One of my kids was on a medication that was super expensive, unless you used a coupon. The doctor didn’t tell us anything about a coupon, we had to find out from the people working at the pharmacy when we went to pick it up. It turned out to be quite a bit of work to find the coupon and print one off, but it greatly slashed the price.
My Dad's doctor was wonderful he worked with drug companies and was able to get my Dad's medication heavily rebated to the point his health coverage covered the difference. Anything else could be claimed on taxes.
Dad would have had to pay about $40K for Esbriet (for IPF a lung disease), and $1,700 per dose once every two weeks for Humira. And other drugs too like morphine, prednisone, laxatives and so on. But basically it ended up being almost $0.
Doctors do and can help a lot with drug costs. At least here in Canada the US who knows doctors probably get more in drug sales than anything.
homero was not disputing that doctors can help, they were pointing out that the expectation of a doctor to know the ins and outs of someone's particular insurance plan and pricing of particular medicines is not reasonable, therefore irrational bringing up how the doctor neglected to mention a coupon in their story is an irrelevant detail since there should not be any expectation of doctors knowing about coupons for the medicine.
Just like there should not be an expectation for the doctor knowing and telling you there is a coupon for vegetables at the grocery store if they tell you to eat more vegetables. If the doctor does know it, that is a bonus.
Doctors are in the business of helping people get healthy. And unfortunately in the US this is tied very tightly with finances.
If a doctor in the US wants to be great at their job, they can’t ignore the financial component of their work — obviously some exceptions here like the doctors who work fee-for-service on the rich.
No idea why you're being down-voted, as I agree completely.
If a doctor recommends a treatment that the patient can't afford, and the patient doesn't discover that until days later at the pharmacy, that likely results in wasted time for all involved. The patient has to meet with the doctor again to discuss cheaper alternatives. Or forgo treatment, and risk more significant health problems, which lead to more cost in the future.
My dermatologist almost always discusses the costs of treatments. One example - a topical cream is available as name-brand or generic. The generic is formulated at a higher strength but costs less. So, I can pay more for a gentler, slower treatment. Or save money, but get a harsher treatment. Both work fine, but after selecting the harsh generic once, I won't do that again - it works faster, but the side-effects were miserable.
This. It isn't the Doctors responsibility to know all the prices of things and such, they should know what meds you need for your ailment. I would say it would be good if your doctor found out about something (via a pharmaceutical rep or another patient) to pass that along, but not sure it makes sense for them to necessarily know the ends and outs of the current best coupon.
Medical pricing is so hopelessly complicated that few doctors can even tell you what a procedure at they perform themselves at their own hospital will cost you. I don’t know how they could keep up with pricing for thousands of drugs interacting with formularies across hundreds of insurance plans.
At least on the Rx side, it's really not that hard to have a general idea. Youre prescribing mostly the same medication over and over and patients give feedback, so knowing a general discount card price isn't difficult.
If the patient has a weird formulary or a high deductible, that's on them to understand.
A good doctor should be considering how to get the best outcome for a patient, availability and affordability is paramount if you intend to get a patient to follow through with a treatment. No, it's not the doctors "job" to make sure you can get your medication, but I don't think it's hard to argue a doctor that takes these things into consideration is better than one that lives in a bubble.
For run of the mill meds, my doctors haven't mentioned considering price, but for an autoimmune issue that required very expensive medication, my doctor helped me participate in a manufacturers program that covered anything my insurance wouldn't over $50 a month.
As it turned out, my insurance wouldn't cover it at all, because they wanted me to try a cheaper, older medicine that had a much worse list of potential side effects.
If it hadn't been for my doctor, I wouldn't have known about the aid program or to enroll in it (technically, it was through a separate, non-profit legal entity, but it still has the manufacturs name in it).
Dr. H. Jack Geiger famously wrote prescriptions for groceries out of his clinic in Mississippi - when challenged on the practice, he replied, "Yeah, well, the last time I looked in my medical textbooks, they said the specific therapy for malnutrition was food."
The best doctors understand that a patient is an entire person, not just some specific problem or disease. Sometimes that means considering factors in their life other than the obvious direct medical causes of their problems. Sometimes that might include the availability of treatments, based on cost or location.
Famous because it's folksy nonsense, not because it pioneered medicine.
> Sometimes that might include the availability of treatments
this is about coupons. your doctor won't help you write your resume, even if they could and it would help you afford medicine in the future. That isn't their domain.
Some doctors are like you're describing. I posit that the best doctors are ones who realize that the domain of "health" is broad and encompasses things that aren't germs.
Geiger believed that the greatest threat to public health of his day was nuclear war, so he founded an organization (Physicians for Social Responsibility) to try to stop it, because he thought that would be more effective than waiting for the bombs to fall and trying to treat the victims.
You can disagree with his assessment, or the efficacy of his methods, but it's pretty unfair to dismiss them as "nonsense".
It feels like you are being deliberately obtuse. This is not about taxes. A doctor who does everything that another doctor PLUS making sure you can afford your medications and will be able to take them appropriately will be a better solution for many people than just a doctor who doesn't do that. That is all.
> PLUS making sure you can afford your medications
ok.
> This is not about taxes
why not? Maybe you are missing the point I am making, but then you are selectively not responding to things I already wrote, that I think I outlined pretty clearly in the last post.
what is out of scope here? Where does it end? You suggest a doctor should do more somehow, but doesn't say where the limit is, if any. the point is your own arguments seem to apply to taxes, resumes, coupons etc as much as anything else more medically related.
I think it's pretty rich complaining about me being "obtuse", when you fail to address the main point of my posts.
I think taxes are out of scope but I do not think knowing medications are out of scope. I would call the medications reasonable and the taxes unreasonable. Maybe that is the limit?
Sure, it would be better, but it's not relevant because you described two different jobs. In theory, the best doctor would do everything: diagnose diseases, install your dishwasher, rotate your car tires, give you a pedicure. But as it is, pharmacists are the ones whose job it is to know and give you advice about this stuff.
I have had private doctors in the UK, Canada, Thailand, and Dubai all make sure I understand there are cheaper generics available of what they're prescribing, and many have also helped me understand where I can use pill cutters and other solutions to mean they can prescribe me more to save me money and make traveling cross-borders easy.
The whole pharmacy coupon thing is an almost entirely American phenomenon. US and NZ are the only countries that allow direct-to-consumer marketing of drugs in the first place.
That's fair, however both my dermatologist and GP have started discussing the price of drugs they're recommending. It's an unfortunate effect of the state of medical care (the entire system) in the US.
True, but they often know the mechanics of the system and a hint that there might be a coupon would be almost zero work for them but incredible benefit to the recipient.
But they do get influence from the pharma companies, and might end up getting kickbacks for it. See the whole Auvi-Q situation, which discounts price to patient to zero, but charges far more than it's sensible to the insurance company: In practice insurance rates go up for everyone, the doctors that prescribe the expensive drug get more money, and the patient's discount make them pick said expensive drug.
I've had very serious pushes from doctors to get medication like this.. the doctor was absolutely aware of the economics involved, including what was good for him. I thought I was not at a doctor's office, but dealing with a used car salesman.
Coupons like that come from the manufacturer, and are given to doctors by drug sales representatives. Many practices don't allow drug reps any more, so the doctors in those practices don't learn about the coupons.
Disclosure laws curb the worst historical excesses, and there are good arguments in favor of further restrictions. Good reps serve an educational purpose, and when the medicines available to treat a disease have evolved dramatically, that education can be necessary.
For example, there are still primary care physicians who just go to sulfa drugs then insulin after metformin. There are much better medicines that actually protect other organ systems too! But they didn't learn about them in med school, and it takes some consistent nudging to get them to break the old prescribing habits.
This is a good thing, regardless of whatever else Amazon is doing.
Large organizations do not monolithically fit one description or judgment. Amazon does lots of other questionable or downright malicious things. This is not one of those.
Honestly this has been one of my thoughts with Amazon getting into prescriptions in the first place.
A lot can be said about Amazon and thats valid, but they do put a lot of focus on their customers.
We can argue that them doing this likely means that they will get more business and that will also prop up the rest of their prescription offerings, but that goal ultimately has a benefit to people that need this medication.
If they can apply this to copay cards and anything else that saves people who need these medications (by that I mean just all medications across the board) money but Amazon still gets their money, it would be huge. The system sucks right now.
The problem is, if you read the stories, Amazon is turning pharmaceutical work into basically another warehouse job of high quotas and speed. To the point that pharmacies just ignore Amazon's requests to transfer meds because Amazon would use autodialers to call pharmacies, and then put the called on pharmacy on hold until the single pharmacist on call at Amazon picks up that call after dealing with dozens of others at the same time. Meanwhile wasting the time of the other pharmacies.
This is just Amazon trying to grow their pharmacy business at all costs. What they are doing in this specific example is a good thing, but who knows what the fallout will be.
Excellent point. It's easy (in the US, at least) to take the widespread availability of pharmacies in grocery stores, street corners, etc for granted. It's not difficult to see Amazon squeezing the industry enough to make a pharmacy in a grocery store unsustainable.
YMMV. But I live in the Seattle area and it seems like the major chains (CVS, Walgreens, Rite Aid) are all doing the same and their pharmacists are quitting in droves.
Rite Aid just bought a beloved local chain and now everyone I know has switched because it’s been run into the ground.
But when a competitor is a behemoth who is able to eat losses until they drive competitors out of business (and has a track record of doing so) so that competition (and customer experience quality) declines in the long run, that's the rare-but-true case of "a new competitor entering the market is bad, actually".
Yeah, seriously. More competition, and monopsony do not dwell in the same space. We’ve been very lax in our reigning in of big companies that destroy competition while claiming they’re competitive. It’s like bringing a gun to a track meet and saying you won the race while one racer lies bleeding on the ground and every other racer has suspiciously slow times.
You say that as if Amazon would be the manufacturer of these drugs. There's a difference between a pharmacy and a drug manufacturer. In this case Amazon is just the pharmacy.
There is an extremely common claim (disclaimer: I haven't noticed experiencing it myself) that Amazon Retail often ships fake products when the real ones are purchased. The concern isn't that Amazon _itself_ is manufacturing poor-quality goods(/drugs) - it's that Amazon's quality control for their suppliers is poor.
I used to think medicine shipped to my door was great too. That is, until I lost my job. My benefits were cut off immediately (the company did a layoff at the end of the month on purpose) and I could no longer access my medication. Despite having a script with the company and plenty of refills from my doctor they outright refused even if I paid cash. I ended up going 2 weeks without medication and having to get an ER doctor to write me a new script. my primary wanted an entirely new visit to rewrite an existing script because they didn't believe my story.
Between this and being treated like a junkie when I need a hold-over dose of a non-addictive non-narcotic medication makes me hate the cards I was dealt. Pharmacists are complicit in this even though they frame themselves as victims of the system as well. Those kickbacks from drug companies and doctors are just too damn good.
Anyone who actually deals with the medical system knows these services are not a universal good. I always advise people to stick with GoodRx and a local (physical) location for medication so you don't get you medication promptly cut off when (not if) you lose benefits.
Your experience sounds terrible, and I am sorry you had to go through that.
To be clear, the thing that I am saying is good is the topic of the article at hand, Amazon automatically applying discounts for insulin. This is orthogonal to their delivery methods.
I consider the idea of applying discounts for medical products amoral customer hostile actions.
Who wins? The people who are granted the knowledge or seek the knowledge themselves. The sellers of these medical products too because they get to advertise the coupon applied price of their product and...
Who loses? The people who are not granted the knowledge or don't seek out the knowledge. Perhaps they don't know the system is a game and there ways of circumventing prices. Perhaps they're desperate for the life giving medication.
Overall USA's medical industry is very opaque and anti-competitive in general. It really really sucks. I'd love it if we rearranged the system such that capitalistic market forces could do its work, such as letting consumers price shop. Its very frustrating.
The problem is that discounts are just a somewhat benign face of a system that is a mess because you have lots of incentives in the wrong place.
Basically discounted medicines are medicines being sold at the market price insurance companies pay in practice. But there’s an incentive for insurance companies for list prices for medicines to be sky high, and given the market power of insurers as buyers, those incentives extend to manufacturers.
Then you have an ideological and advertising machine that convinces patients that things are the way they are because America is the best possible world, and everything in America is necessarily better/more advanced/higher quality then in any other place.
I’ve seen people who really believe that American insulin is absurdly more expensive than in the rest of the world because it is of higher quality. But mind you, even in Western Europe, that arguably has even more stringent standards for a lot of things than the USA, insulin is absurdly less expensive than in America. Do people really believe that people in Switzerland and Norway are getting inferior insulin compared to the “exceptional” American insulin?
>Basically discounted medicines are medicines being sold at the market price insurance companies pay in practice. But there’s an incentive for insurance companies for list prices for medicines to be sky high, and given the market power of insurers as buyers, those incentives extend to manufacturers.
This goes way beyond insurance companies. There's an entire class of middlemen known as PBMs (Pharmacy Benefit Managers). They are probably the largest contributor to medication pricing being a complete scam and disaster in the US.
Of course the scam is so profitable that CVS now owns both an insurer (Aetna) and a PBM (Caremark).
PBMs are so bad, that in some circumstances, pharmacies can owe the PBM money after dispensing a drug.
The PBMs are who contracts with pharmacies over which insurance plans will be accepted. Basically pharmacies have to take the contracts as a whole and do the math over if they'll win or lose across the whole contract. Really only a few companies have the ability and leverage to negotiate somewhat fairly with the PBMs. On top of this, the major PBMs are now all owned by insurance companies so the difference between the PBM and insurance companies are kind of nebulous, and with this consolidation pushes the power more to the insurance company.
The US insulin market is a regulatory and legislative failure.
If you’re a biotech investor with a few billion dollars to burn, sure, a high-margin, high-volume biologic looks like an appealing bet.
But then you look at what’s involved in the FDA approval process even after Congress added carveouts for bio-similar generics.
And at the end of that billion dollar gauntlet, there’s Congress insisting that, damn-the-market and our own regulatory hurdles, insulin is so important it must be sold at a modest fraction over cost of production. This is a life saving substance, to which many who can certainly afford to pay would ascribe considerable value (this is the “demand” in supply & demand). The result of these price controls will inevitably be shortages, which will be blamed on the same greedy capitalists who are being blamed for the state of a market ultimately structured by this same Congress.
The fact is that in a sizable portion of the world (and I am not talking about Cuba, China or some leftist south american government, I am talking about western europe, and western european countries with a higher GDP per capita and higher HDI than the US, like Switzerland, Sweden and Norway)
a) Insulin is cheaper, a fucking lot cheaper
b) Its prices (along with a lot of other drugs) are regulated.
I haven't yet heard from my friends in Switzerland, Norway or Belgium any sad story about people rationing their insulin supplies because it is mind bogling expensive, and shortages are also unheard of.
Insulin is basically a solved problem. I don't care about an hypothetical techbro sad story of how he won't invest his billions to disrupt the insulin market because bad government doesn't allow it to sell untested products.
>But there’s an incentive for insurance companies for list prices for medicines to be sky high, and given the market power of insurers as buyers, those incentives extend to manufacturers.
This does not make any sense to me. If the price for a medicine decreases, then the insurance company's costs decrease. Why would a higher "list" price benefit insurers?
Obviously, manufacturers would like prices for medicine to increase, as that would cause their revenue to increase. But that has nothing to do with insurance companies.
Because the price for the insurance company is already heavily discounted. Keeping the prices high for out-of-insurance customer ensures that you're doubly penalized for not having insurance.
Interesting how Amazon uses “Automated Discounts” to get around “Usual and Customary” prices. Typically, pharmacies only get reimbursed by PBMs (middlemen between insurers, manufacturers, and pharmacies) up to a maximum of of their U&C price so their incentive is to set it really high in order to maximize reimbursement rates.
Amazon’s GoodRX-style discount cards gets around this by basically charging a spread over the reimbursement and kicking back some portion of the spread to the PBMs. By making the price an “Automated Discount” to some number between the U&C price and the reimbursement price, Amazon can charge less without impacting their reimbursement rates while paying the PBMs off.
This is a huge simplification of the US’s broken pharmaceutical system, obviously. One example of the nuances here is that Amazon is probably not able to set the price of the discounted drug.
For most people, the PBM is just a department of the managed care organization (MCO, aka health insurance company) that deals with medicine. So not much of a middleman in those cases.
UHC has OptumRX, Elevance Health has Carelon, CVS has Caremark, Cigna has Express Scripts, Humana has Humana Pharmacy Solutions, etc.
The biggest PBM not owned by MCOs is probably Prime Therapeutics, and they are hired by all the smaller BCBS plans that are not big enough to operate their own PBM, I presume.
But you can ignore a lot of the complexity these days due to consolidation. What used to be a health insurance company selling insurance for medical procedures only, and outsourcing the task of of evaluating coverage and negotiating prices for medicines to a third party known as pharmacy benefit managers, PBMs, is many times no longer outsourced.
Hence the term "managed care organization" (MCO) to supplant "health insurance company". Because now, the same business that sells the insurance can also employ the pharmacist, negotiate pricing for medical procedures and medicines, and employ the doctor providing the healthcare in some cases.
From a patient perspective, you and/or your employer pay the MCO, the MCO pays the doctor and/or pharmacist if the service/medicine is covered, and you pay the deductible/copay and this counts towards your out of pocket maximum.
Kaiser Permanente is an MCO that owns healthcare delivery from hospital to doctors to pharmacies. Some MCOs own more of the healthcare chain than others, and on the other side, you have hospital and doctor groups consolidating to be able to negotiate more favorable terms with increasingly larger MCOs.
The pharmacy pays the medicine distributor (such as Cardinal or McKesson or Amerisource Bergen), and the medicine distributor pays the medicine manufacturer (Pfizer, Merck, NovoNordisk, etc).
Most pharmacies themselves are owned by huge entities. Such as the largest retail pharmacy, CVS, which itself is an MCO. Next up is probably Walmart, Kroger, Costco, Albertsons, and then you have the last 2 big standalone retail pharmacies, Walgreens and Riteaid.
Looking at market capitalization graphs for Walgreens and Riteaid will inform you of how "up or out" the business is.
Thanks! I believe there are some interesting startup opportunities in this space, but is muddy as hell and scary to get into due to built up complexity over the decades.
It's an end run around re-imbursement rates for insurance and how the pharmacy benefit managers get paid. Basically an artifact of why capitalism sucks.
This is price discrimination/segmentation. You want to sell the same product at different prices to different people. And because it is medicine, you do not want (too many) poor people to miss out on getting it, or at least you want plausible deniability for trying to make the product available to poorer people.
Enter manufacturer coupons, PBMs, and myriad government and health insurance reimbursement policies. The whole system is an emergent phenomenon of trying to deliver different quality/quantity of healthcare to different populations, but for political purposes, maintaining plausible deniability that society (via its elected leaders) is okay with some people getting less healthcare than others (or paying more or less than others).
You are conflating crony capitalism with free market capitalism. If we are going to argue in terms of pure theory (which you are) then more competition, and therefore the free market, would select for systems that reduce friction between the customer and their wallet. Crony capitalism is what happens when a mixture of regulatory capture, unhinged corporate lobbying, and greed combine to form a trifecta of fuck for everyone else.
A common trope among anti-capitalists is they conflate capitalism in practice (i.e. crony capitalism) with actual free market capitalism (the theoretical construct).
When debating semantics like you are the difference between these two is fundamentally important.
> You are conflating crony capitalism with free market capitalism.
Phrased a different way: discussing capitalism as it actually always has been, and as the term was coined to refer to, in the real world instead of nonsense fantasy that isn't implementable in reality, and which was only constructed as a distraction from that reality to deflect criticism of the real-world system.
This is an artifact of capitalism driven healthcare. It's only an issue in the U.S. It's the end results of incentive's designed to extract money vs incentives designed to provide healthcare. (i.e. capitalism)
Simple, Tovarisch. No medications are available. Many of the comrades are counting and re-counting wheat berries in the already scarce tillable fields. We have no private property so smart chemists will not produce more than the minimum medications as ordered by the Chairman. The capitalist doctors were sent to the gulag for working outside of the three clinics we have.
I've been wondering why Mark Cuban's drug company - which takes a cost plus model, doesn't make insulin. It seems like a market that is likely growing, effectively has no substitutes, and you need it to live. Is it hard to manufacture? It's been around for 50+ years so I'd think they can make it efficiently by now, but perhaps not?
It's been around about a century. It's difficult to manufacture a consistent biosimilar insulin. Regulation, physicians and patients all place a high premium on consistency and especially avoiding inconsistent doses that cause hypoglycemia. Additionally, the manufacturers, physicians and patients all push to move to new insulins as often as they become available, reducing the demand for generics (which is why, even though Walmart and Costco sell cheap over-the-counter insulin, almost no one uses it.)
One interesting project to watch is the partnership between Civica and the state of California to produce quality generic insulin. CA obviously has deeper pockets than Cuban was willing to commit to Cost Plus, so hopefuly the partnership will be more fruitful.
Insulin sold today is not the same bovine insulin that was originally patented 100 years ago.
Insulin needs to be affordable, but the trade-off we’re seeing (and that comments like this leave out) is that insulin development continues to move forward, with the new stuff being significantly better than what came before it. The $25/vial no Rx stuff at Walmart requires much more discipline and attention than the stuff that is hundreds of dollars per dose. This is the market sending signals that better insulin is worth developing.
It is amazing that there is so much discourse around insulin with such a basic errooneous assumption- that "insulin" is just insulin and completely fungible.
Several people have raised the point that if the discounts are automatic why not just change the pricing? Pharmaceutical pricing and a lot of healthcare pricing in general are strange in the sense that they are organized to capture what certain plans/institutions will pay. If there is a plan out there that says "we will pay $540 for a month of lifesaviex" you are going to see prices at $540 or above to capture that even if in other contexts some patients are getting it at $35 a month. There is a lot to potentially discuss about that but cherry picking one interesting thing... Many very large employer plans are administrated by the insurance companies names you are familiar with, Anthem, United, etc. However the details of the plan, including reimbursements, are actually set by people at the employer, not the plan. There is someone in the giant beauracracy at these companies who compiles/edits/approves a massive spreadsheet and out into the market it goes. Mistakes are common.
In a similar vein, some poorly thought out reimbursement rate setting by CMS/HHS related to drug testing wasted at least 216 million dollars. A virtual cottage industry sprung up around it while it was in effect. It was not an isolated incident.
That doesn't really answer the question. I think there must be some important details missing from the article and your explanation, like does Amazon know the customer has a plan, or qualifies for some discount somehow?
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[ 2.7 ms ] story [ 139 ms ] threadDad would have had to pay about $40K for Esbriet (for IPF a lung disease), and $1,700 per dose once every two weeks for Humira. And other drugs too like morphine, prednisone, laxatives and so on. But basically it ended up being almost $0.
Doctors do and can help a lot with drug costs. At least here in Canada the US who knows doctors probably get more in drug sales than anything.
Just like there should not be an expectation for the doctor knowing and telling you there is a coupon for vegetables at the grocery store if they tell you to eat more vegetables. If the doctor does know it, that is a bonus.
If a doctor in the US wants to be great at their job, they can’t ignore the financial component of their work — obviously some exceptions here like the doctors who work fee-for-service on the rich.
If a doctor recommends a treatment that the patient can't afford, and the patient doesn't discover that until days later at the pharmacy, that likely results in wasted time for all involved. The patient has to meet with the doctor again to discuss cheaper alternatives. Or forgo treatment, and risk more significant health problems, which lead to more cost in the future.
My dermatologist almost always discusses the costs of treatments. One example - a topical cream is available as name-brand or generic. The generic is formulated at a higher strength but costs less. So, I can pay more for a gentler, slower treatment. Or save money, but get a harsher treatment. Both work fine, but after selecting the harsh generic once, I won't do that again - it works faster, but the side-effects were miserable.
If the patient has a weird formulary or a high deductible, that's on them to understand.
As it turned out, my insurance wouldn't cover it at all, because they wanted me to try a cheaper, older medicine that had a much worse list of potential side effects.
If it hadn't been for my doctor, I wouldn't have known about the aid program or to enroll in it (technically, it was through a separate, non-profit legal entity, but it still has the manufacturs name in it).
The best doctors understand that a patient is an entire person, not just some specific problem or disease. Sometimes that means considering factors in their life other than the obvious direct medical causes of their problems. Sometimes that might include the availability of treatments, based on cost or location.
https://en.wikipedia.org/wiki/H._Jack_Geiger
https://www.nytimes.com/2020/12/28/health/h-jack-geiger-dead...
> Sometimes that might include the availability of treatments
this is about coupons. your doctor won't help you write your resume, even if they could and it would help you afford medicine in the future. That isn't their domain.
Doctors are specialists.
Geiger believed that the greatest threat to public health of his day was nuclear war, so he founded an organization (Physicians for Social Responsibility) to try to stop it, because he thought that would be more effective than waiting for the bombs to fall and trying to treat the victims.
You can disagree with his assessment, or the efficacy of his methods, but it's pretty unfair to dismiss them as "nonsense".
not exactly the same as founding an ethics foundation in their own field
> who realize that the domain of "health" is broad and encompasses things that aren't germs.
what things? mental health? still medical, and still deferred to specialists.
Coupon hunting? Resume writing? not medicine.
ok.
> This is not about taxes
why not? Maybe you are missing the point I am making, but then you are selectively not responding to things I already wrote, that I think I outlined pretty clearly in the last post.
what is out of scope here? Where does it end? You suggest a doctor should do more somehow, but doesn't say where the limit is, if any. the point is your own arguments seem to apply to taxes, resumes, coupons etc as much as anything else more medically related.
I think it's pretty rich complaining about me being "obtuse", when you fail to address the main point of my posts.
The whole pharmacy coupon thing is an almost entirely American phenomenon. US and NZ are the only countries that allow direct-to-consumer marketing of drugs in the first place.
I've had very serious pushes from doctors to get medication like this.. the doctor was absolutely aware of the economics involved, including what was good for him. I thought I was not at a doctor's office, but dealing with a used car salesman.
1) you're guilt tripping them
2) you're giving them cover if they get asked about it
It's much nicer to work at a grocery store pharmacy than a dedicated retail chain because of this
Disclosure laws curb the worst historical excesses, and there are good arguments in favor of further restrictions. Good reps serve an educational purpose, and when the medicines available to treat a disease have evolved dramatically, that education can be necessary.
For example, there are still primary care physicians who just go to sulfa drugs then insulin after metformin. There are much better medicines that actually protect other organ systems too! But they didn't learn about them in med school, and it takes some consistent nudging to get them to break the old prescribing habits.
Large organizations do not monolithically fit one description or judgment. Amazon does lots of other questionable or downright malicious things. This is not one of those.
A lot can be said about Amazon and thats valid, but they do put a lot of focus on their customers.
We can argue that them doing this likely means that they will get more business and that will also prop up the rest of their prescription offerings, but that goal ultimately has a benefit to people that need this medication.
If they can apply this to copay cards and anything else that saves people who need these medications (by that I mean just all medications across the board) money but Amazon still gets their money, it would be huge. The system sucks right now.
This is just Amazon trying to grow their pharmacy business at all costs. What they are doing in this specific example is a good thing, but who knows what the fallout will be.
Excellent point. It's easy (in the US, at least) to take the widespread availability of pharmacies in grocery stores, street corners, etc for granted. It's not difficult to see Amazon squeezing the industry enough to make a pharmacy in a grocery store unsustainable.
Rite Aid just bought a beloved local chain and now everyone I know has switched because it’s been run into the ground.
But when a competitor is a behemoth who is able to eat losses until they drive competitors out of business (and has a track record of doing so) so that competition (and customer experience quality) declines in the long run, that's the rare-but-true case of "a new competitor entering the market is bad, actually".
Between this and being treated like a junkie when I need a hold-over dose of a non-addictive non-narcotic medication makes me hate the cards I was dealt. Pharmacists are complicit in this even though they frame themselves as victims of the system as well. Those kickbacks from drug companies and doctors are just too damn good.
Anyone who actually deals with the medical system knows these services are not a universal good. I always advise people to stick with GoodRx and a local (physical) location for medication so you don't get you medication promptly cut off when (not if) you lose benefits.
To be clear, the thing that I am saying is good is the topic of the article at hand, Amazon automatically applying discounts for insulin. This is orthogonal to their delivery methods.
Who wins? The people who are granted the knowledge or seek the knowledge themselves. The sellers of these medical products too because they get to advertise the coupon applied price of their product and...
Who loses? The people who are not granted the knowledge or don't seek out the knowledge. Perhaps they don't know the system is a game and there ways of circumventing prices. Perhaps they're desperate for the life giving medication.
Overall USA's medical industry is very opaque and anti-competitive in general. It really really sucks. I'd love it if we rearranged the system such that capitalistic market forces could do its work, such as letting consumers price shop. Its very frustrating.
Basically discounted medicines are medicines being sold at the market price insurance companies pay in practice. But there’s an incentive for insurance companies for list prices for medicines to be sky high, and given the market power of insurers as buyers, those incentives extend to manufacturers.
Then you have an ideological and advertising machine that convinces patients that things are the way they are because America is the best possible world, and everything in America is necessarily better/more advanced/higher quality then in any other place.
I’ve seen people who really believe that American insulin is absurdly more expensive than in the rest of the world because it is of higher quality. But mind you, even in Western Europe, that arguably has even more stringent standards for a lot of things than the USA, insulin is absurdly less expensive than in America. Do people really believe that people in Switzerland and Norway are getting inferior insulin compared to the “exceptional” American insulin?
This goes way beyond insurance companies. There's an entire class of middlemen known as PBMs (Pharmacy Benefit Managers). They are probably the largest contributor to medication pricing being a complete scam and disaster in the US. Of course the scam is so profitable that CVS now owns both an insurer (Aetna) and a PBM (Caremark).
PBMs are so bad, that in some circumstances, pharmacies can owe the PBM money after dispensing a drug.
Is the theory that PBM’s are foolishly generous and incur undue costs for their clients the insurance companies?
Or that they’re foolishly stingy, and force pharmacies to offer unsustainably low prices?
When the PBM is owned by the insurer in the first place, it is a moot point. The 5 biggest health insurers all have their own PBM.
If you’re a biotech investor with a few billion dollars to burn, sure, a high-margin, high-volume biologic looks like an appealing bet.
But then you look at what’s involved in the FDA approval process even after Congress added carveouts for bio-similar generics.
And at the end of that billion dollar gauntlet, there’s Congress insisting that, damn-the-market and our own regulatory hurdles, insulin is so important it must be sold at a modest fraction over cost of production. This is a life saving substance, to which many who can certainly afford to pay would ascribe considerable value (this is the “demand” in supply & demand). The result of these price controls will inevitably be shortages, which will be blamed on the same greedy capitalists who are being blamed for the state of a market ultimately structured by this same Congress.
a) Insulin is cheaper, a fucking lot cheaper b) Its prices (along with a lot of other drugs) are regulated.
I haven't yet heard from my friends in Switzerland, Norway or Belgium any sad story about people rationing their insulin supplies because it is mind bogling expensive, and shortages are also unheard of.
Insulin is basically a solved problem. I don't care about an hypothetical techbro sad story of how he won't invest his billions to disrupt the insulin market because bad government doesn't allow it to sell untested products.
This does not make any sense to me. If the price for a medicine decreases, then the insurance company's costs decrease. Why would a higher "list" price benefit insurers?
Obviously, manufacturers would like prices for medicine to increase, as that would cause their revenue to increase. But that has nothing to do with insurance companies.
Amazon’s GoodRX-style discount cards gets around this by basically charging a spread over the reimbursement and kicking back some portion of the spread to the PBMs. By making the price an “Automated Discount” to some number between the U&C price and the reimbursement price, Amazon can charge less without impacting their reimbursement rates while paying the PBMs off.
This is a huge simplification of the US’s broken pharmaceutical system, obviously. One example of the nuances here is that Amazon is probably not able to set the price of the discounted drug.
Some reading: https://www.drugchannels.net/2020/08/how-goodrx-profits-from...
UHC has OptumRX, Elevance Health has Carelon, CVS has Caremark, Cigna has Express Scripts, Humana has Humana Pharmacy Solutions, etc.
The biggest PBM not owned by MCOs is probably Prime Therapeutics, and they are hired by all the smaller BCBS plans that are not big enough to operate their own PBM, I presume.
For example
https://www.reddit.com/r/pharmacy/comments/33ac79/what_is_th...
But you can ignore a lot of the complexity these days due to consolidation. What used to be a health insurance company selling insurance for medical procedures only, and outsourcing the task of of evaluating coverage and negotiating prices for medicines to a third party known as pharmacy benefit managers, PBMs, is many times no longer outsourced.
Hence the term "managed care organization" (MCO) to supplant "health insurance company". Because now, the same business that sells the insurance can also employ the pharmacist, negotiate pricing for medical procedures and medicines, and employ the doctor providing the healthcare in some cases.
From a patient perspective, you and/or your employer pay the MCO, the MCO pays the doctor and/or pharmacist if the service/medicine is covered, and you pay the deductible/copay and this counts towards your out of pocket maximum.
Kaiser Permanente is an MCO that owns healthcare delivery from hospital to doctors to pharmacies. Some MCOs own more of the healthcare chain than others, and on the other side, you have hospital and doctor groups consolidating to be able to negotiate more favorable terms with increasingly larger MCOs.
The pharmacy pays the medicine distributor (such as Cardinal or McKesson or Amerisource Bergen), and the medicine distributor pays the medicine manufacturer (Pfizer, Merck, NovoNordisk, etc).
Most pharmacies themselves are owned by huge entities. Such as the largest retail pharmacy, CVS, which itself is an MCO. Next up is probably Walmart, Kroger, Costco, Albertsons, and then you have the last 2 big standalone retail pharmacies, Walgreens and Riteaid.
Looking at market capitalization graphs for Walgreens and Riteaid will inform you of how "up or out" the business is.
I don't think Amazon is "making" the price to some number. It's just applying the manufacturer discount automatically
Is the discount conditional on something that's not mentioned in the article?
This is price discrimination/segmentation. You want to sell the same product at different prices to different people. And because it is medicine, you do not want (too many) poor people to miss out on getting it, or at least you want plausible deniability for trying to make the product available to poorer people.
Enter manufacturer coupons, PBMs, and myriad government and health insurance reimbursement policies. The whole system is an emergent phenomenon of trying to deliver different quality/quantity of healthcare to different populations, but for political purposes, maintaining plausible deniability that society (via its elected leaders) is okay with some people getting less healthcare than others (or paying more or less than others).
A common trope among anti-capitalists is they conflate capitalism in practice (i.e. crony capitalism) with actual free market capitalism (the theoretical construct).
When debating semantics like you are the difference between these two is fundamentally important.
Phrased a different way: discussing capitalism as it actually always has been, and as the term was coined to refer to, in the real world instead of nonsense fantasy that isn't implementable in reality, and which was only constructed as a distraction from that reality to deflect criticism of the real-world system.
So you replied to my post calling out your theorycrafting saying my theorycrafting is wrong.
Alrighty.
Nope, this is wrong already, befoee getting to the rest.
> This is price discrimination/segmentation.
Firms maximizing profits has... something to do with capitalism
So, the discount is conditional?
How does Amazon know if the user is eligible?
I read the article twice, and nowhere does it say these "coupons" and "pledges" are for some subset of customers.
No medication, no problem. You see, tovarisch!
Edit - did a bunch more digging after posting this. Looks like they gave up? https://www.beckershospitalreview.com/pharmacy/cost-plus-dru...
One interesting project to watch is the partnership between Civica and the state of California to produce quality generic insulin. CA obviously has deeper pockets than Cuban was willing to commit to Cost Plus, so hopefuly the partnership will be more fruitful.
Insulin needs to be affordable, but the trade-off we’re seeing (and that comments like this leave out) is that insulin development continues to move forward, with the new stuff being significantly better than what came before it. The $25/vial no Rx stuff at Walmart requires much more discipline and attention than the stuff that is hundreds of dollars per dose. This is the market sending signals that better insulin is worth developing.
In a similar vein, some poorly thought out reimbursement rate setting by CMS/HHS related to drug testing wasted at least 216 million dollars. A virtual cottage industry sprung up around it while it was in effect. It was not an isolated incident.
https://oig.hhs.gov/oas/reports/region9/92103006.pdf