Now I’m European so bare with me and my “Stalinist” ways, but I don’t see why something so essential to society is in the hands of corporations rather than the public.
Research? You could buy a lot of research for the amount of money we’re currently spending on medicine in healthcare and right now we’re really just paying a corporate tax to save lives so that some 1%’et can get even richer.
You're absolutely, completely, 100% right. That amount of money could buy an incredible amount of research!
Right now, the American government institutions that fund this kind of research are infamous for being very risk-averse. They fund research, but do so in a way that takes few chances. Younger researchers get shut out. Researchers chasing novel ideas often get shut out. After all, why fund some moonshot when there's someone with a good track record of results to fund instead?
Basically, there's ample reason to doubt that the American institutions in question could actually do better if they were handing out the funding. Oh, and the grant-giving bureaucracy is also infamous.
Are there alternatives? Well... * Large charities (the Gates Foundation, for example) might be able to fund development of drugs, but would be most likely to focus on a limited number of high-return, lower-risk opportunities. The Foundation's annual total spend ($4.6Bn in 2016) is roughly half of one large Pharma company's R&D spend (https://www.roche.com/research_and_development.htm), so they've clearly not got the clout to enter general drug development. * Governments might be able to enter this space, but then you're betting that a government can do it cheaper/better than big Pharma, which is a major gamble, even before you get into arguments about public- vs. private-sector efficiency. You then also run into the challenge of governments not being great at making major long-term visionary investments in a 4/5-year election cycle, the electoral unpopularity of such an approach if drugs fail, and the ethical requirement of firewalling the government development arm from the drug approval (i.e. public-health-safeguarding) arm. And again, you've got to find the money: sure, Roche's drug development spend per year is only ~a tenth of the UK NHS's annual budget... but that's a super-cash-strapped health service - diverting 10% of its budget to maybe improve things in 10 years would be a tough sell.
Any avenues I'm missing?
(Now... fully agree that it would be possible for government or non-profits to enter the generic space, but... the majority of generics make pennies, if anything, and are certainly not cash cows. For every one 'bad' case that's brought to the public attention, be it a rare antibiotic, or the price of adrenaline pens, there are countless thousands of other examples which aren't a problem. So you'd need a very flexible generics strategy to only focus on these rare 'problem' cases... and this might not even always be scientifically or legally possible.)
http://www.pewtrusts.org/en/research-and-analysis/fact-sheet...
This is money that could have been spent on R&D instead of advertising if we moved to a non-profit pharmaceuticals model.
I think people vastly overestimate their physicians' ability to stay on top of newly published research, and that includes new drugs' safety and efficacy profiles. If I want the stuff I work on to reach patients (and I do), then I want doctors to know about it. In the absence of pharma marketing dollars aimed at doctors and patients, I would like if there were some way to bring doctors the new information. Maybe that should be handled by a third party that doesn't have the interests of pharma companies in mind, funded by all of the drug companies at the time of a new drug approval.
Motivation is primarily to restrict crazy-expensive drugs to those situations where they're actually going to represent value for (the public's) money, but also to point clinicians towards new approaches which can improve the quality of treatment.
So hugely expensive advertising towards physicians is not the only way to do it.
Don't assume that all doctors are committed to making the latest advances (or even older advances) available to patients. They are human, just like all of us, and you'll find stubborn doctors on the conservative (or laggard) end of the spectrum just as much as within any other group or career.
There is no logical reason why we shouldn't prefer an older generic medication if it treats the symptoms of a condition just as effectively and with fewer side effects than a newer option that is no more effective and has more side effects, but doing what is best for patients has to compete against the profit motive of our pharmaceutical companies.
There are checks on this, and I'm not sure if you are thinking of a particular case, but I can't really see how this would happen. In order to get approval, a new drug almost always has to demonstrate that it is at least "non-inferior" to the standard of care. Additionally, there is a lot of pressure in the United States from payers. Insurance companies just won't pay for a drug that is in no way better than the previous standard of care with more detrimental side effects. There are definitely cases where the FDA made a mistake for one reason or another (allowed an entity to move through the wrong approval mechanism, were duped by fraudulent AE reports and didn't catch it, failed to require the appropriate screens for AEs, etc), but the system has some checks on drug companies.
Does Purdue Pharma's decision to push opioids as a safe treatment for everyday pain ring a bell?
https://www.newyorker.com/magazine/2017/10/30/the-family-tha...
Oxycontin was certainly profitable, but it was not good for patients with chronic pain.
This is a case where a Pharma company deliberately misled doctors, patients and regulators because doing so was exceptionally profitable.
>The company that makes the narcotic painkiller OxyContin and three current and former executives pleaded guilty today in federal court here to criminal charges that they misled regulators, doctors and patients about the drug’s risk of addiction and its potential to be abused.
All of its meta-analyses and treatment guidance are available at http://www.nice.org.uk, if you want to explore.
Considering that in 2010, Forbes estimated that the cost of bringing a single drug to market, was between $4-11 billion dollars, you are buying between 2-6 extra drugs per year.
(https://www.forbes.com/sites/matthewherper/2012/02/10/the-tr...)
But that fails to account for the fact that the number of drugs doctors and patients have to choose from currently is staggering, and both groups have proven hesitant to switch to new therapies, and so by not advertising new drugs, the amount of money that can be made dramatically decreases, which further impacts the ability for pharma companies to invest in R&D.
No one thinks it is ludicrous for Google or Apple to throw as much money as they do at marketing. Its capitalism, and if you have a problem with it fine, but it isn't evil for pharma companies to work under the same model that every other industry on the planet has and which has been the driving force of the planet for the last several centuries.
We need one additional drug that treats said condition better than the existing options, but with less side effects.
The profit motive distorts what is best for patients.
For sure, there are plenty of examples (do we need that many statins? do we need so many beta blockers?) to suit your narrative, but you're also missing the huge sums spent and strides taken in other areas, such as oncology. If you don't show a meaningful benefit here, your drug is a failure - it's that simple.
Let's assume, for a moment, that the people running these Pharma companies aren't stupid. We can therefore assume that they will mostly make sensible decisions on how to spend money. It therefore follows that a company calculates that by spending $X on promotion, they'll recoup $X+$Y, where Y is the additional revenue thanks to their promotion, over and above what they'd have made without promotion - i.e, their promotional spend is a worthwhile investment for them.
For each company individually, therefore, promotional spend can be reasonably assumed to generate greater revenue and profit, some of which will be used to fund research into new medicines.
Now, like you, I'd much rather live in a world where there was no promotional spend, and correspondingly lower drug prices... but that's not the current world. And pointing a finger --'but, marketing, sales reps'-- at promotion is not the full story.
Having the pharmaceutical industry arrange everything around the notion of "what is more profitable to us" leads them to ignore the notion of "what is best for patients with this condition".
If unbiased studies show that their treatment is more effective and has less side effects than existing options, then it should become the usual treatment for that condition.
Otherwise, no amount of advertising and promotional activity on their part makes sense when approached from the notion of what is best for patients.
In the case of promoting Oxycontin to treat chronic pain, real harm has been done.
https://www.thebalance.com/who-funds-biomedical-research-266...
Some would suggest that the drug companies actually take on the lower risk research, leaving the high risk work to be funded by other sources:
http://www.latimes.com/opinion/op-ed/la-oe-1027-mazzucato-bi...
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There are different routes by which new drugs are discovered, but very simplistically, we can break them down to two:
1) a researcher somewhere (not in Pharma) comes up with some positive research that might eventually result in the new drug for some disease. To develop this finding, often they will create (spin off) a new private company, and somehow generate funding. The extent to which the original funding institution benefits from this research is likely variable, based on the legal framework and contracts under which the researcher was operating. (And frankly, if a university or other institution doesn't benefit from such a discovery it funded in its labs... they're not doing something right.)
2) a pharmaceutical company funds its own discovery operations, which work to discover new targets and/or drugs for those targets
--
#1 is unpredictable, but can result in great new discoveries which are brought to market --and thus patients-- relatively cheaply (like in the hundreds of millions, rather than billions)
#2 is difficult, and very expensive, but mostly works - some pharmaceutical companies grind out drug after drug. However, ultimate success is less certain, and cumulatively, considering the cost of discovery operations as well as subsequent development, the cost is usually in the billions per successful new drug.
This is also why we're seeing a switch to a mixed model: big Pharma is increasingly spending big on smaller biotech operations with promising drug candidates, as a way of minimising risk.
Would it be permitted to travel to the UK (or somewhere closer) and buy the medicine, then bring it back? Or even order online, there's at least one British pharmacy that can deliver abroad.
Getting through the border and back on foot was a bit of a hassle, and it's probably not a good idea to "bring" too much stuff, but it was a fun experience anyway :-)
And many, if not most, of these medicines are fake. Especially Viagra.
If you get medicine in Mexico, you have to bring your old prescriptions and compare the two. Luck for me, my regular medicine is a cream for my psoriasis that comes in a box that I can take down there and compare the two. If the boxes look too different, I pass on it.
As a non-American (UK and Australia citizen) it bewilders me that this is considered a possibility.
Why are hospitals doing the opposite to offering the best care possible to all citizens? Are they for-profit in the US?
Contrary to sibling comments, no, they generally are not. Most (58.5%) US hospitals are private nonprofits, and another 20.2% are public. Only 21.3% are private, for-profit. [0]
[0] https://www.beckershospitalreview.com/hospital-management-ad...
"A study published in the May issue of Health Affairs revealed that in 2013, seven of the top ten most profitable hospitals in the United States were nonprofit hospitals, with each earning over $163 million in profits from patient care."
https://www.forbes.com/sites/brucelee/2016/05/08/very-profit...
(Forbes, yuck, I know. This Washington Post link covers the same story: https://www.washingtonpost.com/news/to-your-health/wp/2016/0...)
That article links to a CBS "investigation" into the University of Pittsburgh Medical Center, which claims to be a nonprofit but made $948 million from 2011 to 2012, pays its CEO $6 million a year, gets a private chef, chauffeur, and a jet for additional compensation, and has a dozen other administrators each making over a million dollars a year.
https://www.youtube.com/watch?v=zikgppxCFnA
Claiming themselves to be a nonprofit saves them about $200 million in state and federal taxes. So, they're just an "accidentally profitable" nonprofit.
But yeah, sure, let's just keep taking the health care industry at its word when it says it's not profitable.
edit: more, because why use a scalpel when a hammer will work just as well?
"Many nonprofit hospitals calculate their charitable care by using something known as “charge master” pricing; exorbitant, non-negotiated prices which are inflated many times higher than what private insurance or Medicare would pay. This allows facilities to overstate their provision of “charity care,” calculated as revenue loss by the hospital in exchange for their lucrative tax exemptions. In a patient evaluated with chest pain, the allowable for Medicare is $3600; however, in an uninsured patient, the hospital may “write-off” an inflated $25,600 in uncompensated costs, which is 8 times higher than actual cost of care provided."
http://thehealthcareblog.com/blog/2017/04/25/the-fairy-tale-...
"But even many hospitals that showed losses on patient care had positive margins overall. The study found that median net income per adjusted discharge from all activities—including investments, charitable contributions and space rental—was $353 for all hospitals and $178 for hospitals with 50 or fewer beds."
http://www.modernhealthcare.com/article/20160502/NEWS/160509...
"Non-profit is instead simply a tax status, and specifically, it exempts hospitals from paying real estate and other taxes in exchange for contributing a fixed portion of their revenues to ‘community benefit’ rather than paying dividends to shareholders. ... Cleveland Clinic, one of the largest health systems in the country, was held up as an example of a wildly profitable non-profit in a recent article in Politico."
https://www.acsh.org/news/2017/07/19/non-profit-hospitals-ca...
(read that one, it's a good breakdown of the accounting that hospitals use to maintain their nonprofit status while behaving in every other way like any other for-profit business.)
No, they're not.
> they're just using Hollywood accounting and referring to their profits as "excess earnings".
No, they aren't. Excess earnings are the correct technical term. Non-profit status, even in theory, has nothing to do with whether you earn more in revenue than you expend in costs, it has to do with whether there are stockholders or others who have a claim on accumulated returns.
More specifically, charitable nonprofits (which non-profit hospitals are) have a wide variety of additional requirements and restrictions (both in general, and specific additional requirements for hospitals, including several added by the ACA.)
> read that one, it's a good breakdown of the accounting that hospitals use to maintain their nonprofit status while behaving in every other way like any other for-profit business.
No, it's just a bunch of dishonest, or perhaps merely clueless, mischaracterizing; the most obvious example being considering money expended in providing Medicaid services but not covered by Medicaid reimbursement as money the hospital “paid to itself” rather than an external benefit. This isn't money the hospital paid to itself, it's money the hospital paid out to provide services under a public program providing healthcare to the medically indigent but which was not reimbursed by that public program (in general, Medicaid is a money-losing program for providers, as—while there are some exceptions—reimbursement is generally at the lowest of three things: a state set rate, the actual cost of providong the service, or the provider's usual and customary charge for the same or substantially similar service. This is at best break even, but over all, across all providers, it's always going to be, in practice, below actual cost.
You can deny things all you want. The behavior of some "non-profit" hospital chains is out of line with what the public and the government considers appropriate for non-profits, and constitutes tax abuse.
And the simple fact that a non profit can spend 6M USD on compensation to its CEO loudly advertises the healthcare provider market inefficiency.
I'm pretty convinced the market for CEOs in general is broken, but it's also the case that largely eliminating CEO compensation wouldn't move prices much in any business.
The other aggravating factor is that most mutual insurance companies have also converted to a for profit model that reinforces the incestuous coupling between pharma and medical providers. There is no voice left who has an interest in lowering costs.
Yes, with few exceptions.
Here's how this goes: "But if they weren't for-profit, then it would be more like Canada's or England's health care, and I've heard you have to wait months for anything over there. Also it would mean they wouldn't have as much money for innovation, and, y'know, the US has the best health care technology in the world. Oh, sure, only the rich can afford it, but if you're poor you can still go to a hospital and they won't turn you away."
There, that's every single defense of our system, in one paragraph. I don't think I missed anything.
Now, pardon me, I need to go throw up.
> England
You mean Britain.
It wouldn’t be HN without a rant correction.
And you may not be aware but “Each of the UK's health service systems operates independently, and is politically accountable to the relevant government: the Scottish Government; Welsh Government; Northern Ireland Executive; and the UK Government, responsible for England's NHS.”
If anything, a comparison with England is probably more appropriate :)
At the moment.
You raise a good point about drug companies not being the sole source of predatory pricing in US healthcare. US healthcare is in the neighborhood of $3T whereas drug spending is around $300B, though drug spending is going up faster than health spending overall.
My father had good insurance. He went in for a spider bite. He needed to stay the night. I arrived and he thanked me for Teddy Bear, and flowers. I told him I didn't send you anything. He said, "Well someone did?"
Weeks later he called me up, and said the gift shop on the hospital send the gift, and charged the Insurance company $230. Billed under something like "psychological affirmations".
Any who--they are thieving entities. It kills me when I meet people, with no assets, who pay their inflated hospital bills out of American pride? They are so strong in their convictions, I don't even bring up a chapter 7. I understand they save live, but don't financially ruin patients.
One other memory. I went in for something. I had great insurance, so I didn't worry about the bill. They gave me a blood test. A week went by, and I got a bill for $900. I called my union, and they the hospital didn't know I had insurance.
My union said my bill would be $10. She said the hospital sent them the bill of $100, and I would pay my 10 percent. I asked, "Why do they only charge you $100?" She said, "It's about Collective Bargaining. Yea--I find it shocking too."
This should be a reasonable rule if people want to keep capitalist system healthcare. Its not stopping them competing, only applying a transparent and level playing field to the market.
I can't praise the EU enough for making this happen, and making sure said price is written big letters :)