe Adrenaclick and then choose the generic.
A serious question -- what do you mean when you say that Bell Labs was a government mandated monopoly? As far as I was aware, it was a privately funded privately owned research laboratory. I'm genuinely curious, not disagreeing, though I am a little dubious.
The transistor, at least, was definitely patented, and just a cursory search [1] yields tons of patents involving transistors, so I don't think there was a restriction on patents.
And as a minor issue, the IC is generally credited either to TI or Fairchild, depending on what you consider to be a modern integrated circuit; Bell Labs had no significant involvement.
In Bell Labs's heyday, AT&T was a government-sanctioned monopoly. See Part I of Wu's "The Master Switch." The same is true for Xerox PARC. At the time, Xerox was protected from competition by Xerox's printer/copier patents.
They look at the symptom, and might fix one case of high prices with public pressure, legal threats, etc - but if the system is broken, then what good is that?
The question is not "why is this company so evil and greedy?" It's "why dont McDonald's hamburgers also cost $600?", and how do we make the market for drugs as competitive as for burgers?
>It's "why dont McDonald's hamburgers also cost $600?", and how do we make the market for drugs as competitive as for burgers?
Because insurance doesn't pay for McDonalds. To make the market for drugs competitive, step one is to get rid of health insurance. Or at least health insurance coverage for drugs.
I think the going price for an iPhone is $700. How much would an iPhone cost if you only had to pay 20% of the price?
Do the math, and now THAT's why drugs are so expensive.
> Dr. Ezekiel Emmanuel, one of the architects of Obamacare, admits that a free—“uncontrolled”—market would bring down prices. Yet, his solution is more government control, specifically price controls.
> What does history teach us about price controls?
> The U.S.S.R., Cuba, Korea, Spain, and Venezuela amongst others have all used strict government price controls. The results were: shortages of everything, viz., long lines of Russians standing in the snow waiting for government-issued shoes or toilet paper; poor worker productivity; very low standards of living; and no innovation. This is precisely what we don’t want.
From the study:
> The most realistic short-term strategies to address high prices include enforcing more stringent requirements for the award and extension of exclusivity rights; enhancing competition by ensuring timely generic drug availability; providing greater opportunities for meaningful price negotiation by governmental payers; generating more evidence about comparative cost-effectiveness of therapeutic alternatives; and more effectively educating patients, prescribers, payers, and policy makers about these choices.
That article is libertarian trash, and contradicts the study.
Deregulating food - and much worse - drugs, would just end up in dangerous cheap products, and slightly less dangerous but still low quality products. Every company optimizing for profit will take every shortcut available to them. Deregulating opens up a lot of them. Most of them detrimental to consumers, few of them detrimental enough to warrant a decrease in public image.
Forbes trots out an interesting figure: $2.6bn to win FDA approval for a new drug. That sounds like a lot!
It also sounds like a number pulled from a hat.
So I went looking.
It's from a Tufts Center for the Study of Drug Development study published in 2014 [0]. Which is, incidentally, supported financially by the pharmaceutical industry [1]. Even the published pdf is pretty lacking on actual data [2]. Because it's a PR piece. This other study, from the Office of Health Economics, 2012, reported the cost as $1.5bn [3]. (OHE is funded by research grants and consultancy fees from - you guessed it - the British pharma industry). Did the cost magically increase by $1bn in the two years between the studies, or is there something fishy going on here?
One point in the Harvard study abstract was,
> The most important factor that allows manufacturers to set high drug prices is market exclusivity, protected by monopoly rights awarded upon Food and Drug Administration approval and by patents.
And that's true! But that exclusivity is an artifact of medicine-for-profit, instead of medicine-for-health.
It's interesting that all of their recommendations for lowering prices fail to take into account (at least in the abstract, as I don't have access to the full article) the single biggest difference between the only market where per capital spending is $850 and the 19 markets where per capita spending is, on average, $400: for profit healthcare and medicine.
Keep in mind that even after that astronomic cost for drug approval (the figure for which is iffy in providence), for-profit pharmaceutical companies still spend more on marketing than they do on research.
The studies of marketing spending are usually just as disingenuous, reporting the "Selling, general and administrative" line item from annual reports as the amount spent on marketing. But that line item includes things like salaries and office space and such, things that the company has to do to sell products which are not advertising.
Marketing spending is huge, but it undermines their message when they do that.
That seems pretty obviously correct. If you spend less on marketing then you, of course, also hire fewer marketers, leading to lower salaries and less required office space.
Does the FDA have the authority to deny marketing approval for minor improvements?
Mylan pushed generics off the market by making a better cap or something, the FDA should just say no, that improvement is nice but it isn't enough to give you exclusive marketing rights. If you want to incorporate it into your product, license it to your competitors for cheap.
FDA's genesis was bound pretty close to marketing. If you wanted to sell "Aunt Eliza's Magic Elixir" and claim that it "cures all ails: backaches, headaches, etc", you are required to show evidence that validates those claims. See Pure Food and Drug Act.
FDA's responsibility is mutually exclusive with USPTO which would approve/deny patents based on "novelty".
I'm not suggesting that the FDA could deny a patent. I'm suggesting that the FDA could simply refuse to approve the new version of a product.
In the case where there are generics and the improvement is small, it doesn't matter if the company decides to take their ball and go home. It might be a fine line to walk, but the improvements to the Epipen don't seem to be very substantial (it's kind of hard to figure out what the improvements are with so much coverage of the recent events).
What would be the basis on which they would deny a new product? If you were Mylan, you would bring suit. Courts would not side with the FDA, because they'd be wrong.
The FDA's responsibility is dictated by legislation and there's nothing in the US Code that describes "you can't release new products if the new design isn't sufficiently improved."
Legislators have all the power. If they can agree, they can say "Woo party free EpiPens for everyone, put it in the budget." FDA has some small amount of judgment they can apply within reason to restrict products that fail to comply with the law.
(5) evaluated on the basis of the information submitted to him as part of the application and any other information before him with respect to such drug, there is a lack of substantial evidence that the drug will have the effect it purports or is represented to have under the conditions of use prescribed, recommended, or suggested in the proposed labeling thereof; or (6) the application failed to contain the patent information prescribed by subsection
Maybe it's a stretch, but a marginally safer but much less accessible product actually doesn't improve the situation for the public.
I'm partly suggesting here that if the FDA doesn't have the authority, maybe they should.
As someone who has worked with EpiPens for seven years now, administering them to patients weekly, if not more, it's very hard for me to find any claim of "improving the product" to be more than lip service. Certainly I don't consider the drug beyond active ingredient, but in the delivery mechanism (where they've also claimed "significant improvements and refinements", very little has changed. The shape of the container is a bit different, the 'window' to see the drug (to look for cloudiness or discoloration) is a little bigger (mind you, such a window is more akin to "empty space in product coloring and branding").
Certainly, I know some things might happen "behind the scenes". Maybe they found a more durable spring for the needle (not that was ever a problem), or such. But yes, I struggle to see it as anything more than patent extension.
Which is why, after our relatively small county, which THROWS OUT $100,000 of EpiPens a year in the Medic One system (which we are mandated to carry by state law) is moving to train EMTs to draw up epi from $2.80 vials, themselves.
>> Does the FDA have the authority to deny marketing approval for minor improvements?
They certainly don't. Look at Nexium, it is something close to a blatant scam but the FDA approved it and between Medicare and Medicaid alone the federal government has rewarded the scammers (AstraZeneca) with billions of dollars never mind private insurance companies.
Nexium doesn't appear to be relevant to the question I am asking, as Omeprazole was not pulled from the market when it was released (it's maybe a similarly stupid situation).
The additional issue with auto-injectors is that knowing how to correctly use a particular one is important, so there is a legitimate reason to make sure that generics work the same way as the branded version. This means that if the branded version adds a patented safety feature, then there won't be generics for a while.
Nexium is just pre-broken-down Prilosec, which had just run out of patent protection. They then manipulated the results to make it look more effective so they could market it as such:
> AstraZeneca's scientists had misrepresented their research on the drug's efficiency, saying "Instead of using presumably comparable doses [of each drug], the company's scientists used Nexium in higher dosages. They compared 20 and 40 mg Nexium with 20 mg Prilosec. With the cards having been marked in that way, Nexium looked like an improvement – which however was only small and shown in only two of the three studies."
Omeprazole is a mixture of two mirror image molecules. One of the two versions is the active and the other isn't (for 97% of the population). When the patent was running out on omeprazole AstraZeneca patented esomeprazole, which is just the active isomer. In order to show improvement over omeprazole they did clinical trials that used a higher effective dose of esomeprazole than omeprazole. The FDA, for reasons unknown, let them get away with this fraud and approved the drug.
The government has spent literally billions of dollars buying esomeprazole when a double dose of omeprazole is the same damn thing for 97% of the population. I caveated my original statement ("something close to") because there might be some role for esomeprazole as a second line drug for the 3% of the population that is sensitive to the other isomer, but even there a perfectly fine alternative would just be a lower dose of omeprazole.
Nexium is 18th on the list of drugs by global sales in 2014. These are not small potatoes.
>One of the two versions is the active and the other isn't (for 97% of the population)
My understanding is that the inactive form is actually metabolized into the active form by the body.
There is some argument that this happens differently in different people. But if AstraZeneca knew this (which they almost certainly did), why didn't they release esomeprazole at the beginning? They released omeprazole first, then sat on esomeprazole until the omeprazole patent was about to expire. It's obvious why they would do that.
Why is the Epi-Pen body not approved separately from the Drug, allowing the body to be sold without epinephrine and to be filled with whatever, including generic epinephrine from a vial?
Having multiple deadly allergies and needing to purchase EpiPens regularly, their price doesn't seem outrageous to me.
I pay about $10 a pen, insurance pays about $100 per (even after the price increase). That being said, people rarely use this drug. $100 to save your life once a year or so kind of seems like a fair trade.
This seems more like the media is outraged as opposed to the country. All my friends don't even know about this price change, I only know about it because I read the news more often.
It's entirely possible that their PBM has negotiated a price of $100 per pen.
Mylan is happy to give people $300 coupons to get them to use their insurance, it wouldn't be weird for them to agree to sell the pens to an insurer for $100.
You need to purchase EpiPens, and you happy how your insurance pays most of the price. Somebody else on your insurance plan needs some other drug that is overcharged, but subsidized by an insurance. You both think that you've got good deal, but actually you both (or your employer) paying for your drugs (almost) full price anyways - through insurance premium. Or you think the premium will stay same if drug prices keep increasing?
If you have an extreme sensitivity you'd probably be happy to pay $5,000 a year to save your life.
The question is, why don't we operate our regulatory system in such a way that companies making a product that costs ~$30 only make a hefty profit, say 100%. The only answer is because we are stupid.
You say you + your insurance pay $110 per pen, so $220 for a set, so you seem to be paying the price as of right before May 2015, and you haven't bought a pen since then. You might be in for a big surprise next time you have to buy one.
>you seem to be paying the price as of right before May 2015, and you haven't bought a pen since then. You might be in for a big surprise next time you have to buy one.
Express scripts co-pay has only gone up $0.45 in that time.^1
>Express Scripts says it has been able to hold costs steady for its members: its commercially insured population has seen their co-payments for EpiPen go from $73.05 in January 2015 to $73.50 in July 2016, even though the price of EpiPen rose by 51% over that period of time.
Now let's say you got fired tomorrow when you go to work. Aah, this changes EVERYTHING, doesn't it.
The point is not what you actually pay for a Pen. The point is that SOMEONE is paying for it which is not reasonable. Your employer is paying most of the premium so you may not realize. Lose your job and try buying insurance out of pocket. You will know what it really costs. Oh and don't forget to learn all about the various cryptographic terms such as deductible, co-insurance, co-payment, in-network, out of network, PCP referral required...
It's not a "quietly effort", Martin even said that this would be the best course of action on live TV[0].
The government will spend more money, but the public will get it for free. Of course there's two side to every story, but I think I choose to believe Shkreli on this.
The epi-pen equivalent costs a lot less in Europe. See for instance the Emerade Injector, $48 USD for an adult dose. Regulatory hurdles are worse in the US, but you can't explain a 6-7x price difference that way.
This whole drug company argument -- that the only thing that really matters is what end users pay as a co-pay or co-insurance and that no one should care what insurance companies (including governments) pay -- is so breathtakingly bad I can only imagine it is in bad faith. Where do they expect us to believe the institutional payments are coming from, out of thin air?
One of the things I do not understand is, the explanation given is that Obamacare fixes the donut hole where people who are not enrolled in company sponsored/medicare could get insurance.
This has just let the drug companies to raise the price without any backslash because the end user is "not" paying the price. However, the rising premiums and plans with high deductibles meant that the drugs are still not affordable even if you are covered by some insurance.
What is the solution to this? Single-payer health care?
They never have any reason to do that. Too much power. We need to get a system in place that gets rid of too much power away from the insurance companies, plain and simple. With the amount of money and lobbying they do, probably not likely in the near future unless the Congress grows some balls and do something real about healthcare and not just the usual talking points.
How could that ever happen? Information asymmetry is as high as you could imagine. A doctor tells you to take x or you will die. X has a price set by Insurance Co. You have no medical training or pharmaceutical training, so how do you make a decision? If x is really required so that you don't die, demand is completely inelastic, you will literally pay anything you can afford, or you'll take out loans you can't afford. The only limiting factor on price would seem to be median income and credit availability.
They do in a way. By denying claims they can reduce demand for a specific drug or procedure and send a signal to the company that the price is too high.
The slight complication is that people will die without their meds, but the market doesn't care about that. It's only concerned with money.
What literately every other country does: Old fashioned price controls. Government as a buyer or as a regulator puts a cap on the price through a process of negotiation, and be willing to say no when the price is too high and the benefits are too low. The UK's NICE body regularly rejects new products if they don't represent value. New cancer drug that extends life by two months but costs £10k per pill with a course of treatmeant costing £100k; no thanks.
Its a market with inelastic demand - people will literately die if they don't buy the product. We, rightly, through regulation demand high quality assurance because if something is meant save someone from a quick death it better be reliable and not cause greater harm due to product defects. This means the entry barriers are quite high making competition difficult. Without price controls there is literately nothing but the CEO's conscience to keep from pushing the prices up. If the product will stop you from dying and nobody else can offer it, then there is basically no price you won't pay.
There was a programme on R4 about NICE, drug companies and finance in health care a month or two back. I discovered two new (to me) things. First it's common for drug companies to tweak patent protected items suspiciously near end of patent - to find a new use, or reformulate a tablet as a capsule - to buy more patent period.
Second in the case of off patent medicines, some are harder to make or not prescribed widely enough for the generic makers to bother with. These seem to be the things at risk of price gouging. There was an example of something off patent sold by Pfizer to another company who now charge 10x more, as there is no generic alternative. That's now at the competition authorities.
So we mitigate a lot of this, but we apparently don't avoid it entirely.
This. Exactly This. I am sick of hearing "oh you just pay $20 co-pay". No we don't. The real cost is much more and these pharmas and insurance companies know it. I know because I paid it for a family of 4. It costs $1500/Month for a decent plan that does not have high "out of pocket" costs (Read capped at $5000). So you pay $1500 per month and in worst case scenario, you can still pay $5000 out of pocket for a year IF the insurance company does not deny a claim.
I usually don't make political comments but one thing that was disappointing with Obamacare was the fact that it did not address this root cause and instead touted that now anyone can get insurance. Sure, someone with pre-existing condition is now probably a little better off but overall, obamacare did not address the main issue: getting rid of middlemen (insurance companies) and let doctors/hospitals work on fair and transparent pricing. Isn't that what America is all about ? Free Market, eh.
If I may steal the legendary MLK's words, I have a dream. A dream where I can call any doctor/hospital and ask what will it exactly cost to get a simple X-Ray done without saying "Oh no, I ain't got no insurance". Just a dream.
Adding to this, if you have insurance most of the hospitals will jack up the prices. One of my friend did not have the insurance card, so the hospital billed X$ and told him that if he later gives the insurance id they will charge them. He later called the hospital and gave the insurance details and he is charged (X+Y)$. Being the first time he got sick this year, he had to pay his entire deductible meaning he paid more because he HAD insurance.
IMHO providers should be required to charge the same price to all patients. That's not to say hospital X should pay the same as hospital Y, just that X needs to charge the same to all it's patients for a given service/procedure and Y needs to charge their own price for the same to all their patients. If you have insurance, then they need to be charged the same too. This would go a long way to promoting competition and price transparency.
We are legally required to charge the same price to all patients. Specifically, we cannot charge less than we charge Medicare/Medicaid. Insurance companies are charged the same amount too; except, they negotiate a set reimbursement for a given service. Medicare/Medicaid does the same. Individuals are totally able to call up the financial services department of $LocalHospital and negotiate.
In fact, if we accept insurance/Medicare/Medicaid and OFFER a cash discount to an uninsured patient, we are one whistleblower away from a Medicare Fraud investigation.
Allowing differing reimbursement amounts seems pretty similar to charging different prices to different patients. Why not remove negotiation entirely and say price is X for all patients and you must reimburse 100%?
TLDR: Stop capitalizing on suffering. The reason why people on this thread are complaining is not because they have a natural disposition against doctors: it's because they have been taken advantage of!
Long post:
Good point, except that get to see I see the invoice AFTER a service has been provided to me, sometimes MONTHS after the encounter EVEN AFTER SPECIFICALLY asking for an estimate upfront.
No providers office I know of are willing to provide estimates to patients for procedures the same office requires the patients to be financially responsible for!
The reality is that the provider is like a programmer who builds what I discussed with her to build only that I get a $10k bill AFTER THE FACT without having a say in whether I am OK with it or not and she just went ahead and did the project for me without even asking me if I wanted her to do it.
If I don't pay, my credit will be trashed with a collection entry.
This is unacceptable. I am not sure if you agree.
Case in point: I went to a specialist to figure out the ringing in my ears. I made it clear to both the administrative staff and the doctor that I should be told of any charges outside the office visit fee before such a charge would be incurred.
The specialist looked into my ears and said my ears looked fine and the ringing could be due to stress.
A month later I got a $1500 bill for "in office surgery". Apparently, if a specialist inserts anything into my body, it's a surgery and billed in addition to an office visit fee.
I do NOT believe this is proper. The provider took full advantage of my inconvenience.
I am lucky it was a $1500 bill and not a $15000 bill. It could very well have been and I would have NO recourse.
I am happy to pay your negotiated rate as long as you tell me what that rate is and how many hours you estimate it will cost me.
What I am NOT happy to do is be forced to pay an amount that I had no say in the first place.
Providers ARE exploiting their patients and getting away with it by placing the blame on the faceless insurance companies.
Patients are not walking blank checkbooks. They are suffering and under pain and looking to you for a remedy.
Providers have a right to make money. Providers DO NOT have a right to exploit.
There's a lot of rant in this post which I'm going to leave to the side, because I have no idea what happened between you and that physician / billing agency / insurance. "In office surgery" may mean you got scoped, but I'm not an ENT, and I'm not going to speculate on what happened.
First point: If you're willing to pay cash and bypass the insurance / CPT / ICD10 / RVU rigamarole, I'd like to direct you to any number of concierge physicians who will gladly take your money, provide you their cell phone, and give you 24/7 availability. Simply Google "concierge physician san diego", and you'll have your pick of physicians from UCSD or Scripps or other great places in SD.
Second Point: You're conflating a whole lot of stuff. Your insurance doesn't pay us enough to do the whole "personal estimated bill". That's the patient's responsibility. You and your insurance company are the only people who know the status of about 10+ variables which will affect your out-of-pocket-cost. What's your deductible's status: Have you exceeded it? What's your out of pocket max for the year? Do you have a copay or coinsurance for ambulatory services vs hospital provided services? Are we in-network with your variant insurance company's policy? There's no API for us to query all this information from Aetna/BCBS/Humana/et al, and given how insurance companies LOVE to put up barriers to care via prior authorizations, that API is never happening unless mandated by federal law or built by yet ANOTHER company.
>The reality is that the provider is like a programmer who builds what I discussed with her to build only that I get a $10k bill AFTER THE FACT without having a say in whether I am OK with it or not and she just went ahead and did the project for me without even asking me if I wanted her to do it.
This is a false equivalence. The medical equivalent to this scenario would be calling and speaking to a physician on the phone about whether you even need an appointment and then receiving a bill for a consultation with lab testing. Our taking an interview with you, reviewing outside notes/labs/imaging, doing a physical examination, and providing our expert opinion IS our deliverable product, NOT the procedure and definitely NOT the medication we prescribe. You wouldn't engage a business consultant or a lawyer for advice and not expect to pay for their time? Why is it different with physicians?
The "I WANT AN ESTIMATE UP FRONT" request is fine for some areas of care, but if it were up to me, I'd simply give you my charge-master-highest-rate and say "I don't know what your particular insurance company has negotiated and which contract will be in effect at the time of bill submission, so the resulting charge may be lower than this. It will not be higher". For example, I'm in Radiology, so my billing is different. My deliverable is not an in-person consultation, rather a diagnostic imaging examination, interpreted to the best of my expert opinion. I can provide a concrete, encapsulated, whole estimate of charges for both the technical and professional fees, and that estimate will be the maximum I charge all 3rd party payers.
I agree with the answer provided by Quora. You're asking someone to do ALL the work, before you even decide to pay them. This is the equivalent of asking a lawyer to evaluate a contract and then offer you a per-paragraph rate of evaluation based on the projected complexity of each section, before you even then decide to pay them a dime. That estimate is difficult to perform without going ahead and just doing the work. If you're going to play that game in medicine, just pay the physician hourly like in law in 15-minute increments or get a concierge doc.
> Your insurance doesn't pay us enough to do the whole "personal estimated bill"
I respect that you are a MD from Harvard Medical School. Obviously you are very smart, and hard working.
Deep inside you, something must be telling you that it would make no sense for a provider to be in business of seeing patients if they were making no money in it.
I am also confused if you disagree with me that it is reasonable to be told of costs that one is expected to pay BEFORE one is made to incur those costs?
But let's keep that aside; that's a completely separate discussion.
To clarify: I did not ask the provider to tell me what my OOP will be. I am educated enough to figure that on my own. I know how to call my insurance company and speak in English.
All I want the provider to tell me is what they typically bill during a routine service so I can figure out how much my visit will be billed to my insurance company.
I am more than happy to talk with my insurance company to figure out how that cost will be settled.
I don't want the provider to do anything extra for me.
> I'd simply give you my charge-master-highest-rate and say "I don't know what your particular insurance company has negotiated and which contract will be in effect at the time of bill submission, so the resulting charge may be lower than this. It will not be higher"
GREAT!
That is fine and I would welcome it! Seriously. Let me sort out what I need to pay and what my insurance pays.
Just tell me what my maximum financial liability could be and I am a happy camper!
I don't think you still have understood my "rant" but in this case I was not told about the possibility of a "surgery" before, during or after the appointment, with me asking the doctor and office staff at each of those steps if I owed anything. I came to know about it months later when I got the invoice with a due date.
Anyways, I do not want to repeat the detailed discussion that are already in the comments on the Quora post. You are welcome to expand the comments and read them yourself once you are over being condescending.
FYI, the last comment I made there clarified I am more than happy to pay for the consultations and estimates. No one works for free.
I would rather pay $500 for consultations and estimates to figure out what I am going to get and whether its worth it to me than $1500 that I had no say in that just happened to show up in my mail.
Since your first line is all so very dismissive of my whole rant, I will not longer engage with you, as it's probably wasted energy.
You read the anonymous answer, you agreed with it, got what you were already decided on and did not even bother to read further.
For your sake I hope you never get a medical bill you never even thought you would get that would end up destroying you financially and put you in extreme debt.
This actually happens to people in the U.S. on a regular basis, and I dont think that's normal.
I cant personally imagine why smart people even think this practice is OK.
What happened to me during that visit can be summarized by: "oh that peek we did into your ear? yeah, that's $1500. sorry we didn't tell you in advance. If you don't pay it, we will trash your credit".
For other people possibly reading this: the office did not even tell me that the visit might involve extra costs INSPITE of me EXPLICITLY mentioning that I would need to be made aware of such.
TLDR: I am HAPPY to pay for costs that are shared with me BEFORE they are incurred SPECIALLY when I am asking to be made aware of costs that I am expected to pay.
>> You and your insurance company are the only people who know the status of about 10+ variables which will affect your out-of-pocket-cost. What's your deductible's status: Have you exceeded it? What's your out of pocket max for the year? Do you have a copay or coinsurance for ambulatory services vs hospital provided services? Are we in-network with your variant insurance company's policy?
Stop talking about what the patient will have to pay out of pocket and start talking about how much you will receive. I agree that how much of that is covered by my insurance is between me and them, but it starts with what YOU charge for services. And back to my original point, that should be a fixed rate (of your choosing) charges to all of your patients (and their insurance company).
That's the big problem. What we charge is universal across carriers; it's the law. What the carriers then do is try and negotiate me down to accept some fraction. I could charge $5,000 to everyone for a PETCT; Medicare laughs and will pay a set amount. Depending on their market power, private insurance will pay a multiple of what Medicare reimburses. I would be stupid to set my "charge" lower than the maximum a given insurance will possibly pay.
If I charge under what they will pay, they aren't going to reward me with all that savings.
If someone wants to negotiate with me directly, I'll charge you some other price, then write off the rest, just as if you are phkahler insurance co. It's the only "legal" way to offer a discount.
What I want is not possible without legislation. I want you to charge your rate and the insurance companies not be able to negotiate other than walking away. The only way the insurance company can save money then is to not cover the full amount and pass the rest on to the patient. Now you have to compete with others like you, and insurance companies have to compete with others like them. The super-awesome doctors can charge whatever they like and only take cash because insurance companies won't cover their services, and that's fine too - I know of a couple guys like that already and they are awesome at what they do.
>> Is your hourly rate set to a certain price by a central body?
Why should mine be?
You pick your rate. Whatever you like. Now charge that to every one of your patients with no discounts or negotiation. That's all I want you to do. Don't do anything different for insured patients either, your rate is your rate and the insurance company must pay it, or pass the rest on to the patient. Simple as that. The doctor down the street is free to pick his/her rate too, but they must charge that rate for all of their patients.
Transparent medical pricing is not possible so long as hospitals have an obligation to treat sick people whether or not they can pay. Hospitals heavily cross subsidize between insured, uninsured, and Medicare/Medicaid patients. As long as we put expectations on doctors and hospitals that compel them to do that, they cannot provide transparent pricing.
It is not possible in the current setup, yes. But if there was no insurance company to deal with for little things like X-Ray, that's the question. Why is transparent pricing so difficult for a hospital management to come up with if they don't have to answer to an insurance company OR even the Govt. for that matter ? Private Hospitals are mostly run like a business anyway so why not this part ? The status quo is not good enough and that is the point I am making.
Are we going to allow doctors and hospitals to turn away anyone who can't pay the advertised rates? Like we allow every other business to do? And will we require Medicare and Medicaid to pay those advertised rates, without the discounts they currently get? Jose are the things that force cross-subsidization.
The hospitals that are covered by EMTALA (duty to treat) are those that "receive federal assistance, maintain charitable nonprofit tax status, or participate in Medicare". A hospital is free to get off the federal government gravy train if it thinks it can make more money that way.
You can't have the government distorting the market by bringing half of all potential customers under a single taxpayer-funded system then pretend that hospitals have a real choice in whether to participate in those programs.
Many are not part of the system, so they really do have a choice. Granted, location is a big part of this, and it's much simpler to operate this way when population density is high and there are other hospitals in the area.
Those hospitals' standard rates should be paid by direct reimbursement from the government at their set rate. In the event they're out of line with the expected market (no idea what that distribution looks like, but obviously there would be one), then the hospital would be investigated for price gouging all their customers (as customers of this industry are less able to shop around).
The problem we have here is the exact same problem as with taxis/Uber (and telcos somewhat. and actually that public code thread we argued about the other day, too). Rather than just directly subsidizing infrastructure for poor people, governments enticed businesses to provide some service at a loss by giving them special privileges across the board. As the market finds more efficient solutions, the reality disconnect becomes painfully apparent. Market consumers grow sick of the incumbents' overhead, while simultaneously the businesses gradually renege on their unprofitable obligations.
I wonder if it might be possible to start some kind of group buying organization to negotiate insurance like rates without the actual insurance.
I would seriously consider going without insurance except for the highest cost goods & services (say over 100k) except for the fact that it will cost me more to go to the doctor for a check then my insurance company currently pays.
The group discount without the risk sharing would be a very interesting product for me. I wonder how many other people would be interested in such a thing.
This would be pretty great, but so would real healthcare reform where businesses were simply required to publicly post uniform prices.
I think a fundamental problem of trying to privately implement this idea is that medical businesses have an extreme amount of overhead simply to deal with insurance companies, but they don't precisely ascribe it to insurance as payment. From a doctors' office's perspective, the "actual cost" of providing you cash service still includes paying all their back office rather than just actual services rendered.
Coming from the other direction, you have high-deductible plans that effectively do this in many more words. Plus that whole tax subsidy that fueled the growth of this institutional cancer in the first place.
Isn't the risk sharing a component in the discount? That is, aren't the providers more likely to collect from people participating in a risk sharing arrangement?
You're exactly right. We need publicly available databases on what they charge for every procedure/test/product they perform/sell for every insurance plan and for paying out of pocket. We need competition.
THIS. Many Americans don't seem to realize we already have a "socialized" medical system - everyone paying into everyone else's costs - it's just that it's brokered by private companies instead of the gov't. Which means that it's less transparent, less regulated, and subjected to a bigger rake [1] than if it was run by the gov't.
The work done by David Belk MD shows that these costs are an extremely small cost of hospitals, and that you're basically promoting a myth. [1][2]
He directly addresses the inaccuracy of that claim in the following 10 minute video, "The $55,000 Appendectomy: What Everyone Should Know About Hospital Bills". [3]
I'll have to check that out. My primary care physician is located at a teaching hospital that is surrounded by extreme poverty. A few years ago he said that I was one of the few patients that have insurance, and one of the few that comes in for preventative treatment (no surprise, given the lack of insurance). This isn't emergency treatment though, this is normal doctors stuff, the hospital he works for makes a point of treating everyone.
Even so, my last visit was less than $100, including blood work. There wasn't even an in-network discount or anything. So I doubt I'm subsidizing anyone, and I don't think the hospital is suffering too much from treating everyone.
Agreed. Any little price accountability will be lost when they convince that the federal government will need to pay for it.[1]
I have to unfortunately be very vague because I don't remember the actual reference, but I remember a similar problem where the lobbyists didn't get what they wanted , and discreetly added it into some kind of unrelated bill in the midst of some fine print.[2] An excellent use for using something like natural language processing is to find outlier items which simply do not belong in a law which is being passed.
[1] I am also told that from the perspective of the R&D labs which spend a ton of money up front to produce the drug that this is the only way to recoup costs. And the costs for the R&D labs are usually blamed on excess regulation, so that is apparently a sort of justification for these subsidy requests (which still doesn't make sense).
Edit:
[2] I bring this up because the article mentions the following and I think the euphemism has at least one possible explanation:
"But a review of Mylan’s lobbying history makes clear that the company has an exceptional track record at influencing government policies, both in Washington and in state capitals. Heather Bresch, Mylan’s chief executive, called the effort “our unconventional approach to growing this franchise” in remarks to Wall Street analysts last year."
The fact that companies often spend more on marketing than R&D is irrelevant. The fact is that they spend billions on R&D. They have to recoup that. Presumably they don't spend money on marketing for shits and giggles--they spend how much they need to maximize revenue.
Ask yourself, why is the United States the only country in the world where advertising prescription medicine to consumers is allowed?
Why is it even needed? I know some people say "education", but that's backward.
You have a problem. You go to your physician. He works out a treatment plan for you.
For drugs advertised for specific conditions? To enlighten you to alternatives? You can oftentimes assume that alternatives exist, for most common complaints.
For those that don't? Those ads are such a dragnet of wide ranging and vague conditions that oftentimes, the majority of the population would qualify ("Are you feeling run down? Do you have trouble getting to sleep? Ask your doctor about trying XXX". No. Ask your doctor about your conditions. Let them decide whether to try XXX. Or YYY. Or just to get more sleep).
There's no justifiable need that I can see that prescription medication need be advertised to anyone other than physicians and practitioners.
Oh, and it's not "often" that they spend "more". There is not one of the top ten pharma companies that spends more on R&D than marketing. Every one outspends on marketing. And by "more", the smallest gap is "four times more" leading up to "seventeen times more".
And we wonder why healthcare is so expensive here...
Because, contrary to popular belief, doctors aren't gods, and have about the same fraction of slackers as any other occupation. Unless we're ready to have a really aggressive program for revoking licenses of doctors who don't keep up with modern advances, they can and do miss available treatments.
"Hm, I could eagerly search all the latest treatments that might be relevant to my patents, or I could write them up something based on gut feel and what I learned in med school 30 years ago. Both pay the same."
Doctors / nurses / pharmacists are required to submit dozens of hours of continuing medical education every year to maintain their licenses. There is an approximately 0% chance that a patient with no background in medicine will learn something useful from a TV Commercial that everyone in the treatment plan doesn't already know.
I'm seriously claiming that no patient committed to modifying their treatment plan has ever started that process due to a TV commercial and that the societal loss from doctors acquiescing to patient demands for treatment for Restless Leg Syndrome or whatever other made-up disease far outweighs the benefits from airing said commercials.
Any patient engaged enough and knowledgeable enough to participate in improving their care plan is also knowledgeable enough to know that TV commercials for drugs are complete garbage and offer 0 substantive benefit.
>I'm seriously claiming that no patient committed to modifying their treatment plan has ever started that process due to a TV commercial and that the societal loss from doctors acquiescing to patient demands for treatment for Restless Leg Syndrome or whatever other made-up disease far outweighs the benefits from airing said commercials.
Well, originally you said that no doctor could ever learn about anything that they didn't already aggressively seek out due to their diligent efforts to stay in compliance with the continuing education requirements.
Now you're recognizing that it happens but the costs outweigh the benefits.
Could you update your original post and be a bit clearer about your actual claim in the future? I wouldn't want people to be misled.
> Well, originally you said that no doctor could ever learn about anything that they didn't already aggressively seek out due to their diligent efforts to stay in compliance with the continuing education requirements.
Hmm.. maybe you misread the original comment?
I specifically said no patient will learn something from a TV commercial that their doctor/nurse/pharmacist aren't aware of. It wasn't a comment on the infallibility of medical education but the uselessness of pharma advertising.
Of course knowledgeable patients can improve their own care by aggressively researching whatever condition they might have.
Freedom of speech is for humans, not for corporations. Otherwise you also have to accept the bizarre citizens united decision that permits companies to spend an unlimited amount of money to campaign on behalf of political candidates.
Extending personhood rights to corporations is a really bad idea.
Which is to say, they are made up of people. My right to free speech is not diminished by the fact that I choose to work with other people for a common goal.
1. https://www.youtube.com/watch?v=KlPQkd_AA6c My second favorite republican quote that was mistakenly maligned by the left. In first place is, of course, Rumsfeld's rumination on the nature of unknown unknowns.
It's very relevant. With the incentives in place now, the most profitable thing a drug company can do is alter an existing drug enough to extend patent protection for as long as possible. It's sleazy.
Are you not bothered at all about the EpiPen situation? Martin Shkreli doesn't make you angry?
A pharmacologist friend once told me that the best way for a drug company to get a customer for life is to make sure they don't cure or kill them. She was joking, but I think it's true.
They can't "extend patent protection" for the drug. Only the improvement. The existing drug loses patent protection.
And no, the Epipen thing doesn't bother me. It's narrow minded to think about issues one crisis at a time. The only question is: how do you create a system with the proper incentives? At the end of the day, Mylan runs a very capital intensive business and has a profit margin about half what Google or Apple do. I think it creates perverse and absurd incentives for it to be more profitable to be in the advertising business than to be in the business of saving lives. That's the bottom line.
You never said whether or not Martin Shkreli makes you angry. Should investors be encouraged to find undervalued drugs, buy the IP, then raise the price through the roof? That would be good for society?
Part of the reason the advertising business is so profitable is due to companies spending so much money on ads. We banned many kinds of cigarette ads because of public health concerns and I would argue that there are legitimate reasons to ban many types of drug ads as well.
You're confusing different things. Hatch Waxman does not extend the patent term for orphan drugs. It allows the patent term at the time of FDA approval to be extended to account for unusual approval delays, but only up to the point there is 14 years left post-approval. That has nothing to do with extending the patent term for modifications to the drug, as you state above. As to orphan drugs, Hatch Waxman does not extend patent protection. It provides a period of FDA exclusivity by preventing the filing of a new ANDA application. That provision has nothing to do with Epipen.
As for Shkreli--he's an asshole, but it makes no sense to focus narrowly on isolated abuses. Does FDA exclusivity for orphan drugs make up a non-negligible percent of healthcare spending (I think the answer is no)? If not than its just rage-bait, not something that we should base policy judgments on.
The big problem here is that manufacturers of generics have almost zero ability to invest in even minimal R&D. So they won't take an out-of-patent drug and use it to treat a long-tail disease. The orphan drug program is limited to diseases affecting less than 200,000 Americans. In the decade before Hatch-Waxmen, only 10 such drugs came to market. Since then, 400 have. So is it reasonable to judge the whole program by the Shkreli example?
> As for Shkreli--he's an asshole, but it makes no sense to focus narrowly on isolated abuses.
I take it nobody in your family was affected by the price of a Daraprim tablet going from around $10 to $700 per pill?
> The big problem here is that manufacturers of generics have almost zero ability to invest in even minimal R&D.
Because that's not what they do. That's like complaining that Belkin makes lightning cables and they aren't even investing in developing new computers.
It's not irrelevant nor is it much of a corner case. I too buy Epipens.
The nice thing about corner cases is that sometimes they are the tip of the proverbial iceberg. Maybe a market solution only fails in a couple of corner cases or maybe there's a fundamental problem with trying to apply market solutions to something like healthcare.
It's because people seem to believe insurance companies are an endless font of wealth. It's maybe a caricature, but a lot of stuff starts making sense if you assume it: e.g. how people are fine with burdens if they are nominally imposed on "insurers" rather individuals.
I remember there was the controversy in the '08 election about Gov. Palin charging rape victims for their rape kit, and several people refuted it by insisting that they actually billed their health insurer [1]
Forget for the moment whether the argument worked or not, or is valid or not; the fact that they thought it was responsive says volumes about the typical person's "bottomless vault" model of insurance.
How can any article about this issue not mention the word "patent" anywhere? Why is a 1970s technology still under patent? Patents are supposed to allow recouping of R & D costs, not grant an effectively permanent monopoly that can be sold over and over again until someone greedy enough does the inevitable – if we grant that sort of long-lived monopoly, what else can we possibly expect to happen? Reform the broken patent system and this problem vanishes due to natural competition. This patent reform isn't even a hard one: stop allowing patents to get extended indefinitely (with or without minor modifications).
Patents do play a role here, though not the largest role. Both Teva Pharmaceuticals and Sandoz were sued when for patent infringement when they announced plans to introduce competitors to Epipen.
They were, if I understand the background correctly, trying to make a workalike competitor, which King/Mylan asserts they cannot do without violating a patent on the current EpiPen injector. The only thing stopping them from making a non-workalike is getting doctors to prescribe it instead of EpiPen, since pharmacies can't autosubstitute in that case.
The various auto injectors work slightly differently. Rightly or wrongly the FDA expects doctors to instruct their patients in the specific auto injector they prescribe. This prevents pharmacies from subbing out other brands unless they are functionally identical.
If no one is making a generic, or more to the point doctors are prescribing "EpiPen" rather than "epinephrine autoinjector" being out of patent won't help.
In the UK doctors had to switch to prescribing generics I think as far back as the 80s. Brands are now only prescribed, with a few exceptions, when it's something new enough to not have a generic yet. Before that lots of things were often prescribed by brand without good reason.
My experience in the US is that doctors prescribe drugs with generic alternatives anytime they can. I'm not sure if I've ever even taken a branded prescription pill.
Yeah, my old doctor would always prescribe generics, and if he knew you were hard up and might not even be able to afford the generics he would try to get samples from the reps anytime he could and just give them to you.
Furthermore, even if the doctor writes the brand name drug on the prescription in the US and in Canada the pharmacist can substitute the generic, unless the doctor explicitly says no substitutions on the prescription.
Doctors in the US are reimbursed by Medicare/Medicaid and private insurances based on the rates of generics they prescribe. They look at each type of doc (Oncologists obviously use more Brand Name drugs than pediatricians) and make sure that every doctor falls in a tight band with incentives to 'beat' the number.
Most hospitals have specific formularies tilted toward generics as well, if a doctor writes "Tylenol" for a patient, they're given generic acetaminophen. More interesting is that if a doctor writes a script for something like a Brand Name statin, the formulary will auto-substitute for the hospital's drug of choice, now typically generic Lipitor.
> How can any article about this issue not mention the word "patent" anywhere? Why is a 1970s technology still under patent?
Because the 1970s technology isn't patented. And patents can't get "extended indefinitely." Even if you get a patent for an improvement to a previous patented design, the previous design receives no protection once the patent expires.
I attended a recent talk of a leader in bringing drugs to market (not naming names). The current trend in pharma is moving away from R&D to S&D. i.e. Search and Develop. They search for promising molecules developed by startups or by government, then develop that into a final product manufacturing process. Most of the research drug failures are committed by third parties and do not cost big pharma anything...shoukd not contribute to the cost of drugs
Very true, and radically underdiscussed as an issue.
Part of me really wants to know if it is Actually Cheaper for BigPharmaCo to offset research costs to university/government/startups and then do a Merger/Acquisition to get the promising drug past a certain phase (what have you) vs costs to do research in house.
Is lawyering and banking the process to get a drug to market BEFORE final approval really that much cheaper, or is this an accounting slight of hand issue? What is the actual cost minus marketing to develop a drug and bring it to market that created this situation.
Furthermore, what is the cost of marketing on the books for drug companies that also would drive R&D into third parties. Marketing costs are really not cheap - and they have been rising, especially as more prescription drugs are advertised to consumers. How much of this cost is also driving cost cutting/offset of risk?
(especially wondering since these issues appear appears the recall + no more manufacturing of Avui-Q. The auto-injector issues that caused the recall were untraceable/not replicatable at the Sanofi factory - and seem to be based on descriptions user error driven - and lower than the user error/failure rate of EpiPen. Meanwhile, Sanofi isn't the inventor - Kaléo/pair of brother founders is/are, and they brought nearly the exact same injector technology to market by themselves for heroin overdose. Sanofi just licensed the technology - and in the wake of the recall, decided to forfeit the license. I'm wondering how much of that deal's provisions killed the Auvi-Q, since it appears the issues behind the injector are long term fixable and profitable)
>Mylan was actively involved in pushing a 2013 federal law encouraging schools nationwide to stock EpiPens. And the company takes credit for legislation in at least 10 states that require the product in hotels, restaurants and other places, and additional school-related legislation in nearly every state. It is also helping push legislation pending in Congress that would require epinephrine auto-injectors on all commercial airline flights.
It would seem to me that a government-mandated market expansion would require a counter-balancing price regulation, but maybe my sense of reciprocity is misplaced.
I see little indication that that doctor has any experience getting a medical device through the FDA and manufacturing. Couple that with the flexible funding goal and that looks pretty damned scammy.
One thing that really annoys me is the fact that drug makers can refund the co-pay to customers. In the auto repair industry, I believe this has a name: insurance fraud.
The co-pay is a part of the price of the product that your insurer doesn't cover, so technically it's not theirs to begin with. Which is also why it's not a refund of the deductible paid, because that -is- considered part of the insurance contribution, i.e:
(deductible paid by customer + insurance payment) = your insurance contribution
co-pay = your personal contribution to the cost of the treatment.
It's obviously fraud. If your windshield breaks and your deductible (co-pay) is $500, I can't quote you $500 above market rate to fix it and give it back to you in cash to stick it to your insurance company.
Somehow there is a mechanic shop near me with a sign out front advertising that they will pay your deductible. It's not exactly hidden either -- it's located on one of the busiest streets in Chicago.
If the real cost to fix a windshield is $300 but your shop advertises $800 to everyone along with an offer to 'pay the deductible' then it's not illegal. You can claim your shop is more expensive because it offers better service or better parts or whatever. It would only be illegal to quote $300 for those who are uninsured but quote $800 for those who do have a deductible.
It's still clearly a scam against the insurance companies, whether actual fraud charges would stick in court or not.
Deductibles, co-pays, and co-insurance are all separate things with specific definitions:
A deductible is a portion of covered medical expenses that the insured must pay. It is specifically defined as the amount of covered benefit that must be incurred and paid by the insured before benefits become payable by the insurer.
Key in the above is "a portion of covered medical expenses".
A copayment is a flat dollar amount that the insured pays each time a certain kind of service is received. The copayment is not a percentage of the total cost, as it is in coinsurance, but rather is always the same dollar amount even though the cost of the service may vary (a pharma co-pay of $x, regardless of the variable drug price).
It may seem like nit picking, but there are specific reasons for the difference.
Source: myself, who writes and maintains health insurance claims management and adjudication software.
This is all separate to your claim: of course, if your doctor agreed to charge you $x+200 (leaving aside the reality of negotiated and contracted fee schedules) and refund you that $200, then absolutely yes - this is insurance fraud.
However, the co-pay does not form part of the insurance coverage.
> This is all separate to your claim: of course, if your doctor agreed to charge you $x+200 (leaving aside the reality of negotiated and contracted fee schedules) and refund you that $200, then absolutely yes - this is insurance fraud.
If you charge $X more for an Epipen vs. the market rate for a generic epinephrine autoinjector but offer a $X discount for uninsured persons (or a smaller $Y discount for those with copays or deductibles), it is the same scam.
What you need to remember in this case is that the delineation comes FROM the insurance company. They wash their hands of the co-pay entirely and say "no, we+your deductible are covering this (part of the cost)". That becomes the insurance benefit in total. Your co-pay also comes out of your pocket, entirely separately.
There's no fraud, because that's how the insurer defined the separation themselves (for other reasons).
I've been waiting to see a neurologist for a serious and worsening vision problem since May. For those keeping track, that's four and a half months. So between these high drug prices and low healthcare availability, why exactly are we so afraid of single payer again?
By turning healthcare into a humanitarian mission instead of a business venture. My local clinic is for-profit and found that it made better business sense to only have the most rudimentary neurology department possible since it tends to be expensive. Instead they focus on their financial bread and butter like flu shots and annual checkups.
Humanitarian missions and charity are notoriously ineffective at achieving real change. See, for example, the utter failure of aid organizations to achieve any fundamental changes in Africa. Meanwhile, big drug companies and their anti-retro viral cocktails changed the course of the AIDS epidemic there almost overnight.
If you had studied economics, you would know that profit and income are fundamentally different concepts. The existence of profit (rather than breaking even) implies a market failure.
I don't think anyone is suggesting that the doctors are making out like bandits here. Of course they do quite well, and since they are providing most of the value in the equation, every seems to be pretty happy about that.
I live somewhere with single-payer (Ontario, Canada) and while it definitely increases access for the poor or unemployed, the wait times and service quality are far worse than they are for employed persons with insurance in the United States.
I assure you, we still wait 3+ months to see a specialist.
The solution to the cost problem is for competition to enter the market. It is my understanding FDA has in some way restricted market entry as competing firms (eg, generic giant Teva) come up with a device acceptable to the FDA.
Lobbying, crooked NGOs, corruption, price gouging. There is something completely rotten in the US healthcare system.
If this were free markets and capitalism, wouldn't the response be a flood of alternatives at 1/100 or even 1/10 the price since the base ingredient costs pennies, and not this self serving and crafty effort to leech tax payer subsidies? This is organized corruption.
When you let people feed on others desperation you create demons. This is the biggest argument for socialized healthcare.
As a pharmacy company, wanting to charge a higher price for my products, doesn't it sound like an excellent strategy to outrage my customers, get them actively protesting, only to present a solution that many of those outraged customers will support while continuing to allow me to charge my higher price?
This feels like a House of Cards-like strategy: take up an unpopular selfish position only to later use its most vociferous opponents as leverage in maintaining that strategy.
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[ 3.4 ms ] story [ 237 ms ] threadhttp://www.forbes.com/sites/realspin/2016/09/14/government-h...
It's Forbes, but the argument is backed by the recent Harvard study:
http://jama.jamanetwork.com/article.aspx?articleid=2545691
> Most definitely, the solution is not more government controls through regulation.
I agree that we likely don't need any more regulation in this space. But it seems obvious to me that this issue is related to the overall shift lately. Employers are offering high-deductible insurance plans and employees are bearing a greater burden. The outrage over EpiPens is just another symptom of the US public clamoring for what they see as something that should be an entitlement. I don't know that I prefer it but it seems pretty clear to me that it's coming (within another generation or two at max).
The point about patent protection is pretty huge. I wonder: what net effects would there be to removing patents entirely? Would we end up with less ambitious products and services because designs would just get copied by the cheapest production centers? Could we/should we restrict patents among different industries?
The rest of the Forbes Articles seems like the usual delusional libertarian nonsense were they point out well known and obvious downsides of regulation while pretending no such downsides exist in deregulated markets (i.e., poor people would still die, even as prices drop, because some prices can only drop so much, and dangerous drugs brought to market by unscrupulous companies which are always common)
Also I like to remind the HackerNews community, that everything you use every day (transistors, integrated circuits, information theory, communications satellites) were invented in whole or part at a government mandated monopoly (Bell Labs). Of course there were conditions on that mandate, like not patenting what they invented.
The transistor, at least, was definitely patented, and just a cursory search [1] yields tons of patents involving transistors, so I don't think there was a restriction on patents.
And as a minor issue, the IC is generally credited either to TI or Fairchild, depending on what you consider to be a modern integrated circuit; Bell Labs had no significant involvement.
[1] https://www.google.com/search?tbm=pts&hl=en&q=transistor+sch...
The question is not "why is this company so evil and greedy?" It's "why dont McDonald's hamburgers also cost $600?", and how do we make the market for drugs as competitive as for burgers?
Because insurance doesn't pay for McDonalds. To make the market for drugs competitive, step one is to get rid of health insurance. Or at least health insurance coverage for drugs.
I think the going price for an iPhone is $700. How much would an iPhone cost if you only had to pay 20% of the price?
Do the math, and now THAT's why drugs are so expensive.
> Dr. Ezekiel Emmanuel, one of the architects of Obamacare, admits that a free—“uncontrolled”—market would bring down prices. Yet, his solution is more government control, specifically price controls.
> What does history teach us about price controls?
> The U.S.S.R., Cuba, Korea, Spain, and Venezuela amongst others have all used strict government price controls. The results were: shortages of everything, viz., long lines of Russians standing in the snow waiting for government-issued shoes or toilet paper; poor worker productivity; very low standards of living; and no innovation. This is precisely what we don’t want.
From the study:
> The most realistic short-term strategies to address high prices include enforcing more stringent requirements for the award and extension of exclusivity rights; enhancing competition by ensuring timely generic drug availability; providing greater opportunities for meaningful price negotiation by governmental payers; generating more evidence about comparative cost-effectiveness of therapeutic alternatives; and more effectively educating patients, prescribers, payers, and policy makers about these choices.
That article is libertarian trash, and contradicts the study.
Deregulating food - and much worse - drugs, would just end up in dangerous cheap products, and slightly less dangerous but still low quality products. Every company optimizing for profit will take every shortcut available to them. Deregulating opens up a lot of them. Most of them detrimental to consumers, few of them detrimental enough to warrant a decrease in public image.
It also sounds like a number pulled from a hat.
So I went looking.
It's from a Tufts Center for the Study of Drug Development study published in 2014 [0]. Which is, incidentally, supported financially by the pharmaceutical industry [1]. Even the published pdf is pretty lacking on actual data [2]. Because it's a PR piece. This other study, from the Office of Health Economics, 2012, reported the cost as $1.5bn [3]. (OHE is funded by research grants and consultancy fees from - you guessed it - the British pharma industry). Did the cost magically increase by $1bn in the two years between the studies, or is there something fishy going on here?
One point in the Harvard study abstract was,
> The most important factor that allows manufacturers to set high drug prices is market exclusivity, protected by monopoly rights awarded upon Food and Drug Administration approval and by patents.
And that's true! But that exclusivity is an artifact of medicine-for-profit, instead of medicine-for-health.
It's interesting that all of their recommendations for lowering prices fail to take into account (at least in the abstract, as I don't have access to the full article) the single biggest difference between the only market where per capital spending is $850 and the 19 markets where per capita spending is, on average, $400: for profit healthcare and medicine.
Keep in mind that even after that astronomic cost for drug approval (the figure for which is iffy in providence), for-profit pharmaceutical companies still spend more on marketing than they do on research.
0. http://csdd.tufts.edu/news/complete_story/pr_tufts_csdd_2014...
1. http://csdd.tufts.edu/about/corporate_sponsorship
2. http://csdd.tufts.edu/files/uploads/Tufts_CSDD_briefing_on_R...
3. https://www.ohe.org/news/overview-ohe-study-cost-drug-develo...
Marketing spending is huge, but it undermines their message when they do that.
Mylan pushed generics off the market by making a better cap or something, the FDA should just say no, that improvement is nice but it isn't enough to give you exclusive marketing rights. If you want to incorporate it into your product, license it to your competitors for cheap.
FDA's responsibility is mutually exclusive with USPTO which would approve/deny patents based on "novelty".
In the case where there are generics and the improvement is small, it doesn't matter if the company decides to take their ball and go home. It might be a fine line to walk, but the improvements to the Epipen don't seem to be very substantial (it's kind of hard to figure out what the improvements are with so much coverage of the recent events).
The FDA's responsibility is dictated by legislation and there's nothing in the US Code that describes "you can't release new products if the new design isn't sufficiently improved."
Legislators have all the power. If they can agree, they can say "Woo party free EpiPens for everyone, put it in the budget." FDA has some small amount of judgment they can apply within reason to restrict products that fail to comply with the law.
https://www.law.cornell.edu/uscode/text/21/355
(5) evaluated on the basis of the information submitted to him as part of the application and any other information before him with respect to such drug, there is a lack of substantial evidence that the drug will have the effect it purports or is represented to have under the conditions of use prescribed, recommended, or suggested in the proposed labeling thereof; or (6) the application failed to contain the patent information prescribed by subsection
Maybe it's a stretch, but a marginally safer but much less accessible product actually doesn't improve the situation for the public.
I'm partly suggesting here that if the FDA doesn't have the authority, maybe they should.
Certainly, I know some things might happen "behind the scenes". Maybe they found a more durable spring for the needle (not that was ever a problem), or such. But yes, I struggle to see it as anything more than patent extension.
Which is why, after our relatively small county, which THROWS OUT $100,000 of EpiPens a year in the Medic One system (which we are mandated to carry by state law) is moving to train EMTs to draw up epi from $2.80 vials, themselves.
They certainly don't. Look at Nexium, it is something close to a blatant scam but the FDA approved it and between Medicare and Medicaid alone the federal government has rewarded the scammers (AstraZeneca) with billions of dollars never mind private insurance companies.
The additional issue with auto-injectors is that knowing how to correctly use a particular one is important, so there is a legitimate reason to make sure that generics work the same way as the branded version. This means that if the branded version adds a patented safety feature, then there won't be generics for a while.
Nexium is just pre-broken-down Prilosec, which had just run out of patent protection. They then manipulated the results to make it look more effective so they could market it as such:
> AstraZeneca's scientists had misrepresented their research on the drug's efficiency, saying "Instead of using presumably comparable doses [of each drug], the company's scientists used Nexium in higher dosages. They compared 20 and 40 mg Nexium with 20 mg Prilosec. With the cards having been marked in that way, Nexium looked like an improvement – which however was only small and shown in only two of the three studies."
The government has spent literally billions of dollars buying esomeprazole when a double dose of omeprazole is the same damn thing for 97% of the population. I caveated my original statement ("something close to") because there might be some role for esomeprazole as a second line drug for the 3% of the population that is sensitive to the other isomer, but even there a perfectly fine alternative would just be a lower dose of omeprazole.
Nexium is 18th on the list of drugs by global sales in 2014. These are not small potatoes.
My understanding is that the inactive form is actually metabolized into the active form by the body.
There is some argument that this happens differently in different people. But if AstraZeneca knew this (which they almost certainly did), why didn't they release esomeprazole at the beginning? They released omeprazole first, then sat on esomeprazole until the omeprazole patent was about to expire. It's obvious why they would do that.
Medical Devices ALSO need approval from the FDA.
Why is the Epi-Pen body not approved separately from the Drug, allowing the body to be sold without epinephrine and to be filled with whatever, including generic epinephrine from a vial?
I pay about $10 a pen, insurance pays about $100 per (even after the price increase). That being said, people rarely use this drug. $100 to save your life once a year or so kind of seems like a fair trade.
This seems more like the media is outraged as opposed to the country. All my friends don't even know about this price change, I only know about it because I read the news more often.
Part of the reason it is so expensive is because of monopolistic pricing on many drugs and treatments.
You are paying way more than $100
Also you have to buy more than one because they expire.
Mylan is happy to give people $300 coupons to get them to use their insurance, it wouldn't be weird for them to agree to sell the pens to an insurer for $100.
You (and everybody else) pay the increase in increased premiums
Regulation prevents (cheaper) alternatives from reaching the market
Not to mention $100 for an Epipen is just a ridiculous price
The question is, why don't we operate our regulatory system in such a way that companies making a product that costs ~$30 only make a hefty profit, say 100%. The only answer is because we are stupid.
You don't have your facts straight and seem unaware of the more recent increases. The price for a set of 2 pens was:
$103.50 in 2009
$264.50 in July 2013
$461.00 in May 2015
$608.61 in May 2016
Source: http://well.blogs.nytimes.com/2016/08/22/epipen-price-rise-s...
You say you + your insurance pay $110 per pen, so $220 for a set, so you seem to be paying the price as of right before May 2015, and you haven't bought a pen since then. You might be in for a big surprise next time you have to buy one.
Express scripts co-pay has only gone up $0.45 in that time.^1
>Express Scripts says it has been able to hold costs steady for its members: its commercially insured population has seen their co-payments for EpiPen go from $73.05 in January 2015 to $73.50 in July 2016, even though the price of EpiPen rose by 51% over that period of time.
[1]http://www.forbes.com/sites/matthewherper/2016/08/30/the-con...
Now let's say you got fired tomorrow when you go to work. Aah, this changes EVERYTHING, doesn't it.
The point is not what you actually pay for a Pen. The point is that SOMEONE is paying for it which is not reasonable. Your employer is paying most of the premium so you may not realize. Lose your job and try buying insurance out of pocket. You will know what it really costs. Oh and don't forget to learn all about the various cryptographic terms such as deductible, co-insurance, co-payment, in-network, out of network, PCP referral required...
[0] - https://www.youtube.com/watch?v=RoMlxVimwiU
You know where the government gets its money, right?
Is there a specific reason why the price is unreasonable? (don't anchor the previous price)
People are not getting it for free, as you argued.
> Is there a specific reason why the price is unreasonable?
It is a clear case of price gouging and a harm to public health.
> (don't anchor the previous price)
Do I get to forbid you from making arguments too?
http://www.emerade.com/hcp/adrenaline-auto-injector
I hope he makes a fortune and inspires more to come up with those kind of drugs.
This has just let the drug companies to raise the price without any backslash because the end user is "not" paying the price. However, the rising premiums and plans with high deductibles meant that the drugs are still not affordable even if you are covered by some insurance.
What is the solution to this? Single-payer health care?
The slight complication is that people will die without their meds, but the market doesn't care about that. It's only concerned with money.
Its a market with inelastic demand - people will literately die if they don't buy the product. We, rightly, through regulation demand high quality assurance because if something is meant save someone from a quick death it better be reliable and not cause greater harm due to product defects. This means the entry barriers are quite high making competition difficult. Without price controls there is literately nothing but the CEO's conscience to keep from pushing the prices up. If the product will stop you from dying and nobody else can offer it, then there is basically no price you won't pay.
Second in the case of off patent medicines, some are harder to make or not prescribed widely enough for the generic makers to bother with. These seem to be the things at risk of price gouging. There was an example of something off patent sold by Pfizer to another company who now charge 10x more, as there is no generic alternative. That's now at the competition authorities.
So we mitigate a lot of this, but we apparently don't avoid it entirely.
EDIT: Programme page with mp3: http://www.bbc.co.uk/programmes/b07j7j6m
I usually don't make political comments but one thing that was disappointing with Obamacare was the fact that it did not address this root cause and instead touted that now anyone can get insurance. Sure, someone with pre-existing condition is now probably a little better off but overall, obamacare did not address the main issue: getting rid of middlemen (insurance companies) and let doctors/hospitals work on fair and transparent pricing. Isn't that what America is all about ? Free Market, eh.
If I may steal the legendary MLK's words, I have a dream. A dream where I can call any doctor/hospital and ask what will it exactly cost to get a simple X-Ray done without saying "Oh no, I ain't got no insurance". Just a dream.
In fact, if we accept insurance/Medicare/Medicaid and OFFER a cash discount to an uninsured patient, we are one whistleblower away from a Medicare Fraud investigation.
Why should mine be?
Long post:
Good point, except that get to see I see the invoice AFTER a service has been provided to me, sometimes MONTHS after the encounter EVEN AFTER SPECIFICALLY asking for an estimate upfront.
If you know a provider who works otherwise, feel free to answer this question: https://www.quora.com/How-do-I-find-a-general-physician-in-S...
No providers office I know of are willing to provide estimates to patients for procedures the same office requires the patients to be financially responsible for!
The reality is that the provider is like a programmer who builds what I discussed with her to build only that I get a $10k bill AFTER THE FACT without having a say in whether I am OK with it or not and she just went ahead and did the project for me without even asking me if I wanted her to do it.
If I don't pay, my credit will be trashed with a collection entry.
This is unacceptable. I am not sure if you agree.
Case in point: I went to a specialist to figure out the ringing in my ears. I made it clear to both the administrative staff and the doctor that I should be told of any charges outside the office visit fee before such a charge would be incurred.
The specialist looked into my ears and said my ears looked fine and the ringing could be due to stress.
A month later I got a $1500 bill for "in office surgery". Apparently, if a specialist inserts anything into my body, it's a surgery and billed in addition to an office visit fee.
I do NOT believe this is proper. The provider took full advantage of my inconvenience.
I am lucky it was a $1500 bill and not a $15000 bill. It could very well have been and I would have NO recourse.
I am happy to pay your negotiated rate as long as you tell me what that rate is and how many hours you estimate it will cost me.
What I am NOT happy to do is be forced to pay an amount that I had no say in the first place.
Providers ARE exploiting their patients and getting away with it by placing the blame on the faceless insurance companies.
Patients are not walking blank checkbooks. They are suffering and under pain and looking to you for a remedy.
Providers have a right to make money. Providers DO NOT have a right to exploit.
First point: If you're willing to pay cash and bypass the insurance / CPT / ICD10 / RVU rigamarole, I'd like to direct you to any number of concierge physicians who will gladly take your money, provide you their cell phone, and give you 24/7 availability. Simply Google "concierge physician san diego", and you'll have your pick of physicians from UCSD or Scripps or other great places in SD.
Second Point: You're conflating a whole lot of stuff. Your insurance doesn't pay us enough to do the whole "personal estimated bill". That's the patient's responsibility. You and your insurance company are the only people who know the status of about 10+ variables which will affect your out-of-pocket-cost. What's your deductible's status: Have you exceeded it? What's your out of pocket max for the year? Do you have a copay or coinsurance for ambulatory services vs hospital provided services? Are we in-network with your variant insurance company's policy? There's no API for us to query all this information from Aetna/BCBS/Humana/et al, and given how insurance companies LOVE to put up barriers to care via prior authorizations, that API is never happening unless mandated by federal law or built by yet ANOTHER company.
>The reality is that the provider is like a programmer who builds what I discussed with her to build only that I get a $10k bill AFTER THE FACT without having a say in whether I am OK with it or not and she just went ahead and did the project for me without even asking me if I wanted her to do it.
This is a false equivalence. The medical equivalent to this scenario would be calling and speaking to a physician on the phone about whether you even need an appointment and then receiving a bill for a consultation with lab testing. Our taking an interview with you, reviewing outside notes/labs/imaging, doing a physical examination, and providing our expert opinion IS our deliverable product, NOT the procedure and definitely NOT the medication we prescribe. You wouldn't engage a business consultant or a lawyer for advice and not expect to pay for their time? Why is it different with physicians?
The "I WANT AN ESTIMATE UP FRONT" request is fine for some areas of care, but if it were up to me, I'd simply give you my charge-master-highest-rate and say "I don't know what your particular insurance company has negotiated and which contract will be in effect at the time of bill submission, so the resulting charge may be lower than this. It will not be higher". For example, I'm in Radiology, so my billing is different. My deliverable is not an in-person consultation, rather a diagnostic imaging examination, interpreted to the best of my expert opinion. I can provide a concrete, encapsulated, whole estimate of charges for both the technical and professional fees, and that estimate will be the maximum I charge all 3rd party payers.
I agree with the answer provided by Quora. You're asking someone to do ALL the work, before you even decide to pay them. This is the equivalent of asking a lawyer to evaluate a contract and then offer you a per-paragraph rate of evaluation based on the projected complexity of each section, before you even then decide to pay them a dime. That estimate is difficult to perform without going ahead and just doing the work. If you're going to play that game in medicine, just pay the physician hourly like in law in 15-minute increments or get a concierge doc.
I respect that you are a MD from Harvard Medical School. Obviously you are very smart, and hard working.
Deep inside you, something must be telling you that it would make no sense for a provider to be in business of seeing patients if they were making no money in it.
I am also confused if you disagree with me that it is reasonable to be told of costs that one is expected to pay BEFORE one is made to incur those costs?
Someone is paying you and for the computers and GPUs you run your code on. Infact you made a very similar comment: https://news.ycombinator.com/item?id=10930242
But let's keep that aside; that's a completely separate discussion.
To clarify: I did not ask the provider to tell me what my OOP will be. I am educated enough to figure that on my own. I know how to call my insurance company and speak in English.
All I want the provider to tell me is what they typically bill during a routine service so I can figure out how much my visit will be billed to my insurance company.
I am more than happy to talk with my insurance company to figure out how that cost will be settled.
I don't want the provider to do anything extra for me.
> I'd simply give you my charge-master-highest-rate and say "I don't know what your particular insurance company has negotiated and which contract will be in effect at the time of bill submission, so the resulting charge may be lower than this. It will not be higher"
GREAT!
That is fine and I would welcome it! Seriously. Let me sort out what I need to pay and what my insurance pays.
Just tell me what my maximum financial liability could be and I am a happy camper!
I don't think you still have understood my "rant" but in this case I was not told about the possibility of a "surgery" before, during or after the appointment, with me asking the doctor and office staff at each of those steps if I owed anything. I came to know about it months later when I got the invoice with a due date.
Anyways, I do not want to repeat the detailed discussion that are already in the comments on the Quora post. You are welcome to expand the comments and read them yourself once you are over being condescending.
FYI, the last comment I made there clarified I am more than happy to pay for the consultations and estimates. No one works for free.
I would rather pay $500 for consultations and estimates to figure out what I am going to get and whether its worth it to me than $1500 that I had no say in that just happened to show up in my mail.
Since your first line is all so very dismissive of my whole rant, I will not longer engage with you, as it's probably wasted energy.
You read the anonymous answer, you agreed with it, got what you were already decided on and did not even bother to read further.
For your sake I hope you never get a medical bill you never even thought you would get that would end up destroying you financially and put you in extreme debt.
This actually happens to people in the U.S. on a regular basis, and I dont think that's normal.
I cant personally imagine why smart people even think this practice is OK.
What happened to me during that visit can be summarized by: "oh that peek we did into your ear? yeah, that's $1500. sorry we didn't tell you in advance. If you don't pay it, we will trash your credit".
For other people possibly reading this: the office did not even tell me that the visit might involve extra costs INSPITE of me EXPLICITLY mentioning that I would need to be made aware of such.
TLDR: I am HAPPY to pay for costs that are shared with me BEFORE they are incurred SPECIALLY when I am asking to be made aware of costs that I am expected to pay.
Stop talking about what the patient will have to pay out of pocket and start talking about how much you will receive. I agree that how much of that is covered by my insurance is between me and them, but it starts with what YOU charge for services. And back to my original point, that should be a fixed rate (of your choosing) charges to all of your patients (and their insurance company).
If I charge under what they will pay, they aren't going to reward me with all that savings.
If someone wants to negotiate with me directly, I'll charge you some other price, then write off the rest, just as if you are phkahler insurance co. It's the only "legal" way to offer a discount.
Why should mine be?
You pick your rate. Whatever you like. Now charge that to every one of your patients with no discounts or negotiation. That's all I want you to do. Don't do anything different for insured patients either, your rate is your rate and the insurance company must pay it, or pass the rest on to the patient. Simple as that. The doctor down the street is free to pick his/her rate too, but they must charge that rate for all of their patients.
The problem we have here is the exact same problem as with taxis/Uber (and telcos somewhat. and actually that public code thread we argued about the other day, too). Rather than just directly subsidizing infrastructure for poor people, governments enticed businesses to provide some service at a loss by giving them special privileges across the board. As the market finds more efficient solutions, the reality disconnect becomes painfully apparent. Market consumers grow sick of the incumbents' overhead, while simultaneously the businesses gradually renege on their unprofitable obligations.
I would seriously consider going without insurance except for the highest cost goods & services (say over 100k) except for the fact that it will cost me more to go to the doctor for a check then my insurance company currently pays.
The group discount without the risk sharing would be a very interesting product for me. I wonder how many other people would be interested in such a thing.
I think a fundamental problem of trying to privately implement this idea is that medical businesses have an extreme amount of overhead simply to deal with insurance companies, but they don't precisely ascribe it to insurance as payment. From a doctors' office's perspective, the "actual cost" of providing you cash service still includes paying all their back office rather than just actual services rendered.
Coming from the other direction, you have high-deductible plans that effectively do this in many more words. Plus that whole tax subsidy that fueled the growth of this institutional cancer in the first place.
[1] https://en.wikipedia.org/wiki/Rake_(poker)
He directly addresses the inaccuracy of that claim in the following 10 minute video, "The $55,000 Appendectomy: What Everyone Should Know About Hospital Bills". [3]
[1] https://www.reddit.com/r/IAmA/comments/4lgnif/i_am_david_bel...
[2] http://truecostofhealthcare.net/conclusion/
[3] https://www.youtube.com/watch?v=jkAY15p2DN4
Even so, my last visit was less than $100, including blood work. There wasn't even an in-network discount or anything. So I doubt I'm subsidizing anyone, and I don't think the hospital is suffering too much from treating everyone.
I have to unfortunately be very vague because I don't remember the actual reference, but I remember a similar problem where the lobbyists didn't get what they wanted , and discreetly added it into some kind of unrelated bill in the midst of some fine print.[2] An excellent use for using something like natural language processing is to find outlier items which simply do not belong in a law which is being passed.
[1] I am also told that from the perspective of the R&D labs which spend a ton of money up front to produce the drug that this is the only way to recoup costs. And the costs for the R&D labs are usually blamed on excess regulation, so that is apparently a sort of justification for these subsidy requests (which still doesn't make sense).
Edit: [2] I bring this up because the article mentions the following and I think the euphemism has at least one possible explanation:
"But a review of Mylan’s lobbying history makes clear that the company has an exceptional track record at influencing government policies, both in Washington and in state capitals. Heather Bresch, Mylan’s chief executive, called the effort “our unconventional approach to growing this franchise” in remarks to Wall Street analysts last year."
Why is it even needed? I know some people say "education", but that's backward.
You have a problem. You go to your physician. He works out a treatment plan for you.
For drugs advertised for specific conditions? To enlighten you to alternatives? You can oftentimes assume that alternatives exist, for most common complaints.
For those that don't? Those ads are such a dragnet of wide ranging and vague conditions that oftentimes, the majority of the population would qualify ("Are you feeling run down? Do you have trouble getting to sleep? Ask your doctor about trying XXX". No. Ask your doctor about your conditions. Let them decide whether to try XXX. Or YYY. Or just to get more sleep).
There's no justifiable need that I can see that prescription medication need be advertised to anyone other than physicians and practitioners.
Oh, and it's not "often" that they spend "more". There is not one of the top ten pharma companies that spends more on R&D than marketing. Every one outspends on marketing. And by "more", the smallest gap is "four times more" leading up to "seventeen times more".
And we wonder why healthcare is so expensive here...
I believe it's also allowed in New Zealand.
But I totally agree with you, it's a ridiculous practise
Because, contrary to popular belief, doctors aren't gods, and have about the same fraction of slackers as any other occupation. Unless we're ready to have a really aggressive program for revoking licenses of doctors who don't keep up with modern advances, they can and do miss available treatments.
"Hm, I could eagerly search all the latest treatments that might be relevant to my patents, or I could write them up something based on gut feel and what I learned in med school 30 years ago. Both pay the same."
Any patient engaged enough and knowledgeable enough to participate in improving their care plan is also knowledgeable enough to know that TV commercials for drugs are complete garbage and offer 0 substantive benefit.
Well, originally you said that no doctor could ever learn about anything that they didn't already aggressively seek out due to their diligent efforts to stay in compliance with the continuing education requirements.
Now you're recognizing that it happens but the costs outweigh the benefits.
Could you update your original post and be a bit clearer about your actual claim in the future? I wouldn't want people to be misled.
Hmm.. maybe you misread the original comment?
I specifically said no patient will learn something from a TV commercial that their doctor/nurse/pharmacist aren't aware of. It wasn't a comment on the infallibility of medical education but the uselessness of pharma advertising.
Of course knowledgeable patients can improve their own care by aggressively researching whatever condition they might have.
Because the US has the strongest freedom of speech protections in the world.
Extending personhood rights to corporations is a really bad idea.
Which is to say, they are made up of people. My right to free speech is not diminished by the fact that I choose to work with other people for a common goal.
1. https://www.youtube.com/watch?v=KlPQkd_AA6c My second favorite republican quote that was mistakenly maligned by the left. In first place is, of course, Rumsfeld's rumination on the nature of unknown unknowns.
Are you not bothered at all about the EpiPen situation? Martin Shkreli doesn't make you angry?
A pharmacologist friend once told me that the best way for a drug company to get a customer for life is to make sure they don't cure or kill them. She was joking, but I think it's true.
And no, the Epipen thing doesn't bother me. It's narrow minded to think about issues one crisis at a time. The only question is: how do you create a system with the proper incentives? At the end of the day, Mylan runs a very capital intensive business and has a profit margin about half what Google or Apple do. I think it creates perverse and absurd incentives for it to be more profitable to be in the advertising business than to be in the business of saving lives. That's the bottom line.
Yes they can. The Hatch-Waxman Act was written specifically for this. Also see:
http://www.citizen.org/congress/article_redirect.cfm?ID=6435
You never said whether or not Martin Shkreli makes you angry. Should investors be encouraged to find undervalued drugs, buy the IP, then raise the price through the roof? That would be good for society?
Part of the reason the advertising business is so profitable is due to companies spending so much money on ads. We banned many kinds of cigarette ads because of public health concerns and I would argue that there are legitimate reasons to ban many types of drug ads as well.
As for Shkreli--he's an asshole, but it makes no sense to focus narrowly on isolated abuses. Does FDA exclusivity for orphan drugs make up a non-negligible percent of healthcare spending (I think the answer is no)? If not than its just rage-bait, not something that we should base policy judgments on.
The big problem here is that manufacturers of generics have almost zero ability to invest in even minimal R&D. So they won't take an out-of-patent drug and use it to treat a long-tail disease. The orphan drug program is limited to diseases affecting less than 200,000 Americans. In the decade before Hatch-Waxmen, only 10 such drugs came to market. Since then, 400 have. So is it reasonable to judge the whole program by the Shkreli example?
I take it nobody in your family was affected by the price of a Daraprim tablet going from around $10 to $700 per pill?
> The big problem here is that manufacturers of generics have almost zero ability to invest in even minimal R&D.
Because that's not what they do. That's like complaining that Belkin makes lightning cables and they aren't even investing in developing new computers.
No, but I buy Epipens for my daughter. That fact is, of course, irrelevant. Systems shouldn't be designed by hyper-focusing on corner cases.
The nice thing about corner cases is that sometimes they are the tip of the proverbial iceberg. Maybe a market solution only fails in a couple of corner cases or maybe there's a fundamental problem with trying to apply market solutions to something like healthcare.
I remember there was the controversy in the '08 election about Gov. Palin charging rape victims for their rape kit, and several people refuted it by insisting that they actually billed their health insurer [1]
Forget for the moment whether the argument worked or not, or is valid or not; the fact that they thought it was responsive says volumes about the typical person's "bottomless vault" model of insurance.
[1] http://www.politifact.com/truth-o-meter/article/2008/sep/22/...
Because there is no patent here. That is why.
[1] https://www.bloomberg.com/news/articles/2012-04-26/mylan-pfi...
[2] http://www.law360.com/articles/181459/king-pharma-sues-sando...
In the UK doctors had to switch to prescribing generics I think as far back as the 80s. Brands are now only prescribed, with a few exceptions, when it's something new enough to not have a generic yet. Before that lots of things were often prescribed by brand without good reason.
Most hospitals have specific formularies tilted toward generics as well, if a doctor writes "Tylenol" for a patient, they're given generic acetaminophen. More interesting is that if a doctor writes a script for something like a Brand Name statin, the formulary will auto-substitute for the hospital's drug of choice, now typically generic Lipitor.
Because the 1970s technology isn't patented. And patents can't get "extended indefinitely." Even if you get a patent for an improvement to a previous patented design, the previous design receives no protection once the patent expires.
Part of me really wants to know if it is Actually Cheaper for BigPharmaCo to offset research costs to university/government/startups and then do a Merger/Acquisition to get the promising drug past a certain phase (what have you) vs costs to do research in house.
Is lawyering and banking the process to get a drug to market BEFORE final approval really that much cheaper, or is this an accounting slight of hand issue? What is the actual cost minus marketing to develop a drug and bring it to market that created this situation.
Furthermore, what is the cost of marketing on the books for drug companies that also would drive R&D into third parties. Marketing costs are really not cheap - and they have been rising, especially as more prescription drugs are advertised to consumers. How much of this cost is also driving cost cutting/offset of risk?
(especially wondering since these issues appear appears the recall + no more manufacturing of Avui-Q. The auto-injector issues that caused the recall were untraceable/not replicatable at the Sanofi factory - and seem to be based on descriptions user error driven - and lower than the user error/failure rate of EpiPen. Meanwhile, Sanofi isn't the inventor - Kaléo/pair of brother founders is/are, and they brought nearly the exact same injector technology to market by themselves for heroin overdose. Sanofi just licensed the technology - and in the wake of the recall, decided to forfeit the license. I'm wondering how much of that deal's provisions killed the Auvi-Q, since it appears the issues behind the injector are long term fixable and profitable)
It would seem to me that a government-mandated market expansion would require a counter-balancing price regulation, but maybe my sense of reciprocity is misplaced.
https://www.indiegogo.com/projects/allergystop-affordable-ep...
The co-pay is a part of the price of the product that your insurer doesn't cover, so technically it's not theirs to begin with. Which is also why it's not a refund of the deductible paid, because that -is- considered part of the insurance contribution, i.e:
(deductible paid by customer + insurance payment) = your insurance contribution co-pay = your personal contribution to the cost of the treatment.
Here's a street view image: https://goo.gl/maps/hUAUUEJwiQT2
It's still clearly a scam against the insurance companies, whether actual fraud charges would stick in court or not.
Deductibles, co-pays, and co-insurance are all separate things with specific definitions:
A deductible is a portion of covered medical expenses that the insured must pay. It is specifically defined as the amount of covered benefit that must be incurred and paid by the insured before benefits become payable by the insurer.
Key in the above is "a portion of covered medical expenses".
A copayment is a flat dollar amount that the insured pays each time a certain kind of service is received. The copayment is not a percentage of the total cost, as it is in coinsurance, but rather is always the same dollar amount even though the cost of the service may vary (a pharma co-pay of $x, regardless of the variable drug price).
It may seem like nit picking, but there are specific reasons for the difference.
Source: myself, who writes and maintains health insurance claims management and adjudication software.
This is all separate to your claim: of course, if your doctor agreed to charge you $x+200 (leaving aside the reality of negotiated and contracted fee schedules) and refund you that $200, then absolutely yes - this is insurance fraud.
However, the co-pay does not form part of the insurance coverage.
If you charge $X more for an Epipen vs. the market rate for a generic epinephrine autoinjector but offer a $X discount for uninsured persons (or a smaller $Y discount for those with copays or deductibles), it is the same scam.
Maybe not legally, but effectively.
There's no fraud, because that's how the insurer defined the separation themselves (for other reasons).
Is there a reason you think the price should be lower? (remember people working need money too)
Insurance companies don't practice neurology.
I assure you, we still wait 3+ months to see a specialist.
If this were free markets and capitalism, wouldn't the response be a flood of alternatives at 1/100 or even 1/10 the price since the base ingredient costs pennies, and not this self serving and crafty effort to leech tax payer subsidies? This is organized corruption.
When you let people feed on others desperation you create demons. This is the biggest argument for socialized healthcare.
Basically:
This feels like a House of Cards-like strategy: take up an unpopular selfish position only to later use its most vociferous opponents as leverage in maintaining that strategy.