No not really. Just allow euthanasia and be done with it. Yes. there are moral grounds to it. You don't want to live life, why can't you just do it peacefully?
I barely want to live another day of life at the age of 36 :/
The report-writer must have been from Goldman Sachs' B-team. It takes five minutes to turn up ample evidence which demonstrates that curing patients can be extremely profitable.
Take, for instance, Harvoni -- a drug introduced in late 2014 which cures Hepatitis C following a single course of treatment. It has done something like $100B in revenue for Gilead Biosciences, and, minimally, earned them $7-10B in profit. (Possibly much more than that.) Its pricing was scandalous, but that's not the issue here; the point is that it was unequivocally one of the most profitable drug launches in history.
Sure, the eradication of Hep C might make it "unsustainable" -- but it's not as though there's a lack of other diseases or maladies to contend with. Take the profits and plant new seeds, buy new technologies, develop new drugs. Besides, the research and development of new drugs has never been a stable business model, and never truly sustainable off one discovery, on account of patent expiry terms, generic competition, etc.
Meanwhile over in the world where the government sinks a lot of money and energy into its citizen's healthcare, government-funded labs are exploring permanent cures for all kinds of problems via genetic therapy.
But not here. Someone's gotta make mad bank off of every aspect of this shit here.
It doesn’t matter if it is a sustainable business. People will do what they can to maximize their income now. If 10 companies are withholding a cure to milk the patients, any one of them can break from that strategy at any time, with near-instant financial reward and competitive advantage. It is not a stable equilibrium.
“Solution 1: Address large markets: Hemophilia is a $9-10bn WW market (hemophilia A, B), growing at ~6-7% annually.”
“Solution 2: Address disorders with high incidence: Spinal muscular atrophy (SMA) affects the cells (neurons) in the spinal cord, impacting the ability to walk, eat, or breathe.”
“Solution 3: Constant innovation and portfolio expansion: There are hundreds of inherited retinal diseases (genetics forms of blindness) … Pace of innovation will also play a role as future programs can offset the declining revenue trajectory of prior assets.”
It's easy to handwave "capitalism makes curing patients unsustainable" but here we have three strategies for sustainable cures that have a positive impact on society.
e.g. Curing blind children is profitable, since there's so many genetic reasons a child would be blind that you can keep introducing new cures reapplying the same technology.
The analyst is stuck in the past. Genomic solutions are personalized medicine. As long as there are new people, and new combinations of genes, there will be problems to solve.
That questions belies a misunderstanding of how the pharmaceutical industry works and I'm having a hard time figuring out if the journalist made a mistake or the report was written by someone with little experience in the industry (I haven't read it).
Since we've mostly run out of small molecule drugs, the (vast?) majority of drugs are developed outside the pharmaceutical industry by biotechs funded by VCs and public investors. It's a well understood pipeline now that takes IP from university tech transfer to VC biotech to pre-revenue* IPO with the final exit being an acquisition by a pharmaceutical company, which comes in with the manufacturing infrastructure to take the drug from phase III trials or approval to the mass market. Once a drug is approved (or the phase III is very promising like Sofosbuvir), pharmaceutical companies trip over each other trying to buy the IP. The industry has offloaded most of the scientific risk to VCs and the public while sharing the rewards with those investors.
As long as the number of pharmaceutical companies doesn't drop to oligopoly/cartel levels and capture the regulators completely, the incentives are strong for one pharmaceutical company to buy a cure and take it to market to undercut a competitor's treatment. Even if an oligopoly develops, since there's no "product market fit" risk and zero scientific risk once a drug is approved, financing the purchase is trivial and starting a new pharmaceutical company to compete with the oligopoly is relatively easy. The manufacturing bit is no joke but the amount of money involved even with a single drug makes starting up a new pharmaceutical competitor totally worth it, since the manufacturing and quality control is a well understood engineering problem.
On top of that, it's practically impossible for every pharmaceutical company to have a drug that treats the same thing without a ton of consolidation in the market. Drug approvals often use active-comparators and standard of care controls that raise the bar for each new drug on the market that treats the same thing. A cure on the other hand is essentially just competing against a single golden standard (there are many exceptions but it's a good rule of thumb).
Another factor is pricing. Treatments are generally priced based on how they impact quality of life because that decides how much insurers are willing to pay, especially the big state healthcare providers that have to do hard cost benefit calculations. If a treatment is making bank, the ceiling for what you can charge for a cure is a significant fraction of the lifetime cost of the treatment, and not just based on the QOL impact. It creates a strong incentive for both investors and insurers to get the cure to market.
* If you think unprofitable tech IPOs are bad, most biotechs that IPO do so with zero revenue, let alone profit. Usually to fund clinical trials.
I feel kinda bad for the writer, because it's a good question: no, curing patients is not a good business model, just like public transit is not a good business model.
What a lot of folks neglect are N+1-order effects, because those are harder to quantify and fail to reach the predetermined decision some executive or board or shareholder has already made. Is curing patients a bad business model? Sure, for the biotech company it is, but those cured patients are far more likely to go on living longer, healthier lives, and in turn contribute additional value to society - which will impact others in ways that may also create additional value. That doesn't even get into the jobs and value created through the R&D process, testing, manufacturing, logistics of delivery, ongoing monitoring, etc. As long as the value created is more than the cost of the treatment, then it's a net-gain for the economy even if it's a net loss for that singular business.
If all you're judging is the first-order impacts on a single business, you're missing the forest for the trees.
> If all you're judging is the first-order impacts on a single business, you're missing the forest for the trees.
Sounds like typical American C-Suite thinking. From what I can see, maybe Chinese companies see further, and that may just be because the government is so powerful, over there, and the government is known for taking the long view.
Public transit is a great business model, what are you talking about? The only time it seems to be a bad business model is when governments take it over and run it. Transit relies on recurring customers paying you basically every day, or subscribing. It has a reliable, stable revenue stream which is relatively inelastic, which are generally precursors for a good business model
> those cured patients are far more likely to go on living longer, healthier lives, and in turn contribute additional value to society
That's not true for diseases that hit those at or near retirement, which is probably most of them. They are mostly drawing pensions without contributing much economically.
Note 1: This is just stating economic facts, not advocating any ghoulish policy.
Note 2: I expect that Note 1 will be ignored.
There are also higher order effects in terms of business model - if you look at the broader business model of health care.
A concrete examples abound in the infectious disease space - many antibiotics are curative of something that would otherwise be fatal - and while there isn't a huge amount of money in antibiotics it has in effect contributed to the larger market of older people's diseases like cancer.
Every intervention simply delays death - and the older you get the more health care you need.
>As long as the value created is more than the cost of the treatment, then it's a net-gain for the economy even if it's a net loss for that singular business.
Specifically on this - this is pretty much how pharma companies negotiate prices with governments - using quality adjusted years of life or saving from alternative costs.
> If all you're judging is the first-order impacts on a single business,
However you do have to pay the companies involved otherwise the activity doesn't happen ( as the companies will go bust and cease to exist ) - cf lack of significant research into new antibiotics.
I think this is a bad argument for socialized healthcare (Which I am 100% for BTW).
Look at retired people, they contribute very little to society. From a purely economical POV, letting them die is the correct course of action. I, and many others, find this morally abhorrent. We should provide healhcare because it is the correct thing to do, not because it is economically viable. The whole point of a society is for its members to live better lives collectively than they would individually, not to maximize some abstract value.
So, determine democratically how much resources we should pool into healthcare and distribute that fairly among ourselves, on an as-needed basis. That's how it works in much of the 1st world, and it works reasonably well. Better than in America, that's for sure, as can be seen by the higher life expectancies and cheaper medicine overall.
The question is: If a capitalist (or agent in a capitalist system) has a choice between a) investing to produce/producing a cure, or b) investing to produce/producing a more-or-less working symptomatic relief, how many agents/capitalists (in decision-making positions) go for choice B, which essentially turns them into legal drug pushers with a money-printing license?
Capitalist system solve this with competition. If there is already market of people paying for more-or-less working symptomatic relief then it's proof these people are actually a good market to sell a cure for x100 price of relief.
We get threads about this on HN a couple times a year, and I feel like people have never thought this through. The company that cures T1D or MS will make approximately eleventy jillion dollars. The mustache-twirlers engineering MS into a chronic manageable disease rather than curing it would simply be outcompeted and put out of business by the straight-mustached cure owners. If you believe the mustache-twirlers are capable of suppressing knowledge of a viable cure, I'm going to have fun selling you on a lot of more-plausible conspiracy theories; for instance, the faked moon landing, which would have required less collusion and been less impactful to the world.
In a strict sense, curing a single disease isn't a long term "sustainable business", because you'll eventually push the population of affected patients below a threshold of profitability. The premise of a major pharma company is that they keep finding other treatments.
Of course it's sustainable. Gilead Sciences is a $155B company originally built on a single drug (Sovaldi) that literally cures Hepatitis C. Now they are more diversified and have a stacked pipeline. The business model just changes to one like oil or mining exploration where you find a deposit with a limited lifespan and you have to keep the treadmill going to find new ones before the mother lode that funds your firm is all tapped out and you go bust.
But while it makes for amazing ragebait and threads full of grievances aired against the healthcare system in general, I think the question isn't very relevant because in Biotech, this is dynamic already essentially forced, cure or not, because of *patent life*. A perfect example of this is Lipitor and Pfizer. Lipitor was not a cure. Statins do not cure you. But it was the most profitable drug of all time. But it eventually went off-patent and now the average price on GoodRX for a 30 day supply is only $6. Pfizer stock has never recovered from that success, though they certainly have a sustainable business.
The modern-day Pfizer is Merck. Merck has probably the most profitable drug in world history (Keytruda) which is far more profitable than Lipitor, and which has massively increased remission rates for a wide range of cancers, so it's somewhat of a cure as well. But that patent life is about to expire, and 46% of Mercks revenue will disappear with it. Of course, new people are diagnosed with cancer every day, and Keytruda will continue to be prescribed in the millions, but Teva and others will sell the generic version and Merck will lose out on the revenue. So the race is on to get more things through their pipeline, acquire some promising assets, and keep the treadmill going. There are 100+ year old mining and oil companies. None are mining the same asset they had one day one, but this doesn't make the industry unsustainable.
The problem with investors these days is that too many of them seem so focused on short-term gains and showing their numbers increase quarter-over-quarter that we seem to be incapable of looking at an investment over a longer period of time.
>Where an incident pool remains stable (eg, in cancer) the potential for a cure poses less risk to the sustainability of a franchise.
Precisely. Sustainable tech and research must focus on long term disease development, and not merely those already available to the medical industrial complex for continuous revenue. When was the last time we developed a truly new and novel lifelong, chronic but not overly debilitating illness with profitable methods of providing minor alleviation of symptoms? Diabetes is mostly tapped out, cancers are too unpredictable.
Frankly? Covid-19 was a squandered opportunity. There was ample raw material to work with truly innovative medical developments in both pharmaceuticals and medical equipment: long term wearable ventilators with expensive filters that must be regularly replaced; new over the counter medications with rapid half lives for maximum daily dose consumption— heck, bring back otc cough medicine with opioids! Damned effective and great stickiness of user base with only minor churn even after the cough is gone! Instead? Vaccines. Such a waste. The only saving grace there is the massive boost the anti vax community got out of it, so I can at least cross my fingers on a measles come back tour.
This reminds me of the new-ish treatments that promise to regrow tooth enamel or prevent the growth of bacteria that causes cavities. These won't get widespread adoption until the American Dental Association or whatever says they're safe/effective, but there's a clear conflict of interest because it would have a huge negative impact on their members' business model.
There's money to be made selling a cure, but the creative destruction that it can bring will mean entrenched interests will fight tooth and nail (pun intended) to delay it.
There are 190+ other countries that can also approve it (or that aren’t organized enough to care about drug approvals). If there was an amazing treatment working in Lichtenstein, we’d hear about it.
Depends on the market. Everyone dies eventually. Every near-fatal illness you suffer is a windfall for the medical system and ensures another windfall later.
For all other businesses, it's a little more complicated. If the patient/employee's knowledge, connections, etc, are valuable enough, then keeping them alive and mentating appropriately is inherently good for the business. The question then is "How do you measure 'enough'?"
44 comments
[ 6.4 ms ] story [ 59.5 ms ] threadI barely want to live another day of life at the age of 36 :/
Take, for instance, Harvoni -- a drug introduced in late 2014 which cures Hepatitis C following a single course of treatment. It has done something like $100B in revenue for Gilead Biosciences, and, minimally, earned them $7-10B in profit. (Possibly much more than that.) Its pricing was scandalous, but that's not the issue here; the point is that it was unequivocally one of the most profitable drug launches in history.
Sure, the eradication of Hep C might make it "unsustainable" -- but it's not as though there's a lack of other diseases or maladies to contend with. Take the profits and plant new seeds, buy new technologies, develop new drugs. Besides, the research and development of new drugs has never been a stable business model, and never truly sustainable off one discovery, on account of patent expiry terms, generic competition, etc.
But not here. Someone's gotta make mad bank off of every aspect of this shit here.
e.g. Curing blind children is profitable, since there's so many genetic reasons a child would be blind that you can keep introducing new cures reapplying the same technology.
It’s not sustainable for businesses who rely on sickness.
Grow up Goldman.
Since we've mostly run out of small molecule drugs, the (vast?) majority of drugs are developed outside the pharmaceutical industry by biotechs funded by VCs and public investors. It's a well understood pipeline now that takes IP from university tech transfer to VC biotech to pre-revenue* IPO with the final exit being an acquisition by a pharmaceutical company, which comes in with the manufacturing infrastructure to take the drug from phase III trials or approval to the mass market. Once a drug is approved (or the phase III is very promising like Sofosbuvir), pharmaceutical companies trip over each other trying to buy the IP. The industry has offloaded most of the scientific risk to VCs and the public while sharing the rewards with those investors.
As long as the number of pharmaceutical companies doesn't drop to oligopoly/cartel levels and capture the regulators completely, the incentives are strong for one pharmaceutical company to buy a cure and take it to market to undercut a competitor's treatment. Even if an oligopoly develops, since there's no "product market fit" risk and zero scientific risk once a drug is approved, financing the purchase is trivial and starting a new pharmaceutical company to compete with the oligopoly is relatively easy. The manufacturing bit is no joke but the amount of money involved even with a single drug makes starting up a new pharmaceutical competitor totally worth it, since the manufacturing and quality control is a well understood engineering problem.
On top of that, it's practically impossible for every pharmaceutical company to have a drug that treats the same thing without a ton of consolidation in the market. Drug approvals often use active-comparators and standard of care controls that raise the bar for each new drug on the market that treats the same thing. A cure on the other hand is essentially just competing against a single golden standard (there are many exceptions but it's a good rule of thumb).
Another factor is pricing. Treatments are generally priced based on how they impact quality of life because that decides how much insurers are willing to pay, especially the big state healthcare providers that have to do hard cost benefit calculations. If a treatment is making bank, the ceiling for what you can charge for a cure is a significant fraction of the lifetime cost of the treatment, and not just based on the QOL impact. It creates a strong incentive for both investors and insurers to get the cure to market.
* If you think unprofitable tech IPOs are bad, most biotechs that IPO do so with zero revenue, let alone profit. Usually to fund clinical trials.
What a lot of folks neglect are N+1-order effects, because those are harder to quantify and fail to reach the predetermined decision some executive or board or shareholder has already made. Is curing patients a bad business model? Sure, for the biotech company it is, but those cured patients are far more likely to go on living longer, healthier lives, and in turn contribute additional value to society - which will impact others in ways that may also create additional value. That doesn't even get into the jobs and value created through the R&D process, testing, manufacturing, logistics of delivery, ongoing monitoring, etc. As long as the value created is more than the cost of the treatment, then it's a net-gain for the economy even if it's a net loss for that singular business.
If all you're judging is the first-order impacts on a single business, you're missing the forest for the trees.
Sounds like typical American C-Suite thinking. From what I can see, maybe Chinese companies see further, and that may just be because the government is so powerful, over there, and the government is known for taking the long view.
That's not true for diseases that hit those at or near retirement, which is probably most of them. They are mostly drawing pensions without contributing much economically.
Note 1: This is just stating economic facts, not advocating any ghoulish policy. Note 2: I expect that Note 1 will be ignored.
Of course it is, if you charge the right price, just like “building and selling (not leasing out) houses” can be a good business model.
No subscription or 2nd order effects needed.
A concrete examples abound in the infectious disease space - many antibiotics are curative of something that would otherwise be fatal - and while there isn't a huge amount of money in antibiotics it has in effect contributed to the larger market of older people's diseases like cancer.
Every intervention simply delays death - and the older you get the more health care you need.
Specifically on this - this is pretty much how pharma companies negotiate prices with governments - using quality adjusted years of life or saving from alternative costs.
> If all you're judging is the first-order impacts on a single business,
However you do have to pay the companies involved otherwise the activity doesn't happen ( as the companies will go bust and cease to exist ) - cf lack of significant research into new antibiotics.
That's why the above happens.
Look at retired people, they contribute very little to society. From a purely economical POV, letting them die is the correct course of action. I, and many others, find this morally abhorrent. We should provide healhcare because it is the correct thing to do, not because it is economically viable. The whole point of a society is for its members to live better lives collectively than they would individually, not to maximize some abstract value.
So, determine democratically how much resources we should pool into healthcare and distribute that fairly among ourselves, on an as-needed basis. That's how it works in much of the 1st world, and it works reasonably well. Better than in America, that's for sure, as can be seen by the higher life expectancies and cheaper medicine overall.
The question is: If a capitalist (or agent in a capitalist system) has a choice between a) investing to produce/producing a cure, or b) investing to produce/producing a more-or-less working symptomatic relief, how many agents/capitalists (in decision-making positions) go for choice B, which essentially turns them into legal drug pushers with a money-printing license?
In a strict sense, curing a single disease isn't a long term "sustainable business", because you'll eventually push the population of affected patients below a threshold of profitability. The premise of a major pharma company is that they keep finding other treatments.
2018: 448 points, 370 comments https://news.ycombinator.com/item?id=16827248
2021: 104 points, 100 comments https://news.ycombinator.com/item?id=27184116
But while it makes for amazing ragebait and threads full of grievances aired against the healthcare system in general, I think the question isn't very relevant because in Biotech, this is dynamic already essentially forced, cure or not, because of *patent life*. A perfect example of this is Lipitor and Pfizer. Lipitor was not a cure. Statins do not cure you. But it was the most profitable drug of all time. But it eventually went off-patent and now the average price on GoodRX for a 30 day supply is only $6. Pfizer stock has never recovered from that success, though they certainly have a sustainable business.
The modern-day Pfizer is Merck. Merck has probably the most profitable drug in world history (Keytruda) which is far more profitable than Lipitor, and which has massively increased remission rates for a wide range of cancers, so it's somewhat of a cure as well. But that patent life is about to expire, and 46% of Mercks revenue will disappear with it. Of course, new people are diagnosed with cancer every day, and Keytruda will continue to be prescribed in the millions, but Teva and others will sell the generic version and Merck will lose out on the revenue. So the race is on to get more things through their pipeline, acquire some promising assets, and keep the treadmill going. There are 100+ year old mining and oil companies. None are mining the same asset they had one day one, but this doesn't make the industry unsustainable.
Precisely. Sustainable tech and research must focus on long term disease development, and not merely those already available to the medical industrial complex for continuous revenue. When was the last time we developed a truly new and novel lifelong, chronic but not overly debilitating illness with profitable methods of providing minor alleviation of symptoms? Diabetes is mostly tapped out, cancers are too unpredictable.
Frankly? Covid-19 was a squandered opportunity. There was ample raw material to work with truly innovative medical developments in both pharmaceuticals and medical equipment: long term wearable ventilators with expensive filters that must be regularly replaced; new over the counter medications with rapid half lives for maximum daily dose consumption— heck, bring back otc cough medicine with opioids! Damned effective and great stickiness of user base with only minor churn even after the cough is gone! Instead? Vaccines. Such a waste. The only saving grace there is the massive boost the anti vax community got out of it, so I can at least cross my fingers on a measles come back tour.
There's money to be made selling a cure, but the creative destruction that it can bring will mean entrenched interests will fight tooth and nail (pun intended) to delay it.
This, in a nutshell, is the problem with for profit medicine. If the training signal is money then money will be optimized.
For all other businesses, it's a little more complicated. If the patient/employee's knowledge, connections, etc, are valuable enough, then keeping them alive and mentating appropriately is inherently good for the business. The question then is "How do you measure 'enough'?"