Hi guys, Alex Oshmyansky here, CEO of the Mark Cuban Cost Plus Drug Company. Crazy to see our little project at the top of Hacker News!
We're planning to introduce a lot more drugs with transparent prices later this year, cutting out monopolistic middlemen in the supply chain and alleviating pharma drug shortages, particularly for rare and orphan disease conditions.
We are looking for a few devs (fullstack, frontend, and backend). If anybody is interested, drop me a line at alex@costplusdrugs.com
In the meantime, happy to answer questions if anyone is interested!
Hi Alex, do you have any plans on selling or attempting to get FDA approval for drugs that are used and known to be safe in other countries, such as the UK?
Our daughter has a life threatening condition that I’ve posted a lot about on, a complication from spina bifida where she holds her breath when she gets upset. Many kids die from the condition.
There’s a medication, piracetam, that a child with the same complication uses in the UK. It’s safe and has greatly helped the little girl in the UK. When we mentioned it to doctors we were immediately shut down and told it was impossible to get in the US.
Any chance of the Mark Cuban Cost Plus Drug Company seeking FDA approval for piracetam and drugs like it?
Hi Wincy, Sorry to drop my comment here without any scientific evidence or any such certification of experience.
But I had a similar condition in my childhood. Many doctors thought it was some form of complicated asthama or something but couldn't figure out what exactly was it.
Then my parents put me in an breathing camp (yoga retreat kind of thing). I was there for six months and we were convinced there that breathing is life. Breathing is the most important thing in and for life. And slowly, the condition disappeared.
The condition was more of an impediment in the brain blocking the breathing command when I got upset unlike some incurable damage to the lungs. Just teaching and reminding us to breath every second for six months made things a lot better.
If there's no such camp/retreat in your country, you could try India.
You both brought up a memory for the first time where as I child I once decided to hold my breathe and started to panic and worry because I didn't seem to be able to start breathing again. I think it was only a one-time thing, and obviously I started breathing again. I wonder how common it is and what the state of a child who experiences this is - it's fascinating.
The problem, and the reason they’re out, is because of the FDA. While I agree in principal I wish I didn’t have to search websites for piracetam that are all out of stock due to customs not letting them through.
My own interest in nootropics is some years behind me now, but I note that Nootropics Depot does have bulk phenylpiracetam powder in stock, and I don't recall filling my own capsules to have been especially difficult. Slow and exacting work, to be sure, but also the kind of work that a good podcast or TV show helps go faster. With a little practice and a good capsule filling machine, you can make a month's worth of doses in a couple of hours - cheaper than buying prefilled capsules, too.
Stories like this would be a game changer for this new company. I genuinely hope they go for it. In a way, it's surprising that there isn't a charity dedicated to this type of effort for drugs considered safe.
The Wikipedia page [0] says piracetam has been around since the 1950s, and was used to treat epilepsy as early as the 50s. Our daughter’s PEAC [1] is a rare complication of a relatively rare disease.
From my very limited understanding of the regulations, a company would have to spend the million+ dollars it costs to get FDA approval, but then wouldn’t be able to recoup that cost by selling the drug exclusively because the patent has long since expired. The US has this class of drugs that just never got approved and no drug company will ever pay to get approved, even if they are commonplace in other nations.
It sounds like we need a mechanism for a company to be granted short term exclusive distribution for drugs that are out of patent but not approved if they sheppard that drug through the approval process.
I had to check if it would fall under Trump's Right to Try Act [0], but sadly it doesn't seem like it would meet the requirements. Perhaps this is something we can continue pushing for more freedom enabling legislation though.
I’m hesitant to reveal how as the FDA had been cracking down recently, but racetams are very popular in the nootropics community. It’s sad too because there’s a huge difference between her with this medicine and without.
A few times we’ve missed a day and it’s not a fun experience. Something as innocuous as a diaper change can mean giving her getting upset, turning blue, pulling out the a bag and mask, and giving her oxygen and hoping she’ll come to. Then she’ll sleep for hours. If it’s especially bad, like it was before, she’ll forget words which is super scary.
Will your company become obsolete once the US removes the ridiculous law that US citizens can't buy drugs from other countries? Every modern country has solved the low price drug problem except the US because of criminal and fraudulent healthcare laws.
Ideally yeah, would be good if we didn't need to exist. There are a variety of policy initiatives the US could likely implement to bring costs down. My kind of mindset with the company though is I am a nobody from nowhere, and congress isn't going to listen to me. I can make cheap / sell medicine at an affordable price though. So I will do that.
I'm not sure drug importation will work though, not because it's a bad policy per se, but I'm not sure that other countries will let the US import their low-cost medicines if US law changes in order to protect their domestic supplies.
There's Canada as an example case. We have ~10x the population of Canada, and California alone could use up all of Canada's medicines. Not sure Canada would go for it.
Think it's worth a shot though. I know there are some trial programs going into place in Colorado and Florida around allowing drug importation. Will be cool to follow and see how they play out.
Makes sense, I always appreciate healthcare companies that capitalize on bad laws saying that ideally they wouldn't exist and they're trying to work within the existing framework.
Cross-border drug buying works well in the EU, where any European country can buy drugs from any other European country, so whoever has the lowest price usually wins the market.
As a private company, your incentive is to maximize profit for shareholders. Since all you have to do is undercut high drug prices a little, what will stop you from the same price gouging that all other US drug companies perform?
Well, there's some technical measures we've taken and some practical ones to ensure we work to be profitable but remain focused primarily on improving public health and helping patients.
On the technical level, we incorporated as a public benefit corporation, so we are judged not only on how profitable we are for shareholders, but how well be maintain our social mission. That is actually in our charter documents and is a legal requirement.
On a practical level, Mark Cuban is our lead investor and his interest is very much focused on helping people and fixing system issues in healthcare. We also did some screening to ensure our other investors are socially minded and prioritize social benefit as well as profits.
My mindset is that we need to be profitable to be sustainable and grow enough to help the overall system, but we won't be extortionate.
> On a practical level, Mark Cuban is our lead investor and his interest is very much focused on helping people and fixing system issues in healthcare.
Probably more "the company begged someone of high visibility to write their name on it".
Cost of advertising is a serious problem for generic drug makers. There are a lot of drugs where there exists an identical, cheaper, generic version, but the more expensive one gets sold because neither the doctors nor the patients have any idea that it exists. Hence all the "ask your doctor for x" ads, but the problem is that advertising on that scale, especially for low-incidence conditions, is very expensive compared to the amount of money you make, an so will result in just another expensive drug.
A celebrity putting their name on a drug company and then maybe mentioning it a few times publicly in places where normal people hear about it may make people who are facing very expensive drug bills look up the site and see if they make something useful for them.
If there’s an actual generic (e.g. Naproxen Sodium :: Alleve), then your doctor just has to ensure that the Rx isn’t “fill as written”. The pharmacist can then offer you options (Namebrand at X times 5 or generic at X)
If it’s the case where there’s an older generic and a newer product still under patent, that’s a discussion with your doctor: Is the newer product worth the money, or should I stick with the older thing?
For some single source drugs the suppliers absorbed some of the subsidies, while others and generics were cheaper for consumers. It is unfortunate that sometimes customer facing subsidies get abused by single source suppliers.
This study is not about drugs per se, but only some oncology drugs that were popular in 2006. It even states "however, generic oncology drug prices showed no significant changes" in the abstract.
That’s selective quoting. The study states in the abstract the top selling drugs saw price increases. Here is the full abstract.
> The results show that the average annual price of top-selling cancer drugs in 2006, adjusted for inflation and secular changes in drug prices, have increased by US$154 and US$235 for branded and competitive brand drugs, respectively, following the 2010 ACA; however, generic oncology drug prices showed no significant changes.
In Italy our representatives negotiates the prices of the important drugs with the pharmaceutical industry, and they have little or no cost for the individual. There are always some very annoying exceptions, of course, but that's the general rule. We all take it for granted and demand it, doesn't matter the political orientation. I think your representatives are not doing a good job (not that ours are better, eh;), and makes me wonder what you vote for, if not for this basic things.
> There's Canada as an example case. We have ~10x the population of Canada, and California alone could use up all of Canada's medicines. Not sure Canada would go for it.
Depends on the country. For example India is the largest generic drug manufacturer and has a population of over 1 billion, and they already export their drugs to many countries.
Would it not be somewhere in the middle though? Instead of completely saying yes or no, maybe Canada would say "We'll allow you to purchase X% of all drugs produced in the country, as we need to hold onto some, but we'd love it if you'd buy the surplus."
Canada produces very little. They are importing it from the big manufacturers. Last time importation from Canada became an issue the companies just said to Canada “we’ll sell you what you bought last year plus 5%.”. Then Canada got to choose - give those drugs to Canadians or sell them to the US. But they can’t do both.
> We have ~10x the population of Canada, and California alone could use up all of Canada's medicines. Not sure Canada would go for it.
Couldn't Canadian drug companies increase supply if the demand was there? In the short term, sure, they would not be able to handle our level of demand, but unless there's some constraint I'm not aware of they could always just scale up and make more animal insulin or whatever.
The history is that Canada used to have "compulsory licensing" for patented drugs. Anyone could manufacture a patented drug in Canada and pay a ?6?% or whatever royalty to the patent owner and they just had to deal with it.
Over the years, first 4, then 10 years of exclusivity were provided to the patent owner.
Then the WTO came along, and presently, everyone has agreed to ~20y exclusivity and charge/pay the median price of OECD countries before it's a royalty-free free-for-all.
Other countries don't solve the problem via re-importation.
Re-importation shouldn't be illegal, but it shouldn't be necessary - it's really kinda dumb. Other countries have solved this problem by making healthcare universal, and forming a bulk purchasing group which strong-arms providers into charging something the system can bear. The end user doesn't have to care how much that is, because most developed countries simply pay for the drugs people need in the first place.
The ideal way to obsolete this problem is to follow their lead - get Medicare for All to happen and restore Medicare's ability to negotiate the price of drugs directly with manufacturers.
Then nobody has to pay for the drugs directly in the first place.
Strong arming is the right term. United Healthcare in the US has 40 million members. Bigger than the entire population of Canada. Yet they can’t negotiate prices anywhere as low.
the bulk prices developed countries in Europe are paying is still much greater than some countries that have a truly free market system. For example, I lived in Tanzania and all drugs were imported and all of them over the counter. Drugs that literally cost thousands of dollars a month in America without insurance would usually come to around $5-10.
I doubt the American people (or American industry) would ever allow such a truly free market system to transpire, but I know for a fact it can work.
Labor is cheaper in Tanzania obviously, but even if you adjusted for the more expensive labor, a free market system (vs the crony capitalist system we have now) would probably be 10-100x cheaper.
Also, even controlling for median wage, the drugs are vastly cheaper in Tanzania vs America. A median worker there might make around $5-10 in wage, so most drugs for a month supply would be only a day of work. Median hourly wage in America of $15 would correspond to drug prices between $60-120 dollars, much cheaper than most medications without insurance. In reality, it should be much cheaper, as the marginal cost can be reduced a lot through online pharmacies (remember that $5-10 cost in Tanzania not only factors in product cost and labor cost, but a staggeringly inefficient distribution network).
In short, I don't believe there's any theoretical reason why generic drugs couldn't be dirt cheap and affordable by all in a free market system. After all, capitalism has done a stellar job at reducing the cost of consumer goods over time, and medication should be no different.
If everyone could buy lightly regulated pills from alibaba, it would definitely be a win from a utility standpoint. But of course such a thing would never fly, as maximizing total utility doesn't get people elected. Everyone might win except one guy who died from bad pills and the whole gig would be up, even though the total utility function of every citizen in aggregate was being correctly maximized.
The strong needs of the few always trumps the weak needs of the many. If everyone paid one $1 dollar per day in order to prevent one death, I'm sure some politician would call it a massive win, even though that's an aggregate loss of 100bn dollars annually and the money saved generated more utility than the utility lost by that one guy dying.
Unfortunately, human beings are unable to make correct statistical/utilitarian decisions and support so many policies that are a net negative utility wise.
Drugs in countries like Tanzania are cheap because drug companies don’t think they can get more money out of it, it’s more of a charity project. They offer them to developing countries well below cost - Tanzania is the 15th poorest country in the world with a GDP per capita of $500 (2011). It’s not an example of a free market.
I'm not sure that's true. Most of the medication I came across came from third rate Russian or Indian suppliers. I highly doubt the sales of drugs from these countries (also poor countries) to another poor country (Tanzania) was charity.
It ain't a charity: after the initial development, drug production is usually very cheap.
Aligning prices with purchasing power allows pharmaceutical companies to get _something_ out of the markets they'd get nothing out of. And with large numbers, that something might turn out to be a bit more.
Third rate Indian suppliers? I’m not sure if you’re implying that the price is low or the quality is poor. If it’s the latter, you don’t know much about Indian pharma companies. Btw, Indian pharma companies selling high quality anti retro viral drugs to African countries at low prices is why HIV is relatively under control right now.
You need to distinguish between drug development and production.
Sure production cost is usually low and that technically allows to sell to poor countries essentially at cost plus a tiny margin.
But that's only half the story. Drugs need to be developed. From idea to market only a tiny fraction of medication makes it. You need studies ovet studies, and most of the time a drug does not make it through that process because it's ineffective or dangerous or both. The few that make it need to compensate for the cost of this process, not just their own but all of those that didn't make it.
So, in "rich" countries, a pill that costs $0.10 to produce can easily cost $1000. That's a necessity to finance the whole process of getting there.
After that is all done and established, sure, you may get that same pill for $1 since it's either that or no sale. But that does not mean the whole system would work for $1 per pill everywhere in the world. Then the pill would not exist in the first place.
See also: region locking in video games. Again, the development costs vastly outweigh the marginal cost of producing an extra unit to sell, so they sell the product at whatever the local market will bear, which breaks down if richer markets have access to supply from poorer ones.
The laws regarding importation from other countries are odd, but they are not what you think they are.
In effect, it's about 're-importation' of drugs, not so much regular import.
The Government of Ontario negotiates drug prices for it's citizens, as to other entities elsewhere.
By selling to XYZ regime at ABC price, drug companies create a situation wherein 'the resulting price will be the lowest price we sell to any regime' - because of course everyone will want to import from there.
In many cases, the price sold to XYA regime isn't quite a very good measure of net market prices.
Ergo, it's a weird law, but it's rational on a level.
To start - there could be a slew of laws requiring transparency on pricing for everything in the medical domain. That would be a good start.
More challenging - Americans could actually get together and start negotiating hard on prices. This may require some legislation.
So the 're-importation' issue is an artifact of an odd system, not in and of itself the issue.
Ontario's a great example of how this problem is usually solved in developed countries.
OHIP negotiates the prices of all drugs on behalf of Ontarians by being the sole purchaser, and then drugs are sold at that rate (cost plus, I believe) in pharmacies. Further, the cost of all services is listed on the OHIP website. [1] Not that anyone needs to worry about that as they are fully covered for everyone - not the drugs (yet, fingers crossed), the procedures.
However of course consider delays in getting a drug to market aren’t always provincial; Health Canada has their own timelines and schedules for approvals, sometimes it’s faster than in America and sometimes it’s slower.
The difference is frequently you’re forced to sue insurers as they have a profit motive to screw you. The province only cares about getting you healthy within their means.
The thing about MC company is they have no obligation to keep their pricing or business model moving forward. They can sell to an insurer or pharma company or just raise their margins. This is good but shouldn’t be integral.
This would just screw over poor countries. See the example of Tanzania someone gives below: selling drugs cheaper in such a country will stop immediately if it risks undercutting the US market.
While the general idea that rich countries should help poorer ones has some merits, the idea that poor people in rich countries should be shafted in order to provide cheaper drugs for everybody else doesn't quite make sense to me.
I've heard the argument that Americans effectively subsidize drugs for everybody else. While it may be true, it still seems like a terrible situation to me, even as a non-american. There's got to be a fairer way to work this out.
How is the example cost of Albendazole right? Technically, it's a generic drug, and the cost is 10c (locally in India, atleast). What marks this up 130x in the US?
Pharmaceutical companies in the US charge whatever they can get away with, with the argument that insurance will cover it for most people. The price of insulin (clearly not a new drug) has increased 10x in the last 15 years.
This is a misconception. There are dozens of different drugs people refer to as Insulin, some new insulin analogs are better, and expensive. You can still get old synthetic formulations very cheaply. Walmart famously sells them for $25.
This is missing the point. The insulin Walmart sells for cheaps is definitely lower quality, which causes serious complications in the long run because it's impossible to _accurately_ regulate your blood glucose levels.
The newer, better insulin costs around €7 (~$8.50) per pen in Europe. That same pen costs $180+ in the US. The markup these companies charge is criminal.
Exactly, and that the Walmart version is not "low quality". It is the older formulation. The newer better insulin analogs aren't the same old drug, but priced up. They are new, different drugs that are better.
It's absolutely insane really. $25 is not cheap for something you need to live.
Sometimes I'm so happy to live in Ireland, I know we have our faults. But at least with some things, we seem to get it right.
Diabetics in Ireland have 0 cost associated with it. They can go to any pharmacy, and get anything related to Diabetes for free, and as much of it as they need.
This should be the case for any life long illness - or any illness for that matter, in any country; in my opinion. Healthcare should be free for all, it amazes me that this is not yet the case. I do know deep down that it will be eventually though.
But it's not 'free' in Ireland, right? It's just covered (as it should be). Here in Czechia it costs around $30 - covered of course. But the US price doesn't seem out of reality - it's cheaper than here!
Yeah, in CZ you also get it without any out of pocket payment if you have prescription - the insurance pays it directly to the pharmacy. But I guess you can't go and get it for free without any prescription in Ireland, right?
> Healthcare should be free for all, it amazes me that this is not yet the case.
Why are you amazed? It's impossible to provide a valuable product or service for free without institutionalizing either slavery or robbery, and not everyone agrees on that trade-off.
Regardless of where you fall on the spectrum of opinion regarding this, it shouldn't come as a surprise that there are some people with philosophical objections to encoding nonconsensual interactions like slavery or robbery into the fabric of our society.
Many reasonable people agree that providing healthcare (or other important services) for "free" to all people is more important than not having the government rob people to pay for it.
Many reasonable people agree that that is a bridge too far, and that we shouldn't be robbing people, regardless of what the stolen money is used to do.
Both are sincere positions held by sane, reasonable, intelligent, empathetic people.
Have you studied healthcare/drug distribution in other countries? If so, could you identify things that work from those examples, and comment on why the USA lacks those characteristics, and how your new venture might go some way towards making amends?
The US is kind of unique in a lot of its healthcare dysfunctions and there are a lot of individual policies that might help.
For example, one thing most other developed countries do is have a central state agency negotiate prices for drugs for the whole country at once, which exerts a lot of buying power to drive costs down.
The idea of Medicare in the US doing that has been proposed several times, but has been blocked, most famously during the initial ObamaCare debate.
The stated reason for blocking that is that decreasing reimbursements would decrease the profit motive for pharma companies to innovate and create new drugs. The more practical reason is.... probably just that lobbyists exist.
But that is just one policy among many. We are simple folk here at the MCCPDC, we just charge less. :-)
I’m the Founder of mailmyprescriptions.com (now rebranded as geniusrx.com) the second online pharmacy / first wholesale online pharmacy (similar cost plus model) - just sent you an email. Love what you guys are doing, would love to help. Keep driving those prices down!!
The website says you're planning to build your own manufacturing plant. What will that plant do? Will you actually be manufacturing your own medication?
If so, would that include manufacturing the active pharmaceutical ingredients or will you be sourcing them from generic manufacturers and then making the final drugs at your plant?
It will be a sterile fill-finish facility. The facility will fill vials of sterile injectable medicine. Those tend to be the drugs which are most affected by shortages and price gouging overall. The facility will just do finished drug products.
Our initial drugs are supplied on "private label" arrangements where other companies actually do the manufacturing, and we just add our labels and our own NDC code so we can set the price. Since we don't go through middlemen, that price can often times be a lot lower.
We'll have to source API (active pharmaceutical ingredients) elsewhere for now. At some point, would like to completely internalize our supply chain, but one step at a time. :-)
I know this is crazy, but have you talked with Bill Gates?
He planned to pre-fund several coronavirus vaccine manufacturing plans _prior to FDA approval_ just to speed up vaccine production. He expected several of those would end up being wasted money. [1]
If I'm understanding correctly, once a drug patent expires there are 2 possibilities:
1) The FDA grants a single company the exclusive right to manufacture, distribute, market and sell a generic version of a drug. In this case, the price will be lower than the brand drug, but not by much, since there's only one maker and no competition.
2) Several drug companies are allowed to design their own versions of the brand drug. Because there are several competing brands with essentially the same product in the marketplace, competition causes the prices drop.
If your company targets the first type, you replace another company as the sole producer of the generic, and there's still no competition to drive the price down.
If you target the second type, you become an additional competitor to the other generic drug makers, so the market gets a bit more competitive, but the prices in theory were already competitive because of the number of makers. For example, the Lexapro generic Escitalopram has many makers, so you can get it for as low as $10.
So in terms of generics, the options are either single source agreements where pricing won't be competitive by design, or multiple makers, where the pricing is likely already competitive. Having said that, which of those does your company want to target, and how do they plan to tackle it?
I don't know if this question was asked before the question was asked upthread ("how do we know you won't cave to investor pressure to raise profits?", basically) but the answer was that they're chartered as a "public benefit corporation" and that comes with a legal requirement to "maintain the social mission". So, if they're targeting the first type, the theory is that you don't need market pressure to drive the price down because they're only "allowed" to make enough margin to cover expenses.
If they target the first type, won't there be TWO competitors where there used to be a monopoly? Shouldn't prices then come down? As to the second type, just because there's an oligopoly doesn't mean competition will ensue and prices must drop. Look at the insane price on insulins.
I suspect their intended mission is to cover their costs with only a modest profit and thereby drive down prices where they are most inflated.
Given the proliferation of people like Martin Shkreli and companies like Purdue, there's a lot of pharmaceutical fruit out there to be pulled down and made low hanging once more.
You’re on the right track, but there’s a big difference between under patent and post-patent expiry drugs. Patents last 20 years, so if you invent a drug, patent it, then go through FDA approval, you can charge whatever price you want to recoup development cost until the patent expires. After the patent expires other firms can make ‘generic’ versions of the drug without having to license it. The goal with generics was traditionally take expensive patent drugs and make them more affordable while still retaining reasonable profit - in theory multiple drug makers would create an efficient market price. However, many generics for critical but low volume drugs have become single sourced, and there has been a move over the last 20 years for single sourced drugs to dramatically raise their prices and bleed insurance companies and the unlucky individuals that aren’t covered by insurance. This is what MCDC are fighting.
That's the first approximation estimate, But drug production requires a significant fixed investment to build the "factory" for the drug in the first place. Drugs with crazy prices tend to be those where a rational actor would choose to invest in a safer investment instead of expanding the supply, because they are being priced by people who are smart enough to make sure that is true.
Basically, there's is an international shortage for one of the most effective treatment for severe depression because of an unfortunate series of events, the drug's long history as a generic and the manufacturers' willingness to replace the drug class, and constantly produce new patented molecules with chemical tricks(ex. just taking one isomer in the citalopram->escitalopram case, or even metabolites in the case of venlafaxine -> desvenlafaxine case) like they are 'annual smartphone model releases', except efficacy even goes down.
You can read more about it the drug itself on the blog of Scott Alexander (the rationalist/Bayesian psychiatrist guy) as well: https://slatestarcodex.com/2015/04/30/prescriptions-paradoxe...
And now some years down the line after his observation, the price has exploded, very few new patients get a prescription due to uncertainty and there's no alternative. Your options are either taking taking an atypical antidepressant like vortioxetine or an experimental ketamine.
That's exactly the point. The selective classes (SNRI/SSRI) are marketed as a complete and safe replacement for MAOIs, on top of the chemical structure irony. Even the new atypicals with innovative chemical structure (and targets other than 5-HT1/SERT) are of significantly worse efficacy MAOIs
selegiline is cheap. Rasagiline is available but I suspect cost inflated. However, I don't think either are targeted at depression, esp at the doses available.
I supposed I should have read it more carefully. It refers to phenelzine which is...both. It's nonselective so it's an A and B inhibitor.
How good is it, I cannot say as not a lot of people prescribe it anymore. The problem with it is that a risk of hypertensive crisis, especially in combination with tyramine in aged foods, or inducing an overload in combination w/ any other drug that raises monoamine neurotransmitter levels, i.e. SSRI's etc. It's become kind of a bogeyman. So the original source seems to be trying to fight that particular "meme" in medical education. I'm not about to wade into pubmed regarding how often hypertensive crisis happens in a 60 or 70 year old drug, but there may be a point in that as medical students, we memorize the "quick bites" of some of these things as our time and attention is extremely limited in figuring out what to study for the boards. and if we do want to prescribe it, we have a pharmacist pushing back on the other end of the phone because it has this thing as a big scary Black Box Warning on the drug.
I will say, MAO-B inhibitors (at least those studied in anti-parkinsonian trials and doses) don't seem to do anything. No hypertensive crisis, but we haven't been able to see a huge therapeutic effect either. The psych people dose them at 6 times the parkinsonian dose though...<shrug>
The other potential angle on that post is...this may reflect on some aspect of an unregulated generics market. Aside from phenelzine, I seem to see weird swings in availability and pricing of generics in the past few years.
Currently our frontend is react, backend node.js, and a MySQL database with a graphql API (edit).
Would be looking for folks to help make a more robust consumer facing site as we add products and different types of customers.
We've been focusing mostly on filling roles for the sterile fill-finish facility we are constructing in Dallas (QA, formulation specialists, etc.) and have put building out the dev team for the web sit kind of on the backburner with me just kind of personally managing it at the moment.
Not a question but a request: might not be a massively used drug, however pharmacies where I live don't seem to even carry the generic version of it, but dopamine agonists could use some competition.
I would love to help as a software developer but I'm super busy with school and my PhD studies. Best of luck! Please make the repos publicly available so we can contribute for the greater good.
Hi do I have the ability to invest/buy stock of your company?! I am a huge fan of shark tank/especially Mark Cuban and would be excited to play a part in a company he also believes in. Even if it's just a miniscule role.
How will you avoid shortages, when the returns to drugs with chronic shortages are no better than those to drugs with plentiful supply on the market already?
Short answer... it's complicated. And it's intentionally complicated to make it difficult for people to understand how they are getting ripped off on the price of drugs and by who.
If you are referring to the issues with Ranitidine, it is erroneous to consider that a generic drug problem. Research has shown that the NDMA is a degradation product of the drug itself and that the brand of the preparation does not affect it.
Maybe for ranitidine, but for the ARBs (common blood pressure treatment drugs) that are a few decades old, the NMxA source was sourced from a new synthetic route and that's when they appeared in the drug supply: "It believes there has been NDMA contamination in those drugs for up to four years."
> Ultimately, scientists traced the contamination back to a change in valsartan’s synthesis. The antihypertensive drug contains a tetrazole ring, which is an aromatic five-membered ring with one carbon atom and four nitrogens. For many years, the synthesis for this compound, developed by Novartis, used tributyltin azide to form the tetrazole, with xylene as a solvent. However, in 2014, China’s Zhejiang Huahai Pharmaceutical, which makes valsartan for some companies, filed a patent for an improved method for forming the tetrazole ring.
It's all blood pressure medications like Valsartan, losartan and irbesartan, and metformin the diabetes drug.
These are just the ones that have been tracked. Sometimes the drugs come in with higher doses than they should, or less than they should. Or sometimes the pills are mislabeled.
If you apply to jobs where the stack advertised looks like it's from a decade or more ago, you might have to actually deal with technology from two to three decades ago (or not, but it's probably more likely). People like new things, and often switch jobs looking for something new, and in tech that's often new technology they've played with but not got a chance to use in production.
Honestly, something that's advertised as ruby/python and HTML will probably put a lot of devs off that used to happily do that all day, and so a company might have to pay higher for good talent, or put up with worse talent applying for the same salary.
You might actually be worth more not knowing react. Communicating that to prospective employers might be hard though.
In other words, you can probably make really good money slinging COBOL if you know it and can communicate your talent sufficiently for the same reason, but more extreme.
I've wondered for a long time how much money could be saved if the non-trivial administrative overhead of insurance companies were removed from all but truly catastrophic cases (where claims start at $10k or more) and medical, dental, and drug costs were paid out of pocket (including via an HSA account). There are numerous cases where cash-only medical clinics are able to offer up-front pricing for a fraction of what is billed to medical insurance companies. If Cuban's idea is "we don't do insurance but you're free to pay with an HSA card or seek reimbursement from your insurance company" then this could be a huge winner.
A good comparison is veterinary medicine in the US. All the functionality is fundamentally the same, but insurance isn't common. Prices are vastly lower, and it's all super-convenient. Typical for an injury requiring stitches: $150, plus $15 for some antibiotics, which they hand you as you walk out.
Every time I go to the doctor I wish I could take myself to the vet instead.
Even more importantly: When you walk into the vet, they can estimate what your options will cost, so that you can make an informed decision.
When it was our cat's time too, I was struck by his end of life experience versus that of a human. Whereas a human could have exhausted their life savings on futile treatment or end of life hospice care, Denver cat went quietly into that good night on his favorite blanket surrounded by his loved ones.
I'm currently in need of some very common medical treatment, but the maze of providers I need to go through in order to get a referral just ain't worth it. Versus, if I were a cat or dog, I could simply go to the area university veterinary hospital and likely get my answer same day.
I had to get medical attention in Thailand and it was wonderful. I walked into the hospital, explained my symptoms to the nurse, got wheeled to a private waiting room, met with a specialist 10 minutes later, got some scans done on state of the art equipment (newer than what you would find in an American hospital), had a consultation, prescription, settled up for ~$90 and I was out of there in just under an hour.
I plan to go back if I ever need a major medical procedure.
The major difference is what happens when something goes wrong - you really want to be in a situation where you can be transferred to a research hospital that has the guy who has handled the three other times X has happened before.
I've always opted to be treated locally when needed - but I also pay for an emergency evacuation service that puts my butt on a jet back to the states if things go pear shaped.
This experience is often available for humans too (even in countries without risk of medical bills bankrupting oneself) - it largely depends on how far the religious right has embedded itself in government.
Pieter Hintjens (of ZeroMQ and AMQP fame) chose this option when diagnosed with terminal cancer, and wrote about it extensively at [1] and [2].
I'm cautiously optimistic that euthanasia will become widely available by the time I'm old. It seems to preferred over dementia by most people I've spoken to in both my generation (late twenties) and my parents.
Anecdotally - it seems like a non-trivial percentage of my mom's trips to the vet end in euthanasia.
I suspect there is an order of magnitude in the difference in level of care that goes into the average person vs dog. I mean, for one, it is very common to hear things like - "well, you have to remember, their lifespan is short. They only have a year or so left to live." This just isn't a discussion that is had with people.
I'm with them. I have no desire to transfer my assets to an already-wealthy bunch of doctors and healthcare conglomerates in exchange for dragging out the inevitable.
You are currently thinking with the rational part of your brain.
Find a 4-5 story parking garage and stand up on the edge. That part of your brain that kicks in and tells you to get back down to safety will also tell you to pour every cent you have in to buying a few more weeks.
> Find a 4-5 story parking garage and stand up on the edge. That part of your brain that kicks in and tells you to get back down to safety will also tell you to pour every cent you have in to buying a few more weeks.
This can change when there is no "back to normal" available. When your quality of life is shot and you know that tomorrow won't be better than today.
In a suicidal person who jumps off that building we consider this a tragedy because there's usually no physical reason that those feelings couldn't have passed, why their life couldn't have been normal again.
But in someone with a terminal condition and a body that's just done... and especially if they're well informed about the realities of their medical condition... yes, there can be things you care about more than throwing every cent you have into extending the pain.
I'm pretty sure you're wrong, but time will tell I guess. I've already watched both my parents die of the inevitable effects of getting old, and I have pretty firm ideas about what parts of that process I want to avoid for myself.
That is the sort of discussion that happens around old or terminally ill people. Some people prolong things as long as they possibly can, but in my observations this generally only seems to cause misery to everyone involved.
> Anecdotally - it seems like a non-trivial percentage of my mom's trips to the vet end in euthanasia.
Part of this could be that pets are limited in their ability to communicate details of their feelings to humans, making it harder for humans to tell the difference between a pet that is acting off because of something that they will recover from without a trip to the vet and one that is acting that way because of something that is serious and is going to go downhill fast if you don't take them to a vet soon.
This leads to vets first going to the vet for a given illness later into that illness than a human with a similar illness would have went to the doctor, hence a greater chance of it being too late.
I’m not a religious or spiritual person, but I assure you my cat told me when he wanted to fight, and when he was ready to go. I’ve never seen a cat so happy as when he saw me again after that long week in the hospital, and likewise when he was on the floor of the bedroom in pain, his face and his little weak voice told me he was ready to go the same as each person I’ve been with in their last moments.
Maybe that’s part of the problem? I mean - my grandmother lived to be 96, was “healthy” nearly to the end, but realistically was ready to go a good decade before that.
With my cat (and this would likely be the case with any of my cats...) we took a reasoned look at the medical options and the quality of life choices. It wasn’t exactly cheap, but we basically bought him a year of life. If it had been a human family member, we would have gone through exactly the same decision, IE: do you want to keep fighting and do you want to go through this procedure or not?
In Canada (at least in my experience) it's the opposite. Vet clinics look a lot like US medical centres, including the state-of-the-art equipment and corresponding prices. Meanwhile the limited for-profit medical services are (mostly) affordable because they do general procedures with relatively low barriers for competitors. Generic drugs are dirt cheap when available; non-generics cost as much as the US. Dental care is all over the map from very affordable to ridiculously overpriced.
Another Canadian here with a similar experience— friends with dogs even pay for insurance because of the potential for frightfully expensive private surgeries down the road. Though I do wonder if there's a psychological thing there where dogs form stronger bonds and so people go to greater lengths for them, whereas other animals are easier to let go of if circumstances indicate that the time has come.
And yes, dental care is all over the map— it feels very much like what I imagine US healthcare to be, with co-pays and mystery charges and having to log into my insurance company's online portal to do stuff. The NDP made a bunch of noise in the last election about a national dental plan, though even that effort would only have covered family incomes up to CAD$90k [1], so it wasn't anything like the universal no-questions coverage we have for core healthcare.
> And yes, dental care is all over the map— it feels very much like what I imagine US healthcare to be,
Funny enough, dental insurance in the US is very straight forward. I have always gotten quotes up front with very clearly explained charges. The way it has worked is dentist talks over with me what they want done, billing person runs the numbers and gives me paper with estimates, and if I agree I pay whatever balance I owe on the way out.
Amazingly straight forward, kind of like how everything else should work...
FWIW Eye doctors and insurance on glasses works just as well.
Ha, I mean that's basically what it is in Canada as well— it's just so much more than going to the doctor, where you never even see a bill.
An example of my frustration with dental: I went to my usual dentist for a checkup, but then he referred me to a specialist. The specialist appointment wasn't going to be for a month, but then they call suddenly and have a cancellation the next day. I end up having to pay full price for the specialist appointment because my insurance doesn't like that I had two "assessment" appointments back to back.
On another occasion, I was quoted a procedure, and my decision for when I wanted to have it done was driven entirely by which insurance-year it was going to fall under, rather than by my convenience or how urgent it was, or anything else.
I know these are fundamentally "insurance issues" and I suppose better supplemental insurance could make them go away, but at the end of the day, just like with Americans, my insurance is chosen by my employer and I have basically no control over it.
It's uncommon here in Norway, unheard of in fact as far as I am concerned. I have a checkup once a year that includes a really thorough cleaning procedure and x-rays. That costs about 120 USD. If I need a filling that will probably add about 100 USD at the most and the two crowns (milled ceramic done on site, on demand) that I have cost about 500 USD each so over the last thirty years I have spent about 6000 USD on dentistry, so an average of 200 USD per year.
Do people in the States not pay for pet insurance?
We sure did go for it in Toronto. Vets seem to charge by the pound (wait, sorry, kilogram, immigrant…). Large dogs seem to come with large medical bills, and we were strongly advised by friends and family to go for pet insurance.
Now, I am not actually sure that pet insurance, versus setting up a dedicated savings account that we sock money into, was the best idea. If anything, we went for it because I am from the States, and I assume any non-trivial medical issue will be cripplingly expensive.
I don't. Part of the reason is I'm ok with a small chance of a few thousands dollars bill, but a bigger reason is I don't trust insurers: their standard contract would first explain how I have no rights and then add that if I have a problem with that, I can go to their pocket court (arbitration) to learn that I really have no rights.
It's available, and some people pay for it. I would be very careful to read all the fine print though.
For me, the cost of routine care, spay/neuter, and a certain amount of unforseen expenses should be part of what you plan for when you get a pet. Beyond that, it's a judgment call as to whether the cost of some treatment is worth it. I know people who have spent thousands of dollars treating cancer in an old dog, and others who have euthanized younger pets who developed expensive but in theory treatable health problems. I don't think either approach is wrong, it's up to the owner.
My dog just had major knee surgery (TPLO). Its cost will be total of about $5k when we have some x-rays in a few weeks. I don't have pet insurance, however, most companies don't cover it. There are tons of loopholes, like human insurance.
Vets vary widely in the US. Vet clinics are wildly expensive in many locations here, with veterinarians earning well-paid doctor wages and using modern vet equipment.
They can, but they vary. I'm a citizen of both countries and there's one allergy medicine I take where the generic price in the US is the same as the name brand price in Canada. The name brand in the US is 7x higher than the name brand in Canada.
Not disagreeing, but one factor that complicates it is that they're allowed to take bigger risks with pets (both with regulations and potential civil liability) than with humans.
As the other reply mentioned, I wonder if this is just the human cost insanity infecting veterinary costs -- MRI tech could be used for humans, so the machine is absurdly expensive, and vets have to charge more to justify the cost of having a dedicated pet MRI.
True, but in my experience getting a few MRIs, the price from various imaging centers nearby varied (for the exact same MRI) from $500 to $2000.
The $2000 place is associated with a local hospital chain that is well regarded. I guess that is how they could negotiate $2000 for an MRI with insurance and the other place (that I went to) was only able to negotiate $500.
Honestly, the price for health care in the US is all funny money. I've gotten a single shot, of a very common drug, that was billed at $20k, knocked down to $10k with the "insurance discount", so my 10% co-pay ended up $1000, with insurance!
I had a surgery that was billied at $250k where the "discount" was over $150k. That $250k price is clearly not real.
And theae kinda of prices are why I'll probably never choose to live in the US. How do people live with the possibility that a freak accident could completely and permanently finacially ruin them.
The highest medical bill I've ever paid is £8.50. Of course I pay National Insurance to cover the costs of the healthcare system. But as far as I can tell that's no more expensive than what people in the US pay despite their insurance having not nearly the same coverage.
Do you sell all your assets, like realty where you live in, personal possessions, car, tickets to vacation you happen to buy beforehand? Or declaring bancrupcy is really harmless and easy?
It varies by state. There's a list at https://www.nolo.com/legal-encyclopedia/bankruptcy-exemption.... Basically you can keep stuff like the house you live in, your not-flashy car, household goods, tools of your trade, a small amount of personal property (if you own, say, a nice musical instrument or some jewelry worth $2k or whatever). As a general rule, anyone rich enough to have to sell property in a bankruptcy already has health insurance.
And please don't take any of this as a defense of the current abominable US system. I lost my dad to complications of untreated diabetes because he didn't have health insurance. What I'm saying is that people who should declare bankruptcy often don't, because they think bankruptcy will ruin their life. It won't. It protects you from predatory lenders and gives you a fresh start.
> As a general rule, anyone rich enough to have to sell property in a bankruptcy already has health insurance.
Isn't the issue that health insurance often doesn't cover everything. And that it's very difficult to get health insurance at all if you have pre-existing or chronic conditions (exactly the people who need it the most).
Pets tend to be smaller than humans, so manufacturers could ensure that pet MRIs don't drag down human MRI prices by making smaller MRI machines that only work for pets. They probably do.
There are "small animal" MRI machines, which are mostly intended for research.
The bores are really small: 55mm or so is not uncommon, so a mouse would fit, but nothing much bigger. Other animals are usually scanned on a machine meant for humans (sometimes even the exact same ones, very early in the morning or late at night).
My dad, a radiologist once had patient that was so large that they couldn't fit them on a conventional CT scanner. Luckily this was a university town, so they were able to access the vet's large animal scanner.
Part of that is probably the lower volume, so they have to amortize the costs over fewer procedures. Most pet injuries don't need an MRI or if the injury/illness is that bad the euthanasia or palliative only option is more considered.
Last time looked at the costs of imaging I got the impression that there are a monopoly and other captive market effects at work.
You'll hear medical professionals claim imaging is expensive because the machines are expensive. Which just says to me that medical professionals aren't accountants.
Consider a dental w-ray machine. $15-30k. That's the cost of Prius used as a Taxi. You don't pay a couple dollars for a 15 minute Taxi cab ride.
An MRI machine, I forget how much those cost. But whatever, lets compare one with a modern passenger airliner. Cost is about equivalent on a 'per passenger' basis. And an airliner requires highly trained professionals to keep it running.
My dog had MRIs and ultrasound recently. Each event was $700-$900 a pop.
I take my dog for routine full checkup that includes MRI and Ultrasound whenever I travel to south america. They use the same machine brand as in the US, with same diagnostics. I pay $50-$85 over there for the same tests.
Vets over in SA (not business owners) make about $500-$1000 USD per month.
It would seem the huge cost is not from the machine. Its the labor. I think these are the 2 key differences:
a) Based on my understanding, getting licensed in this SA country is a nonissue. There is in fact an oversupply of vets because its easy to practice.
b) The price for the vet studies is on the 2k-5k year for a private U. Compare with US Colleges.
Regarding quality: Our vet in SA diagnosed my dog after seeing the US diagnostic test reports , over whatsapp. She was correct on her diagnosis from the start.
It took 4 different US vets, 3 separate facilities, 4 days of hospital bills ($5000) to arrive at the same conclusion that I got from a whatsapp.
It is not the machine problem. It is a captive market with huge costs related to labor.
MRIs are principally taken by technicians then a doctor will interpret them but the bulk of the operation isn't done by doctors and the techs are well paid but are paid less than a first year commercial airline pilot. IF you include all the maintenance and support around in airplane and around an MRI machine I think the airplane will be even further ahead.
Thanks, I learned something today. I think the point still stands if you include the time of the radiologist and tech, capital and employment costs for MRI in the US are substantial.
I agree that it is a very strange comparison between MRI and a plane, I was just chiming in on the capital and employment cost for each could be comparable on a per trip basis, not that MRI prices are where they should be.
In my personal opinion, a major problem with US healthcare is a race to the top, where the newest and best care is sought irrespective of the price. A judgement call needs to made somewhere on cost/marginal benefit, and post-procedure reimbursement debates is the worst way to do it. CT machines can cost between 250K and 14 million, as I mentioned in a sibling post. Similarly, MRI costs can range from $170-$5,500 [1]. In the current system, almost nobody is incentivized to keep costs down. Doctors and insured patients want the best care, as costs are externalized to the insurance pool. Insurance companies want to maximize costs, because their profit margin is limited by a % of spending.
I was quoting the number for a modern 3 tesla MRI machines, which would fall into the 500k+ range on your link. These are high end but not necessarily rare. For example, UCSF has 4 of these machines. These can easily be on the order of 3 million+ with installation
3 T machines are not necessarily better, it depends on what they're trying to look at, getter a sharper image of noise is not useful.
Anyway, your estimate seems to be way off, basing it on a 6 year old puff piece for a cutting edge model that was deployed in a lab. The cost for a typical new MRI is more like $500k.
I never said I was talking about averages ct machines any more than a brand new 787-9 is the average plane. You can get a 20 year 737 for a lot less than 200mil, and is probably closer to the average.
If your point is that MRIs less than 3T exist, I agree. If your point is that cheaper MRI exist, I agree. If your point is that nobody has spent 3 mil on a CT, then I disagree. A link showing the price of used machines 10-15 years old isn’t going to change that.
Very similar in developing countries, as well. I've gotten stitches in Mexico and Colombia for less than $40 USD each time which healed comparably or better to the stitches I've paid >$500 for in the US. Consultation for an eye infection along with the antibiotics in Mexico was $23 USD.
"Every time I go to the doctor I wish I could take myself to the vet instead."
Kramer thought that in a Seinfeld episode; it was a great episode. Season 8 Episode 10.
I feel like the demand for veterinary services has gone up drastically. It shocks me how my millennial friends will spend $5000 without a second thought to keep a dog alive. Older generations often seem to put pets down in that situation.
I haven't come to that yet, but when our 3 year old GSD went blind, even though it was an elective surgery it wasn't a super difficult choice to spend that much to restore his sight (cataract surgery) given that the same problem basically can't come back. He is six now, and it has really improved his quality of life (he enjoys chasing sticks in the lake again). If he was 10, we would probably not have made the same choice to spend the money; because he would get much less benefit from it.
You spend more time with your dog than most people, and I certainly care about him more than any person who is not in my immediate family.
It would work fairly well for minimal routine care and relatively minor trauma, as long as euthanasia is on the table for major long-term care, major trauma, and for those who cannot pay.
> For example, in 2011 in America, the average charge for an office visit for an established patient, level 3, requiring approximately 15 minutes with a doctor, was $104. The average total paid was $69. Some more examples: a cholesterol test has an average submitted charge of $72; and a glucose tolerant test (GTT) has a submitted charge of $60.
Seems pretty similar to the vet. But that's just an office visit. The expensive stuff is at a hospital when the CYA care shows up.
Hmm, I'm not sure how I feel about that comparison. Most vets double up as pharmacies, restrict access to prescriptions, and sell at least some prescription drugs at prices that have been marked up by at least an order of magnitude by the manufacturer.
Some of the bills that I've run into have still managed to approach the cost of routine visits at some specialists when billed to my HSA.
My experience conflicts with your assertion. Costs for veterinary care have sky rocketed over the last 15 years, and costs for procedures without pet insurance are sometimes 75% to nearly the same price as the same procedures on humans. Prices for MRIs, X-rays, surgery and drugs are all very close to human medical care costs.
FWIW: I wonder if you are in an urban area? When I compare the cost of vet services with my friends in an urban setting relative to what we pay here in rural, small-town America, I'm shocked at the difference. We have a university about a two hour drive away with a noted vet hospital - even their services were priced better than those I've heard anecdotally on the other (more urbanized) side of the state.
I'm guessing vets take advantage of the ever growing tendency to consider pets as family members to inflate the price. Especially since (from very anecdotal evidences) it seems to be mostly middle/upper class people who are so invested into their pets.
In the countryside people tend to have a more utilitarian view of animals and would simply get a new one rather than wasting money keeping a sick animal alive.
It's way more complicated than that: there are differences in metabolism as well as size. It varies from drug to drug too, but as a rule of thumb dog needs about twice the human dose (in mg/kg). A 60 lb dog therefore needs about the same as a smallish adult.
Large dogs can be the same weight as small humans, so I'm not sure what accounts for 1/10th. Even medium-sized dogs like labs are about half the weight of a healthy, average-sized person.
Depends on the drug, but their metabolism isnt identical to ours, and humans can often require significantly higher doses compared to other animals when controlling for dosage per weight unit. But again it depends and there is no hard and fast rule as far as I’m aware.
Having just put down two pets with costly late in life medical conditions I'm kicking myself for not getting health insurance. We were able to afford most recommended procedures but not many can. In fact, there are several programs locally for people who can't pay for their vet bills which I've considered contributing to now that I've seen first-hand the anguish people have to face when considering procedures they can't afford for animals they love like children.
Me too. I suspect some of this is regulatory overhead and compliance. I can give pets injections (inoculations and antibiotics) without even talking to a vet. The only exception I ever ran into was antibiotics for a snake, as the feed store didn't carry that. To get those things for myself would require a prescription from a doctor.
It can be the opposite as well. I work in a vet clinic, but I also am in New Zealand- where there is free/subsidized public healthcare. Thus you get people who go to the vet expecting things to be free or cheap.
You can certainly go to Farm and Feeds and get penicillin amongst other pharmaceuticals. Plenty of farmers hours away from metro hospitals and providers commonly use these sources.
The last time I needed stitches, it cost between $70 and $80 AUD (unsubsidised - this is what an international visitor would have paid), and was wholly covered by the government.
Actually pet health insurance is very common. Everybody that I know with a pet has one and even work has discounted pet health insurance as part of employee perks
I generally agree with your sentiment - regulation and insurance overhead are big costs. I do think some people should be able to do the basics at home if they wanted. Basic sutures are a pretty good example, you could even save that $150 that you mentioned.
While I'm usually a DIY kinda guy, giving this advice on a large scale is a perfect recipe for disaster and really encapsulates the dark-ages dystopia that the current US medical system has become.
While looking for moldable plastic material ("Sugru" and similar) on Amazon, I was a bit taken aback by the reviews for one such substance. Multiple reviewers were stating that they were using this stuff to make their own dental crowns or some other DIY tooth repair because they couldn't afford a dentist. I found this quite shocking and I'm not sure if these people were serious.
If someone self-studies basic things, it shouldn't be a big problem. Just look at first aid. There are many people who have no idea what to do for minor injuries because they never took the time to learn. Suturing is on the borderline of of falling into first aid. There are people today who learn the basics of it for emergencies or because they live in remote locations.
Specialization of labour is what's primarily responsible for the industrial revolution - while this is a hyperbolic comparison, is the only reasonable way to fix healthcare to throw away all specialization and go back to "do it at home"?
The service needs to be available in some form at least for folks like me that have an essential tremour or otherwise are limited in fine motor skills.
I'm not saying do everything at home for everyone. But if some people did minor things (first aid type stuff) at home, that would free up the system for more important cases. Just think of all the people that fo to the doctor with a cold. A little education could go a long way.
People keep talking about patients going to the doctor for frivolous reasons, but what I see is that it is much more common for patients to ignore symptoms or take some over-the-counter medicine, and take too long to see a doctor.
This, I think, is a natural result of the US insurance system. Being sick is quite expensive and not being sick but being proven to not be sick is also rather expensive so people will naturally tend to avoid formal treatment longer in the hope that everything just magically goes away.
This also contributes to the amount of emergency room treatments that could have been trivially handled with earlier intervention. A boil that has gone septic is a very serious medical condition, but nearly all boils can be trivially resolved with a short regimen of antibiotics.
You could end up with a brain infection, very easily.
If you cannot afford US dental care, and you are not super poor, get a 1 way ticket via Kiwi.com to a more “eastern” European Union country like Croatia or Poland. If you use scripts from GitHub or are very good at searching you can get such tickets for $200-$250. You can find extremely excellent dentists with great qualifications and reviews in countries like that, and many have amazing reviews and are super cheap.
A lot of people from EU countries, that do not have “socialized dental care” go to countries like that a couple times a year to get dental care.
> If you use scripts from GitHub or are very good at searching you can get such tickets for $200-$250.
This is the average cost, per tooth, of the work I had done here 2 years ago, in the US, at a dentist where I paid cash.
> You can find extremely excellent dentists with great qualifications and reviews in countries like that, and many have amazing reviews and are super cheap.
I’m wondering how cheap they have to be in order to make it cheaper to fly to europe. How much would be an extraction or a filling replacement?
Well, I am a dual US|EU citizen, currently living in Croatia. So, I do travel abroad a lot.
When I lived in the US, I had an individual plan through Costco (Delta Dental) that was quite a good deal. It was a Dental HMO plan, though. Really, the only thing I noticed that it did not cover was implants. However, Costco only offers it in a handful of states: https://www.costco.com/dental-insurance-services.html
In both cases above, if you get the Dental HMO, it has no annual or lifetime maximum dollar limits, no waiting periods, or pre-existing condition clauses.
Anyways, I used my American dental insurance to get cleanings, X-Rays, and fillings. I go to Europe a couple times a year at minimum anyways, so I use that to my advantage by getting more advanced dental care there.
Dental implants, especially Swiss implants, can be 8 times cheaper than what some dentists charge in the US. A Swiss implant, when all said and done, costs about $1000 USD in the more eastern EU countries.
I would stick to European Union countries, as the quality of materials is very high. There is some website like the link I posted above, that has implant success rates posted, by dentist. I just do not remember the website's name. Anyways, you take your time and do extensive research before you choose your dentist.
Anyways, I have a very rare immune-mediated disease affecting my autonomic nervous system, which affects salivation, so my teeth are totally jacked up, even though they look really nice. I also have type 1 diabetes, and it makes my teeth naturally more prone to infections. So, cost-wise, I am screwed when it comes to dental care. I know somebody with the rare disease I have, that has about 20 implants in her mouth.
But, if your teeth are really jacked up, and especially if you need implants (of course it is better than dentures), it is way cheaper to go to European Union countries. This is even for 1 implant. If you may need thousands of dollars in dental care, you may be better off going to the European Union to get that care.
If you really want to be frugal, why not go all John Rambo style and just cauterize the wound with some gunpowder? It's probably <$2 for enough to make sure you don't bleed out.
That's what insurance is supposed to be: coverage for the catastrophic cases. This use of insurance for ordinary, everyday medical care is ridiculous. I have insurance on my car in case of a catastrophic collision; can you imagine if I had to deal with them for every oil change and brake job?
I make the same argument and people don't get it. We are so brainwashed about the whole health insurance thing in America. Get rid of insurance middleman in EVERYTHING and see how prices drop.
I don't understand your argument. Even on insurance, a lot of Americans routinely ignore preventive care because of the hassles, overhead and out of pocket costs even after insurance. Unless you are lucky to have great insurance by your employer. The point is that insurance should NOT be involved in preventive care. It should be a direct free market cash exchange b/w just 2 parties. Patient and doctor. That's it. NO premiums, no copays, no coinsurance, no claim paperwork, no calling insurance companies to figure out the charges etc etc and most importantly, no dependency on having a job to be able to afford going to a doctor even for preventive care.
You will see a lot of people using the (expensive) ER to treat their health issues. The reason they are there in the first place is that they couldn't pay for preventative care, so naturally they can't pay for the ER either. As a society when someone who can't pay ends up in the ER we have two options: treat them anyways, or turn them away.
Yes but that is due to our current expensive healthcare system where out of pocket costs are just some insane arbritrary number. Most hospitals cannot even tell you a "cash" price until you really push. My whole point is that it is all so expensive BECAUSE of insurance. If insurance was not involved in preventive care for example, all hospitals and doctors would have to compete on cash price and that would lower the out of pocket costs significantly. I bet less people will need to got ER because now they don't need to pay $10,000 for a doctor visit.
BTW, there's no out of pocket cost for preventive care for those with insurance in the US. There hasn't been since the Affordable Care Act became effective.
yes, and if routine procedures cost money, then people won't do them until they are emergencies. Why? Many people feel that they "shouldn't" "have to" spend money on those things.
The problem is that your catastrophic costs are likely to be massively higher if your problems are not caught by routine checkups and standard screenings. But if we make people pay the full costs for routine checkups and standard screenings, they won't bother getting them. So it is in the interest of your insurance company to make sure you get those checkups and screenings.
By contrast your odds of a catastrophic collision have more to do with drivers and driving collisions than they do with whether you got an oil change recently. If they were insuring your cost of major repairs and buying a new car, then they would have an incentive to get involved with routine maintenance as well.
I have good insurance from my employer but I haven't been to a doctor in at least 10 years. I don't think it's a given that people get routine care just because insurance covers it, or would avoid it if they had to pay (a predictable, modest amount) for it out-of-pocket.
It is not a given. But there is a correlation. And the correlation is enough for insurance companies to statistically benefit from their attempts to encourage people to do it.
There is a middle ground (this is how most dental care in Germany works):
Regular cleanings are not covered by your insurance, giving an incentive for price competition. However, if you need major dental work your insurance might not cover it if you skipped the regular cleaning.
> But if we make people pay the full costs for routine checkups and standard screenings, they won't bother getting them.
Alas, those checkups and screenings still cost the same, regardless of who is paying for them. So when you decouple payment from benefit, you create adverse incentives.
I fully agree that at least in principle it seems wrong to have insurance for routine care, when most insurance only covers catastrophe.
I think the two practical problems with this view are (a) what's routine to you might be catastrophic (or at least seriously detrimental) to someone else, and (b) missing routine care often leads to catastrophic outcomes.
> what's routine to you might be catastrophic (or at least seriously detrimental) to someone else,
Whether a cost is insurable is not subjective. The gp observed that insurance only works to manage risk. Insurance against a risk of 100% certainty costs more than managing the risk itself. Insurance that covers doctor’s visits takes a certain expense and runs it through a system designed for uncertain expenses, thereby adding essentially parasitic loss.
> missing routine care often leads to catastrophic outcomes.
As a sibling comment observed, this is already something that insurance companies deal with. Failure to obtain regular and preventative care makes one more likely to need intervention, which means the cost of insuring the patient is more. Therefore people who are actually paying for catastrophic insurance can save money by going to checkups. This would decrease costs, rather than cause them to baloon like insuring high probability events.
Auto insurance does give discounts for things like taking a defensive driving course. Some will give discounts for installing a tracker on your car to show that you don't speed.
So it's not entirely out of the question that they could give discounts for properly maintaining your vehicle, if that were a major cause of accidents and it could be tracked.
And yet pretty much all of the developed world manages to do this much cheaper than the US whether or not there are insurers involved. This is not an insurance problem in the US.
It's a healthcare regulations being used as corporate welfare problem.
What are you talking about? You’re suggesting things like diabetes isn’t covered by health insurance? That’s just not true. In fact, making sure “pre-existing conditions” are covered is a signature act by Obama to keep most people insured.
You’re using a very narrow definition of insurance that doesn’t cover health insurance in the US.
I completely agree with you. That is why we started Tangerine Health (https://www.tangerinehealth.co). We charge a flat rate of $25 per visit. With new policy changes to Telehealth, we also launched virtual primary care with the same pricing model. If you have insurance we accept Aetna and UHC. We are in the process of getting Blue Cross as well. I believe also doctor's office visits are covered by HSA (not 100% sure but here's a link found: https://www.foley.com/en/insights/publications/2020/03/covid...).
This is actually the idea behind Direct Primary Care[1]; basically the idea is that by not taking insurance the overall cost of care goes down due to the decreased overhead around the claims process.
My dad is a PCP who switched his practice over to that model several years ago. From what he's told me he prefers it a lot over the traditional model specifically because it allows him to have a subscription based model rather than charging per-visit. That means that his revenues are more consistent but also has the benefit of aligning the patients' and doctors' incentives more directly: the doctor makes more money when their patients are healthy than when they are sick so they're incentivized to do a better job.
It also meshes well with telemedicine and chat-based consultations. He was offering both of those options to his patients well before covid because it tends to save both doctor and patient a lot of time, and there's no concern over "how much do I bill for telemedicine vs a normal visit, and how do I bill insurance for it."
I don't know if it's because of this, but as a European I was flabbergasted the first time I went to a pharmacy in US with a prescription and they told me "come back in an hour". Like what? In Europe you talk to the pharmacist, give the presciption and 5 minutes later you're out.
That varies by location quite a bit. I can generally walk in my local pharmacy and have a prescription filled in a few minutes. Maybe more like 15 minutes if it's a controlled substance. But as a practical matter I just walk in, pay, and pick it up, my doctor sends the prescription over electronically. And lately, any recurring prescriptions are handled by mail anyway.
Have I ever experienced that "come back in an hour" phenomenon? You bet. Then I went to a different pharmacy.
There is always an amount “billed” to insurance companies which is strictly imaginary. There is this billed rate, the negotiated rate per insurance provider, and a cash rate.
An equally imaginary number that gets hauled out during debates so that health care providers can pretend that insurance companies are the ones responsible for price inflation. If you actually try to obtain the cash rate, they'll give you a 2% "lol nice try" discount off the billed rate.
No, there’s just a base rate that nobody pays used as a negotiation tactic that’s still published on bills for whatever reason, you can see what your insurance provider actually pays as well.
Yea and for people who cannot even afford the lower costs out of pocket, subsidize the HSA card for them. This could work better than trying the big bang Single payer approach which btw I am for if that's the only option. I am desperate to try anything other than what we have right now in the US.
There's a cash-based medical practice in my town. They don't accept or file insurance claims (they will give you an invoice with billing codes so you can file your own claim if you want). Their prices:
That's significantly more than my doctor - who is part of a major hospital/healthcare network and works primarily with insured patients - charges out-of-pocket...
(I know this because they screwed up billing the insurance company and got denied, and tried to switch me to cash and bill me the higher amount instead. I love our healthcare system.)
Yeah it didn't strike me as especially cheap either, and I have not used this practice myself, but as I understand it he does spend a lot more time with the patient discussing their questions and concerns than most docs do. He also pretty clearly markets to an upscale clientele, not people looking for bargain price medicine.
We can fix a lot about with a few small changes that don't even require raising taxes. The #1 and easiest change is for the government to just pass a law mandating reference based pricing. This is not M4A, the government just says you can't charge more than Medicare plus 20% (e.g.) and cash gets your Medicare flat. This gets rid of brokers, negotiations, out of network and any of the other nonsense. Probably removes 20% of the national healthcare spend. The other changes are straightforward too and again require no new taxes and are not single payer.
Medicare already get gouged because of restrictions on leveraging their market power to negotiate best possible prices.
Medicare + Medicaid costs US taxpayers as much per capita as the NHS costs UK taxpayers per capita. Only the NHS provides universal cover for that cost.
The article has much more than that. Scroll down to "There’s No One Else to Pay the Bill" where it says:
"For fun, let’s imagine confiscating all the profits of all the famously greedy health-insurance companies. That would pay for four days of health care for all Americans. Let’s add in the profits of the 10 biggest rapacious U.S. drug companies. Another 7 days. Indeed, confiscating all the profits of all American companies, in every industry, wouldn’t cover even five months of our health-care expenses."
From some of the studies that I've seen of primary care practices moving to a cash only model, I think its in the range of 15-20% reduction in overhead costs. These were for the most part smaller independent clinics, so the number is probably lower for large health systems.
Generic manufacturers don't have anything to do with insurance companies, though, do they? Other than perhaps trying to convince insurance companies to put their drug on the formulary. It would be between the pharmacy & insurance.
I’ve been buying my drugs for cash for a decade. I’m lucky, I’ve got 5 prescriptions that run me ~$1000. I started when I found that open market pricing was lower than my insurance (UHC Optum) pricing.
Do drug companies get involved with insurance companies? I thought the pharmacies purchased the drugs, and then they handled that at the point of sale.
Yes, they do but the insurers don’t touch the drugs (unless they own a pharmacy too).
You know how a drug can be tier 2 ($25 copay) or tier 3 (20% coinsurance)? That often the manufacturer offering a lower price in exchange for easier and cheaper access for patients.
Drug companies can also rebate on the back end. If an insurance pays for 1,000 vials of drug, they get a 10% rebate. 2,000 vials, a 20% rebate.
Why do we need a system as complex as this instead of just funding healthcare through tax dollars and giving it to everyone like many other developed nations?
Can you show where the tax funded systems are not complex? It might remove some issues, but it can create others. I don't think a simplistic solution exists anywhere in the modern world.
You're right that the back-end of any healthcare system is complex, but a government-funded single-payer system is simpler for the end user (every citizen), that was my point.
Here are some things in the current system I'm hoping a single payer system would fix:
* I walk in, and they can tell me right away whether I will be billed or not. There's no "we'll see" and then maybe I get a bill in a few weeks.
* I walk in to a different doctor's office and the answer as to whether I'm billed or not is the same as at the other doctor.
* Because of these first two items, I walk in and they can tell me ahead of time what my bill will be.
* We can now replace "walk in" with "check their websites (or call) and comparison shop".
Maybe they can't tell me if my treatment is taxed until I'm diagnosed, but that still gives me the option to find out my bill before treatment. Once I'm diagnosed, if it's non-urgent I can shop around.
Price transparency is non-existent in US healthcare. There's no big mystery as to why that would cause inefficiency and absurd costs.
Insurance companies do have tools to price compare between facilities. I've used it on my insurance company's website. Manh states have price transparency requirements for cash payers too.
In the current US system, if your employer does not provide (any|sufficient) insurance coverage, you have to get your own and there are a million options all ready to fleece you. It is almost impossible to comparison shop and choose between 100 bad options.
Yes, the mechanics are the same (go to doctor, get a bill), but your purchasing power as individual patient is really small compared to a whole country.
"In the current US system, if your employer does not provide (any|sufficient) insurance coverage, you have to get your own and there are a million options all ready to fleece you. It is almost impossible to comparison shop and choose between 100 bad options."
I've been using the ACA marketplace here in good ol' Alabama, and I've had the opposite problem. There are four choices, all from BC/BS.
Note: I love the ACA. I will fight for the ACA unless and until I'm presented with an actual better option. Prior to the ACA, I had options from other companies, none of which covered my major problem.
I agree many options are bad. Even employer insurance is expensive.
Where is the individual's purchasing power a part of that scenario? Regardless of the group or person paying the provider, the bill is still substantial. The main money saver between the types is in system efficiencies like removing overhead, or instituting restrictions.
Maybe other governments. Medicare has billions in fraud each year. The process for signing up for Medicare and Medicaid can be complicated. If you've ever served in the military or government you know how much waste can be involved.
The difference is in the NHS everyone is "on the same side", so the amount of bill inflation and money juggling that happens is basically zero.
The NHS does demand management with waiting lists instead. Basically it's amazing for things that can be easily identified and given cheap medication for (insulin, antibiotics etc), amazing for emergencies which can be resolved with surgery, OK (but variable) for obstetrics, does a decent job at screening for common conditions, but tends to leave anything that won't actually kill you to wait.
At the same time you can get super-cheap private insurance in the UK because they are effectively a "queue-jumping service" that leaves most urgent and lethal conditions to the NHS and gives you access to private treatments for the things the NHS would put on a waiting list, while cutting their costs by renting excess capacity from the NHS (some private clinics are even run by NHS trusts, as the trusts are allowed to derive some income from private treatments).
I think the best demonstration of the quality of the NHS is that despite the low cost of private insurance in the UK, and despite the fact many companies offer health insurance as a perk, only about 10% of the population has any kind of private cover.
If you earn the poverty level or higher (to a point), you're eligible for subsidies. If you're below that level, you qualify for Medicaid, even without the expansion.
Do you have insurance? I fail to she how being healthy and not self-employed affects the scenario as described (present card, get treated, recieve a bill).
If you are not self-employed in the US, typically your employer provides insurance coverage, most of which is pretty decent. If you are healthy, it doesn't really matter either way; unless you are involved in a serious accident or something, your interactions with the health system are infrequent and relatively simple.
I have, among other things, asthma. I'm a 1099 contractor; I buy my own health insurance. Prior to the ACA, which people keep threatening to revoke, I could not buy insurance that covered my asthma. I tried. I shopped around a lot. The same company that provided complete coverage at a previous employer had a pre-existing condition rider on the same policy.
After the ACA, my policy now covers my pre-existing condition (Yay!), but I'm paying $750 or so per month for it. If I could not afford $750/month, my options would be considerably narrowed. (And that's before the prescriptions for my pre-existing condition.)
Yes, I go in, I get treated. But my situation demands a pretty hefty bill anyway, or potentially a very large bill. Possibly enough to make me consider not going to get treatment.
I’m sorry you have a chronic illness. Do you understand that this is not about insurance, but about your ability to share the cost of your illness with society?
"It feels like youre trying not to understand how a public option could be better."
This statement assumes a public option (which varies wildly depending on the one) is better.
The parent comment wasn't about a public option or getting a card. It was a complaint that recieving care at a provider is extremely complicated. At that stage of the process, that claim is incorrect.
That bill can be for an amount that varies wildly based on your insurance, the doctor, who helps the doctor, what lab they send things too, and a large number of other options. If things work out well, your bill could be for $30. If you don't remember to ask the right questions, the bill could be $30,000.
However, if your in-network doctor sends your bloodwork out to a lab that is not in-network, you're now paying a lot more.
Or (until recently), you go in for surgery where the surgeon is covered, but then get billed for an out-of-network doctor that consulted without anyone asking you.
One of the recent situations that I've heard about are nurse practitioners and doctors at your doctor's practice, contracted by your in-network doctor. The person who comes into the room to ask you what you're there about may not be in-network even though the ostensible doctor-in-charge is.
You can't. You should select a plan that covers you at all the local hospitals. If you look it up before hand you can usually specify which hospital you want to go to from memory. I do this not just for the network, but also for quality.
Then you should do research before going or accept that it is an unlikely scenario. This is what people do when travelling, especially internationally. You can also select a plan with the most extensive network to reduce the likelihood.
> If Cuban's idea is "we don't do insurance but you're free to pay with an HSA card or seek reimbursement from your insurance company" then this could be a huge winner.
This is the way it works for a lot of therapy and mental health services and it’s horrible. Prices are absolutely insane, practitioners are not accommodating to patient schedules, and patients have absolutely zero bargaining power.
In some ways doing it through insurance is kind of like a union. You all agree to accept certain inefficiencies, bureaucracy, etc., (and associated cost) in order for better collective bargaining terms.
Of course people with great jobs usually don’t care about unions. They don’t need the collective bargaining power and thus figure the bureaucracy cost is just a loss they don’t need.
Same thing with very healthy people and insurance. If you’re healthy you just figure, give me cheap catastrophe insurance, what do I care? But if you’re in the depths of the medical industrial complex because you need frequent treatment for chronic conditions, you quickly learn that papering everything over with lots of bureaucracy to adhere it to better collective bargaining for patients is way better, and I’d rather take the nasty, churning quagmire of price inflating insurance than deal with spartan libertarian mini-insurance that essentially just results in rich-get-richer (i.e. genetically lucky healthy people just get to save money while everyone else suffers).
I'm sure individual experiences vary widely, but I know several people getting frequent treatment for chronic conditions, and none of them talk about how happy they are that an insurance company is collectively bargaining on their behalf. Most of them curse their insurance provider with every breath, and are firmly of the opinion that it would shoot them in the head if it thought it could get away with it.
They clearly haven’t tried navigating treatment options in markets without insurance. I’m glad they are privileged enough (from the insurance) to make those complaints.
The supply and demand imbalance in clinical psychology and psychiatry is why they can choose to be out of network. Demand is not only wanting a good or service but being able to pay for it. Mentally ill people tend to have less or much less money.
The long term trend is not good; why become a psychiatrist when you can earn more as almost any other specialist? (With exception of pediatry). Jails are collectively America's largest mental health service providers. If there was money in psych work you'd see even private equity pump it up like urgent care chains.
Even with single payer or heavily regulated universal insurance schemes there's often a mental health services gap.
> This is the way it works for a lot of therapy and mental health services and it’s horrible. Prices are absolutely insane, practitioners are not accommodating to patient schedules, and patients have absolutely zero bargaining power.
I think that is more a supply/demand issue.
I am not sure why people aren't rushing to become psychologists, it seems like it'd be a profitable field, but there is certainly a huge shortage, at least in major metro areas.
I'd really like to read a proper analysis of the situation...
Is there any data to support this? I was talking to my therapist about it recently and she suggested the opposite. There’s a huge glut of therapists, they just only want to have clients who pay out of pocket because then they offload the work of any insurance reimbursement, paperwork or other overhead to the client. She also suggested therapists want good filters to avoid difficult clients, like low-income clients that have a hard time paying and have more difficult social or behavioral issues.
As I understood it, she was saying basically this:
1. therapists typically just want to work freelance, make their own hours, and don’t mind having very few clients / taking extended breaks from working many hours.
2. therapists don’t want to deal with “challenging” clients (who generally are the most in need of therapy in the first place). “Ability to pay out of pocket” is a good filter to implicitly reject “undesirable” clients.
3. therapists want to externalize the labor burden of coordinating with insurance onto the patient
4. None of this has any connection to charging higher prices - that’s a separate supply & demand phenomenon based on the talent of the therapist, population & demographics of the area, and specializations that deal with issues more correlated with wealthy clients.
My impression from all this has been a massive negative opinion of “working class” therapists and counselors, to the point where I believe they should be required to accept insurance and they should be required to manage the paperwork process of insurance claims as a regulated condition of practicing therapy - it’s a matter of public health that’s in all our collective best interest to enforce with regulation.
> Is there any data to support this? I was talking to my therapist about it recently and she suggested the opposite. There’s a huge glut of therapists, they just only want to have clients who pay out of pocket because then they offload the work of any insurance reimbursement, paperwork or other overhead to the client. She also suggested therapists want good filters to avoid difficult clients, like low-income clients that have a hard time paying and have more difficult social or behavioral issues.
Try to find a psychologist, not therapist (there are many paths to get qualifications to become a therapist, and not all of them are exactly HQ), in the pacific NW some time.
I don't know, maybe the government should regulate the predatory behaviors or business instead of weird libertarian strategy that is already not working for people who have no insurance and their life is destroyed when they get sick?
What? I went to a specialist today. My doctor scheduled the appointment. I had no say in it. This doctor is at one of two offices that I am allowed to choose from based on my insurance's negotiated contracts. This is insurance that is provided by my employer that I had no choice in. When I first saw the doctor, he prescribed meds that I had no choice in. The specific meds he prescribed were chosen as these are what the insurance company would prefer from a clinical perspective although they were extremely unlikely to help. And, on top of all of this, not once was I informed of the cost prior to services being rendered and if I had asked, I would have been told this wasn't possible.
How is any of this libertarian? The libertarian solution would be that only individuals would be allowed to purchase insurance, that insurance would distribute funds to the individual (not the doctor or pharmacy), all fees would be provided prior to service being rendered and individuals would purchase meds without a prescription.
> The specific meds he prescribed were chosen as these are what the insurance company would prefer from a clinical perspective although they were extremely unlikely to help.
I work close enough to healthcare that I can say that while insurers do take cost of treatment into account they are looking to minimize ongoing treatment costs - if there is a 5$ pill and a 500$ pill available for treatment the insurer may prefer to trial you initially on the 5$ pill if it's been proven effective for a good proportion of patients, but they do use calculations to minimize those ongoing costs that includes costs from condition escalation (i.e. if you have a boil you're absolutely going to get antibiotics covered since dealing with a septic boil is an emergency room visit.
That's pretty much what I described. I was prescribed antibiotics for a chronic issue. It made no sense at all, but the DR said it's what he must to do to follow the hospitals guidelines (which are determined by what the insurers want to see). I have gastro issues and modern antibiotics cause me all sorts of problems, so of course I had to deal with the pain and discomfort for 2 weeks all for something that made no difference whatsoever.
Did you try saying no, that you weren't comfortable with this solution, and you'd like to discuss other options? You can always discuss what options are available with your doctor and then reach out to your insurance to see what and why they will do about it. You may not get the answer you want, and it will use up a lot of your time, but it is an option.
Note: I've spent on the order of 30 hours on the phone over the past couple months trying to get things sorted out between my doctor, my insurance, and the provider of the drug that I need for my vision. The folks at the insurance can't always help, but they've always been willing to discuss things and see what they _can_ do.
Given the issue I'm dealing with, I'm more interested in getting it resolved than dealing with debates between insurance, dr, etc. This was the quickest path to getting an ultrasound scheduled, so I complied.
What should have happened is that they should do the ultrasound right there, on the spot. But, the dr's office can't do ultrasounds. That has to go to the imaging department, which had to be scheduled 4 weeks out. Sigh... I won't keep going, but this whole situation is stupid and engineered to extract as much money as possible.
I'm sorry to hear it was so difficult for you. I agree that it seems like every step along the way is there just to add more money (to what they can charge you or, for the insurance, what they can get you to pay instead of them). The long hours on the phone I mentioned are another expression of that (maybe if we keep giving him the runaround, he'll just go away). The fact that you're dealing with said issues just makes you more likely to give up, and they know that.
The next time something like this comes up, if you're feeling up to it, try pushing back. If you have the time to throw at it, the worst outcome of trying is usually just staying where you started.
At the end of my many hours on multiple phone calls getting everyone to agree to pay for treatment I need... the company in charge of making it called to let me know they've been retasked to making COVID vaccine and won't be making the drug I need for at least 3 months. So no treatment for at least that long. So that's fun.
What?? You had no say in it?? Your doctor forced you to accept the pill he chose??? Didn’t even talk to you about it?? Give you options?? That is weird.
The "weird libertarian strategy" came about through 20th-century gatekeeping by the AMA to prevent mutual aid societies and unions from paying for medical services, and it makes actual libertarians furious: https://reason.com/2020/04/05/how-doctors-broke-health-care/
In general, the US has a problem where it pretends to love free markets, but when you look under the hood there's horrific regulatory capture and crony capitalism.
The libertarian angle does not work in real life, even if we ignore the regulatory capture practiced by insurers. Because there are not enough doctors/nurses in the country, you as a patient will always compete for medical attention with other patients. This will only drive prices up.
Libertarians would also allow more doctors to be educated. We don't have enough doctors now because the AMA acts as a cartel to limit supply of doctors. Libertarians don't like that either.
The free market has decided that they don't want more doctors educated though. Guilds are very free market, do you not believe in freedom of association?
I guess the true libertarian answer is that we don't really need certification at all, or that anyone should be able to start their own certification board. Like Rand Paul and his fake ophthalmology board he started to give himself credentials.
Nothing is ever libertarian enough until we've removed all the regulations and let quacks practice medicine, is it?
Which is exactly the “libertarians want to be able to make up fake credentials like Rand Paul’s fake ophthalmology board he made up for himself” I mentioned.
Essentially, yes. People refuse to understand that it is impossible for there to be a "health care market" in the usual sense because (1) like cable, running a hospital or clinic is expensive enough that many people have only one option, whether or not it is regulated, and (2) unlike cable, many people cannot choose whether or not to participate.
To me, libertarianism is simply “might makes right,” with the liberty part being everyone has the opportunity to grow into a bully. I’ve never seen a SINGLE libertarian policy that couldn’t be interpreted this way, and I’m quite open to being corrected.
Here's a handful of typical libertarian positions (though certainly there's some variance): pro-choice, anti-war, pro-civil rights, pro-immigration, anti-drug-war. They don't seem to match your description of "might makes right".
With respect, this feels like moving the goal posts. The position has to disagree with the Left to count?
How about Kelo vs New London? This was the Supreme Court case establishing that the government could use eminent domain to seize people's homes and hand the property to private developers, in the interest of raising tax revenue for the city. Libertarians were against it; liberals were for it. Is that "might makes right"?
So libertarians support laws making legal subtle force and fraud, ca. carried interest, private prisons, private ownership of everything, with no commons.
Libertarianism started on the far left, explicitly opposed to private property, largely overlapping with anarchism. Modern US-style right-wing libertarianism basically cribbed most of it but added a property right fetish.
(Dejaque, the founder of libertarianism called Proudhon, the founder of anarchism, a "moderate anarchist, liberal, but not libertarian")
The last time this came up, several people responded that they would be happy to go to a 'doctor' educated on YouTube.
Which is lovely and all, until those doctors tell you vaccines are worthless and dangerous, and to slather a mixture of beef tallow, garlic, leek, and honey on your injuries.
The issue is how you, as a (potential) patient, is going to interpret the fact that Doctor X graduated from a given med school. As a reader of libertarian stuff for 30 years, the usual answers are some combination of:
1) independent rating agency for med schools
2) independent rating agency for doctors (i.e. med school was irrelevant)
3) patient reviews for doctors
25 years of amzn have helped established serious questions about (3)
(1) and (2) have the usual "who watches the watchers?" problems, which are fairly isomorphous to the problems with (3). And even without those issues, who wants to have do this level of research? Yeah, I know, libertarian nerds (meant with all possible respect). But almost nobody else.
Part of the point (not all of it, to be sure) of things like the AMA, the FDA and other governmental regulation is to make people's lives simpler. Stop worrying about whether the doctor you're going to see has even met a basic level of medical qualification, and focus on whether you like their personality and approach, for example.
> (1) and (2) have the usual "who watches the watchers?" problems,
Since we already deal with “who watches the watchers” problems in our current system, I see no problem here.
> And even without those issues, who wants to have do this level of research? Yeah, I know, libertarian nerds (meant with all possible respect). But almost nobody else.
Anyone who wants a good physician.
> Part of the point (not all of it, to be sure) of things like the AMA, the FDA and other governmental regulation is to make people's lives simpler. Stop worrying about whether the doctor you're going to see has even met a basic level of medical qualification, and focus on whether you like their personality and approach, for example.
If those things worked, this would be a point. Currently people can’t even afford to go to medical school, or afford to see a doctor, and when they get past the gatekeepers they are so desparate to get treatment that they can’t really even fathom rejecting a doctor because of a poor bedside manner.
> If those things worked, this would be a point. Currently people can’t even afford to go to medical school, or afford to see a doctor, and when they get past the gatekeepers they are so desparate to get treatment that they can’t really even fathom rejecting a doctor because of a poor bedside manner.
Other countries with socialized health care systems (i.e. doctor credential gatekeeping) do not have these issues (certainly not to anything like the extent that we do). I suspect therefore that changing the credentialling process is unlikely to have much impact on these issues and/or is not the most effective way to impact these issues.
> Anyone who wants a good physician.
I'm 57 years old. I've never, ever met anyone who isn't a libertarian nerd (I have friends ...) that checks to see what medical school a physician attended. If they are "checking" at something approximating that level, they do so via clinical affiliation (e.g. "anyone at the Mayo has to be great").
> Since we already deal with “who watches the watchers” problems in our current system, I see no problem here.
Not really. The "watchers" in our current system are government agencies, not private (potentially for-profit, or at least for-big-salary) corporations. The incentives align in significantly different ways.
> I suspect therefore that changing the credentialling process is unlikely to have much impact on these issues and/or is not the most effective way to impact these issues.
The easiest way to expand medicine access would probably just be to remove government restrictions on the number of medical schools, the number of hospitals, and the number of physicians. I don’t think we need to dismantle the credential system.
> I'm 57 years old. I've never, ever met anyone who isn't a libertarian nerd (I have friends ...) that checks to see what medical school a physician attended.
This why we have to be careful about generalizing from our own experience conclusively :)
> If they are "checking" at something approximating that level, they do so via clinical affiliation (e.g. "anyone at the Mayo has to be great").
There’s how things are, and how things should be. People ought to take more responsibility for their healthcare and that includes who provides it.
> Not really. The "watchers" in our current system are government agencies, not private (potentially for-profit, or at least for-big-salary) corporations. The incentives align in significantly different ways.
Perhaps you haven’t noticed but the watchers in government agencies and the for-profit, big salary corporations they are supposed to be watching are the same people. its called “regulatory capture” and “revolving door”.
This seems to suppose one (or both) of two things:
1) access to medicine is limited because of the supply of health care providers, so more providers would help
2) access to medicine is limited due to cost, and more providers would force the cost down, as per "supply and demand", "the market" etc.
I'm not aware of much evidence for (1), though I don't deny that it is possible. For (2) to be true, it would have to be the case there can actually be a competitive marketplace for all kinds of health care, and we know that this is not true for (at least) emergency care. Many volumes have been written by people much smarter than me that explain the many reasons why health care is not really susceptible to what are supposedly "normal market" behaviors and benefits. Just increasing the number of doctors will (a) not necessarily drive down the cost of health care nor (b) expand access to health care.
> This why we have to be careful about generalizing from our own experience conclusively :)
Certainly in general, this is true. But when the claim is that "anyone who wants a good physician" would do this, not so much. Falsifiability, and all that.
> People ought to take more responsibility ...
This is a moral statement, not some sort of fundamental statement about the nature of reality. Not only is the level of personal responsibility up for the debate, but so is the form such responsibility should take. Citizens in many other countries have chosen to "take more responsibility" for their healthcare in different ways than you are proposing (by taking aggregate action to create socialized health care systems that delegate many things to the system, intentionally).
> Perhaps you haven’t noticed but the watchers in government agencies and the for-profit, big salary corporations they are supposed to be watching are the same people. its called “regulatory capture” and “revolving door”.
Speaking of over-generalizing ... also, "There’s how things are, and how things should be." I do not believe that regulatory capture is an inevitable outcome of a democratic-ish governmental structure.
> For (2) to be true, it would have to be the case there can actually be a competitive marketplace for all kinds of health care, and we know that this is not true for (at least) emergency care.
I’m really not sure what to make of this, there is already a market for things such as emergency care. Even with all the regulation, when you get in an ambulance you can tell them to take you to a specific hospital.
When people are treating non-emergency conditions, the same regulated market offers them even more options. Ikm not really sure what you mean here.
> Many volumes have been written by people much smarter than me that explain the many reasons why health care is not really susceptible to what are supposedly "normal market" behaviors and benefits.
Many volumes have been written on how the four humours can be used to diagnose and treat disease. However modern medicine no longer uses the four humours model. Perhaps it is also time for modern medicine to embrace the scarcity management aspects of markets rather than looking for answers in musty old volumes.
> I'm not aware of much evidence for (1), though I don't deny that it is possible.
It is not only possible, it is the case. The bottleneck is at schools, at residencies, and at licenses. Possibly elsewhere. In a basic simple mathematical way, fewer providers means less access to care.
> Certainly in general, this is true. But when the claim is that "anyone who wants a good physician" would do this, not so much. Falsifiability, and all that.
Certain values of “want” may not be sufficient, as with anything else. Anyone who wants a good physician enough to look for one would perform the due diligence required to obtain one. Kind of like now, actually.
> This is a moral statement, not some sort of fundamental statement about the nature of reality. Not only is the level of personal responsibility up for the debate, but so is the form such responsibility should take. Citizens in many other countries have chosen to "take more responsibility" for their healthcare in different ways than you are proposing (by taking aggregate action to create socialized health care systems that delegate many things to the system, intentionally).
Yes, its a moral statement. And its an interesting question whether people who entrust bureaucrats with healthcare have taken reaponsibility or shirked it.
> Speaking of over-generalizing ... also, "There’s how things are, and how things should be." I do not believe that regulatory capture is an inevitable outcome of a democratic-ish governmental structure.
The problem is that things like social planning of healthcare provision are evidently flawed in every respect due to the belief that they can’t be trusted to markets. We don’t want to believe we are getting competent care because the government says so, we want to have confidence we are getting competent care because the incentive structure is aligned witn the outcome from the patient’s perspective. We don’t want to believe we are getting the best price for drugs because a bureaucrat claims to negotiate on our behalf with his cronies, we want to know that we get the best price in drugs because they are sold in a competitive market where companies are rivals for the business of patients.
> Even with all the regulation, when you get in an ambulance you can tell them to take you to a specific hospital.
A) you may be unconscious B) you may not know anything that would allow you to differentiate ER facilities C) you almost certainly have no information on the current wait times at an ER facility, let alone specific physicians on call D) you may be unaware of the intersection between your insurance and hospital choice (for example, I had insurance once that only covered care at a (very fine, major urban) hospital that was unable to treat my amputation accident).
So really ... just no.
If you're going to start dismissing the fact that smart people have written smart stuff on a topic by saying that we revise what is considered smart, then I'd just do the same in reverse, and say that none of the worldview/policy view that you're arguing for is supported by anyone worth paying attention to, since it's all just out of date and/or will be consigned to the trash heap of history very soon.
The books I am talking about are not "musty old volumes".
> In a basic simple mathematical way, fewer providers means less access to care.
That's a response to a completely inverted point. If there are already enough providers, then more providers doesn't mean more access to care (certainly not based on access to providers, rather than cost).
> The problem is that things like social planning of healthcare provision are evidently flawed in every respect due to the belief that they can’t be trusted to markets.
You're on the edge of a no true scotsman argument here, which means I'm going to bed.
Insurance companies are a symptom of the problem but the real solution is either single payer, something NHS like or something like the German model (which is probably the most similar of the major countries to what the US has now - though it’s still three quarters state funded).
The NHS was to an extent a statistical fluke (right politician in the right place, just post-WWII) that the right wing has been trying to dismantle for decades, without WW2 I’d be surprised if we had anything like the NHS.
Basically you need politicians to ignore the lobbyists and do their job of regulating this shit for a better society.
Sadly I don’t see it happening though there are some hopeful trends.
There is no single solution, the world isn’t that neat however the NHS problems and it does have them are a result in large part to it been a political football for decades.
Even with those problems we spend about half per capita on healthcare with about equal outcomes, also the US gov in one form or another already foots about 50% of the bill itself.
> Results The UK spent the least per capita on healthcare in 2017 compared with all other countries studied (UK $3825 (£2972; €3392); mean $5700), and spending was growing at slightly lower levels (0.02% of gross domestic product in the previous four years, compared with a mean of 0.07%). The UK had the lowest rates of unmet need and among the lowest numbers of doctors and nurses per capita.
They do more for less with less and mostly do it well.
Compare that to any other major country and it’s good, compared to the US system it’s very good.
Does the US have amazing doctors, hell yeah of course but do they have a fair system when on average everyone gets what they need if not always what they want, I’d argue no.
Ironically, the US Employer-Oriented health insurance also exists in large part because of the US response to WW2.
During the war the US froze wages in order to try and prevent skyrocketing salaries due to the extreme demand for labor.
To compete, most employers started offering generous benefit packages in lieu of the raises they were no longer able to offer.
After the war, the larger employers found that the generous benefit packages were more cost-effective at retaining employees compared to higher pay, so they became "fans" if you will, and have supported the employer-based benefit programs in the US ever since.
The German model is really quite interesting, even though some aspects are extremely strange (like high income earners opting out of the public system or public servants mostly using private insurance). I like that public insurance companies still need to compete with each other on customer service etc. America is probably beyond help but I could see a system where 5% of your income HAS to go to an insurance company that you can choose gaining acceptance.
The Australian private insurance system also works like that. Private insurers have to offer pre-defined tiers with pre-defined coverage.
> The average American can’t afford a 400 dollar expense
The average American has $432,000 in net assets, is the second richest in the world (behind Switzerland), and can trivially afford such an expense.
Did you mean that around 12-16% of the population can't afford an immediate out of pocket $400 expense? Because that's the real figure according to the Federal Reserve study that's constantly misquoted.
The median American has a higher net worth than either Germany or Sweden, and among the highest disposable income of any nation.
Now that’s just being petty with stats. You knew I was talking about the majority of Americans not the richest. Sure if you take the arithmetic average of assets it will come out very high. But that’s because the millionaires and billionaires skew the numbers.
Exactly. A bond trader steps into a subway car and the other people are some college students, a hobo, and some essential workers. The average wealth doubles.
"Poorer" countries than the US like Portugal, France, Japan, UK have far better health outcomes including lower infant mortality, lower chronic diseases, better life expectancy than the US.
As far as infant mortality and life expectancy, the picture is a lot more complicated than you portray.
The US is including in their life expectancy data cases of stillbirths or nonviable fetuses at birth, which are not recorded in EU numbers, for example.
" measurement problems arise in international comparisons because the data are not consistently gathered or reported. Although the World Health Organization (WHO) has a formal definition of what should be included in the infant mortality statistics, anecdotal evidence suggests that countries do not use consistent practices in measuring these data (Haub and Yanagishita, 1991; Hartford, 1992). "
The biggest problem is that most of the money in healthcare actually goes to pay salaries, mostly those of nurses and doctors, but administrators are up there too. Pharmaceutical companies are not as profitable as one might imagine, and drugs are a relatively small fraction of total healthcare costs.
That is a pretty vague statement which I've not seen born out. I work in tech loosely associated with healthcare and I've needed to learn how the different companies involved in the charging process interact and it's super murky - there are a lot of "preferred rates" offered by HCPs to insurers. These "preferred rates" end up leading to the outrageous out-of-network charges some folks have been exposed to. These only seem to exist to justify the constant spending into marketing and sales on both sides to make it appear that negotiations are saving companies 80% of the "cost" in their partnership - while nobody ever ends up paying full price except really unlucky patients. Additionally the system of manufacturer rebates on prescriptions appears to exist solely to bump up the price to insurer - so a 80$ med sold for 160$ with an 80$ rebate might trigger the insurer to pay out 80$ as half the cost of the medication before the patient receives the medicine for free due to the additional rebate - this ends up squeezing the insurer who will squeeze the patient all that much harder when it comes time to settle the monthly fees.
The US system is absolutely lousy with corruption and ends up diverting a large amount of money toward marketing which is rather baffling - whether a treatment is appropriate or not is a decision I'd rather my doctor made on the basis of efficacy - not because one of the companies had a catchy jingle or because one of them recently took him out to lunch.
Hospital administration does cost a fair amount, but be careful here - it's like education - some of those administrators have moved up the seniority chain to positions where they essentially do nothing and get paid for having their ass in a chair - but a lot of that administration goes to fighting against the extremely aggressive tactics of insurers and manufacturers. While those administrators would ideally be unnecessary due to better regulations being in place they do provide justifiable savings for the hospital (it's cheaper than not having them in many cases) under the current system.
Pharmaceutical companies are actually far more profitable than I imagined.
Pharma companies enjoy a profit margin averaging 26%, medical device companies 12%, and hospital groups (which includes non-profits) 8%. Insurance companies are closer to 3%.
Salaries are certainly a part of it - medical staff are paid much lower in other countries.
Because they don't have to pay for their education. Governments there recognize that having lots of doctors is a public good and don't saddle them with hundreds of thousands of dollars of debt from medical school.
Doctors aren't the ones who pay that medical school bill (if they get a job). It's their patients who pay the medical school bills.
The problem of medical expenses in the US is a very complex one. It's essentially at the nexus of a whole bunch of problems with our society. Higher education is too expensive. We have too many middlemen. Strong intellectual property laws make drugs and devices expensive. Patent laws make evergreening more profitable than innovation. Intense regulatory requirements for approval make competition very limited for pharmaceuticals. The government doesn't maintain control of the products resulting from the blue-sky R&D it funds. etc etc.
This will partially ignore your attribution that the US problem is a complex multi-faceted issue (I agree with that but wanted to focus in) - you mention that higher education is too expensive and suggest that there are many other societal factors that make the US noncompetitive. This can cause an effect like we're seeing with the US healthcare market but the US does well in a lot of the more transferable industries (like software development) and I'm not seeing how the factors you're highlighting for healthcare wouldn't equally apply to all of those transferable jobs.
Software scales extremely well. Healthcare suffers the same baumol's cost disease as education and any other labor intensive industry including construction.
This is like saying that filet mignon from French laundry is expensive because he has to pay his wait staff top dollar. Fine. But.I can still go to costco and buy a great steak for a reasonable price and cook it myself. And if I want to I can buy a whole cow.
A lot of countries have much better health systems, with people fully insured (this is really designed for people who are underinsured), with significantly better outcomes, than the US. The US lifespan is also significantly trailing compared to other developed countries, and we are not a “normal” country at all. It’s going to be more appalling by 2040.
You can spend hundreds of hours studying the data on that website, along with extreme specifics about medical care. I used it to inform my decision of where to live in Europe with rare immune mediated neurological diseases and type 1 diabetes.
The problem with drug prices isn't because of the drug manufacturers, it's with the middle-men and private insurance companies. At least, that's what the manufacturers are saying
For instance, with the manufacturers of insulin, none of them are American and they offer to sell the insulin to everyone at the same price.
The problem is that the large insurance companies use just three middle-men drug buyers called Pharmacy Benefits Managers (PBM) who DEMAND growing discounts every year from drug manufacturers, so the drug manufactures have to raise the prices to the US market every year to keep making a profit.
Novo Nordisk is willing to sell insulin much cheaper, but the drug buyers demand about a 75% discount off of the wholesale cost or they'll make the product not covered by the insurance companies they represent. To compensate, they raise the wholesale price in the US so after the forced discounts, they still make the same amount of money.
The people who suffer are the ones who don't have insurance.
The solution, at least in the case of insulin, isn't cheaper prices from the manufacturer, it's for the US to pass a law that prevents insurance companies from dropping a product based on the refusal to discount the product if it's under a certain price-per-month.
Two different things entirely. The fake “Discount off MSRP” demanded by the PBM has nothing to do with the profit margin of the PBM, that would be based on markup they charge to their customers above the price they actually pay.
But the regular uninsured consumer sure gets screwed.
I think this is why there are now self-pay “codes” you can give a pharmacy to get a significant discount off retail price. Sometimes less than your co-pay, but of course then it doesn’t count toward your deductible.
I wish they would simply ban these pricing gimmicks as part of a price transparency law.
There should be one price and one price only the manufacturer can charge in the USA per dose of an FDA approved medicine, with no ability to do price differentiation, period. No more negotiating, no more kickbacks. Insurance should have to show you the actual price they paid, and no other. And then you pay the patient responsibility of the bill based on your standard policy formula.
The same pricing transparency should be applied to labs and procedures where it should be illegal for a given facility to charge two different patients two different prices for the same product or service.
That 2-3% is for the insurance layer, not the parent organization.
Consider CVS Health which owns Aetna (an insurer), Caremark (a PBM) and CVS (a pharmacy). Aetna is required to spend 80% on premiums whereas Caremark and CVS face no such constraints on their profit margins.
There's a reason why there's so much M&A in this space while consumers are simultaneously facing higher premiums.
The 3% to 5% profit margin is for the whole company. For all the hate health insurers get as profiteering parasites, their owners sure aren’t pocketing much.
Similarly, Anthem at 4.22%, CVS at 3%, Cigna at 3.38%, Humana at 5.58%, Molina at 4.57%, Centene at 2.12%.
The reason there’s so much M&A in this space is because there’s no margins, so it’s either go big and win in economies of scale, or go home and go out of business. And people face higher premiums because more people are getting more access to healthcare. There’s no lifetime benefit maximums or pre existing condition exclusions anymore. And the highest premiums are capped at 3x the lowest premiums.
A similar situation in local political health care plans. I did medical billing. Our local govt agency (this was for medicaid level care) required that they only pay 25% of the price of the service. When 90% of your patients are on medicaid, you raise the price so that 25% of price is now what price should be.
But very funny when someone comes in and wants to pay cash. While that would be SO much easier than dealing with the agency - you got to charge them 4x so some politician and HN posters can go on about how much money the govt "saves".
I just wish prices (cash paid) had to be posted publicly.
I got a very nice discount on some dental work that was considered 'cosmetic' and not covered by my shitty dental insurance who thought amalgams were just fine for molars. They were going to pay like 25% or something silly like that.
So we went sliding scale uninsured, and despite being in the top end of the scale, I ended up paying about 1/3 less than I would have through insurance. I probably still ended up subsidizing some kid who needed fillings worse than I did, which was the only silver lining in that whole stupid affair.
How would forcing insurance companies to pay whatever drug companies ask not just raise insurance premiums? How do you differentiate dropping a drug because they're not willing to sell underpriced from dropping a drug because it's overpriced?
There is a similarly interesting, nonprofit drug company that is trying to resolve shortages and price problems, and where the founding hospital system is also a nonprofit with a very good, long-term reputation (and good personal experience--their intake forms to get a blood sample drawn totaled 2 reasonable pages, where the next-nearest hospital came out at 11 pages of icky legalese including documents by reference), and have generally done friendly good work for a long time as far as I can tell.
Wikipedia says (lightly edited here for brevity): "Civica Rx is a nonprofit generic drug manufacturer .... started by national philanthropies and leading US health systems. By [EO] 2019, over 45 health systems representing 1200 hospitals were members of Civica. Member ... pharmacists and clinicians help prioritize the medications Civica makes.... By the end of 2019 Civica had 18 medications (28 SKUs) in production, and plans to bring over 100 medications to market in five years through various manufacturing approaches such as partnerships, developing ANDAs, and building its own manufacturing capability. ... The first shipment of Civica private-label medication was vancomycin, delivered to Riverton Hospital, a part of Civica founder health system Intermountain Healthcare, in October 2019." ( https://en.wikipedia.org/wiki/Civica_Rx )
(edit: somebody else here also mentions civica and has a couple of other links, in their comment.)
Does Tablet, mean one, single pill? ( Just making sure )
And they sell Albendazole for $225 Per tablet in US?
And quote
>our cost to make and distribute the drug is approximately $13.00 per tablet
It cost $13 to make one Tablet, or one pill?
And this is lowcost?
Anyone from Europe or UK living in US could sort of explain a little bit here. I know US medication are expensive, but this is... something else. I cant comprehend what I am reading here.
I'm reminded of the time I was in the EU, in an area where tourism isn't common. Due to a lack of planning on multiple levels, I had to stay an extra two weeks. I went to get a refill for a prescription I need.
The pharmacist was clearly unconformable with the discussion that needed to happen. They informed me there would be a charge for the medicine. After some back and forth because neither of us was fluent in the other's language, it turned out they were asking me to pay the cost of the drug, an amount of money less than my normal copay, and something like 5% of what my insurance claimed the drug normally cost.
The pharmacist was most confused why I was happy to pay. I don't think they believed me when I tried to explain how much it normally cost me.
The pharmacist told me that they were having a hard time confirming my insurance. After a ridiculously long delay, I asked how much the drug was to pay for out of pocket... It was $12. My copay was $10 anyway. So both the pharmacist and I wasted a lot of time and hassle trying to save me $2.
I think they don't want to make judgements about your ability to play.
It's one reason why there's prescription-strength ibuprofen. I can personally just go buy OTC ibuprofen and take the required dosage, but some people can't afford that, so they get the prescription strength where their out-of-pocket cost is $0.
can't afford it? in the UK ibuprofen and paracetamol are like, 20p for a pack of 16!
though I do miss the giant packs you get in the US, all pills come in small blister packs with purchase limits in all shops, to make overdosing more difficult
Had a similar situation in India. I'd fallen ill and my partner went off to find medication. Spoke with a doctor/pharmacist who gave her an assortment of packets of tablets, rehydrating sachets and so on.
~This medicine is for sale here in the Netherlands, over the counter, for $3.3 dollars. No that period is not a mistake.~
~That's for a pack of 6 tablets. How the heck do they end up at $13 cost?~
Edit: Google autocorrected to a similar drug. This specific drug is actually $4.50 per tablet here and prescription only. That's still a massive difference.
Relevant sidenote: it's fully covered as well so I wouldn't even get a bill.
>This specific drug is actually $4.50 per tablet here and prescription only.
Yes. It is like someone told you a canCoca ColaCoke in US is $220, and their latest innovation is to give you the same for $20.
All while you are picking one up at a convenience Store in EU for $1 and you can get a pack of 8 in a large supermarket for $3.
As you walk out of the convenience Store while drinking your coke, you are left wondering what the hell is going on with people and the world across the pond.
And that medicine is likely subsidized. If this company is truly transparent, then we can see that it cost more than $3.30 to make it. So you are paying more, just in taxes.
Yes, a tablet is a single pill. Sometimes you'll split the pill, so a tablet might be 2 doses. But 1 pill.
Note that retail pricing is an unreliable indication of actual cost to consumers. They jack it up so that they various plans can claim huge discount policies. Some of these plans are free, so there's very few people who are paying this "retail" price.
The pill makers get paid by the consumers and, in most cases, by the plan-owners. And such agreements are made exceedingly complicated. IMO, only to make them more opaque and more difficult to regulate.
Unfortunately, such a system is highly regressive as the richest tend to have the best plans, the poorest tend to have a meager plan, and the transient have no plan other than showing up at a hospital.
* hospitals run as non profits, so they dont pay federal taxes
* they still pay local taxes, so they need to generate a large loss to offset these taxes
* insurance companies negotiate huge "discounts" on list prices, and then go back to their customers (large corporations) and boast about these discounts, meanwhile the hospital gets its tax writeoff
This entire system is rigged to also grow the number of hospitals/ the overall size of healthcare in america.
Pharma companies play this game too, and anyone who doesnt have insurance can quietly get a "coupon" from them to bring down the cash price to the same as insurance.
No politician will close hospitals, so at this stage any move to "single payer" will just move the boasting role to the government.
Yes, medical care is absolutely insane here. Like jaw dropping on a nearly daily basis insane. Lots of Americans just don't realise how much they're being screwed by the system that has been built, and they buy in the narrative they constantly get told about it being the best health care system in the world, and that coming with a cost.
Note: few people will pay that $225. Most of that gets handled by your health insurance, who will often also have bulk purchasing deals with medical companies that helps drive down the cost to them. You do have a co-pay to cover, plus a little extra, so it's still more expensive than you'd pay in the UK for medicine.
Prices can go as low as $300 for two tablets, if you have a GoodRx annual subscription. I think the $13 is actually a wholesale substitution price, as there are lower prices available for this drug for the same dosage through veterinary channels.
GoodRX has the cheapest at $140 for a pack of 4 200mg. $35 a pill, not the $225 that Cuban's website says.
Cuban's actually playing pretty fast and loose with numbers here. He says $15 wholesale for $20 retail. But usually retail is going to have higher markups than that. Especially for stuff that has to be verified by a pharmacist. His $15 probably isn't much if any discount off the existing wholesale price.
I'm inclined to trust Wikipedia more than Cuban. They had a wikiwar sometime back about the inclusion of drug prices (the anti-price faction won), but older article versions still list the sticker price in the developing world at USD 0.01 to 0.06. That's credible, considering what a simple molecule the active principle is.
Just guessing, I suspect that the regulatory environment in the US adds cost. It costs more to buy or lease the space here, and it costs more here to hire people. It all adds up.
Albendazole is a large-volume generic, the manufacturer will sit somewhere in India or China. The stuff already has FDA registration since you can buy it in the US (although at wildly inflated prices).
Not really defending anything here. Just saying that producing drugs in the US costs more than other places. Unless they are buying tablets from a manufacturer that are already FDA approved, they still have to prove the similarity of their generic product to the FDA - the product has to provably be what it is labeled to be.
"We will let everyone know what it costs to manufacture, distribute, and market our drugs to pharmacies. We add a flat 15% margin to get our wholesale prices. This makes sure we remain viable and profitable. There are no hidden costs, no middlemen, no rebates only available to insurance companies. Everybody gets the same low price for every drug we make."
I guess we'll get to see where the price comes from.
For some context on why this cost-plus is necessary and great, several generic manufacturers have been colluding and price-fixing. There are ongoing lawsuits from the Department of Justice and 46 states, and at least one pharma co pled guilty, and was fined $200 million.
I wish cost plus worked but its just as easily gamed. Ive seen many industries that contracted cost-plus and the costs magically went up a lot. If there is money to be made the system can always be gamed/contorted/scammed, etc...
While true, wouldn't the point of such a rule be to provide a framework for fighting against exactly that? Without the rule they don't even need to try to manipulate the books, so there's even less to find as evidence that might be used to either improve the rule or enforce it differently.
Of course, market pressure is much simpler if one manufacturer just decides to do it according to a consistent and justifiable method and stick with it.
> Without the rule they don't even need to try to manipulate the books
Screwing with cost plus doesn't require manipulating books. If you're passing on your costs, you have no incentive to find cheaper suppliers. Need to hire a bunch of people? Meh. Guy didn't show up to work for two weeks? Not your payroll, really.
Enabling new entrants where possible, and regulating where not, is a simpler and more-scalable solution. Pharmaceuticals manufacturing seems to be light on the former.
Thank you for the explanation, I do agree that such a system does discourage you from using less expensive suppliers... assuming a lack of competition which you rightly point out is the bigger issue.
Of course, if there were sufficient honest competition it wouldn't need to be cost plus either, it could just be an honest competitive market price.
As long as they are actually manufacturing it the main pressure would be when they inevitably internally question why they are selling it for less than market price. I have seen that discussion, there's a big difference between "we can sell it profitably for this much" and "we can sell it for this much and make this much money".
So how do you provide that internal pressure? One honest competitor that publishes transparent methods for estimating the cost of manufacturing the drug along with case studies making it easy to do in other cases, and commit to using that process.
Or medicare of course, I don't see any reason it needs to be a private company. If they could estimate the true manufacturing cost in a vacuum I would certainly hope they could negotiate better but maybe they just don't know how because they aren't the manufacturer.
Quite damning, and that's only the most blatant infractions, because it's such a high bar to prove collusion and price fixing. The most disingenuous tactics to prevent competition that are harder to prove in court continue to cause harm to the average consumer nevertheless.
I heard once that cost-plus is related to the bloating of US defense budget and Boeing, Lockheed etc post WW2. Could someone familiar share some thoughts on what differences there are w this in pharma?
It is definitely related to the bloating of the military budget but Cuban's pharma idea is different than the "cost-plus" of the military. It's an unfortunate name collision that seems like an unforced error by Cuban since people like you (and many others) make the same association, even though the name is quite descriptive and accurate when used correctly.
What follows is a lengthy explanation of federal contract types, awards, and some light commentary on what you posited.
Federal contracts are usually, but not always issued under the rules of the FAR. Within the FAR there are several types of contracts supported including among others Firm Fixed Price (FFP), Cost Plus Incentive, Cost Plus Fixed Fee (CPFF), and Time and Materials (T&M). The other way that contracts can be issued is via an OTA or (Other Transactional Authority) and I won't really discuss those contracts as apart from semantics they usually obey the FAR rules as pertains to this discussion.
In a Firm Fixed Price contract, the contractor is considered to be holding all of the risk. The contractor is responsible for fulfilling the terms of the contract and must meet those requirements even if in doing so they lose money. When bidding a FFP contract, you develop an estimate of the work required, determine what the risks are and assign mitigation costs and likelihoods, determine what your desired profit margin is, and offer the government you best and lowest price. Usually these contracts are competitively awarded although that is not always the case (a). The "Firm" in FFP does not mean that the price can not increase. If the government changes what is desired or incurs costs on the contractor that were not specified in the original contract, the contractor can request equitable adjustment. FFP contracts are most commonly used when producing goods with known qualities that already exist or require slight modification of existing goods in the market.
Cost Plus contracts (Cost Plus Incentive or CPFF) entail cost sharing between the government and the contractor. In a Cost based contract, the government is considered to hold some of the risk. These contracts are generally used as development contracts when a new or significant evolution of an existing system is required. The government is responsible for reimbursing the contractor their costs incurred during development. These costs include both direct and indirect costs. Direct costs are what you would usually assume is meant by cost, e.g. the actual cost of the people and equipment used in pursuit of a single contract objective. Indirect costs are costs that are incurred in support of multiple contract objectives e.g. lighting and power for a building, HR and finance people. Significant portions of the FAR are involved in cost pooling and I won't get into it much more here. Because the government is responsible for reimbursing costs the contractor is not under as great of an obligation to minimize those costs. Effectively, there is a very low risk of losing money on a Cost contract because your actual costs are reimbursed. In cost contracts, the government can use the allocation of profit (fee) as an incentive to have the contractor meet time or total cost goals but is still responsible for reimbursing all reasonable costs. Most major new systems development happens under the guise of Cost contracts although some have been developed using FFP or OTA mechanisms. If the contractor fails to perform, the government will usually still reimburse the costs up to the point where work was stopped. It requires a lengthy legal battle to recover costs in a breach of contract suit.
Time and Material contracts are the most disfavored by the government. They have no performance objective apart from labor. The contractor is required to supply labor in a desired quantity and place but no actual performance (e.g. those 10 guys actually finish digging the ditch) is embedded. These contracts are fairly rare but are used occasionally.
To address the asked question regarding budgets post WW2. The Department of Defense publishes a daily list of every contract awarded above a certain value (I think 2 million) here https://www.defense.gov/Newsroom/Contracts/. Contract modifications (and new delivery orders under an existing IDIQ contract vehicle) Most of the largest of these contracts seem to be awarded via the sole-source justification. It is hard to put the blame squarely on cost contracts. There are cases, say developing a novel weapon system, where the government can not fully articulate it's needs at the starting point. Over-specification of requirements will cause the bidders on an FFP to give higher prices because they must be able to account for every requirement in their bids. When developing a brand new system, cost contracts can be effective although I do agree that the mechanism is over applied. I also believe that the sole source justification to avoid competition significantly undermines the cost control measures of both FFP and Cost contracts.
Now to briefly discuss what I believe is happening with this company. They appear to be functioning under rules most similar to CPFF, so I will analyze along those lines. Do they have a contractual goal? Yes, they have to produce the drugs needed based on transactions and contracts they accept. Do they have a reason to minimize their costs? Yes, their entire existence is predicated on the price differential between their products and those of other members of the market. If they allow their costs to balloon beyond a certain point, it will diminish their marketability. It doesn't mean that the stated margin will be over raw material and production costs as marketing is also included. I would like to see a public commitment to price transparency including all major line items in the cost similar to what is done with not for profit organizations (they have alluded to doing so with the statement "We will let everyone know what it costs to manufacture, distribute, and market our drugs to pharmacies.")
Source: In a previous life I was heavily involved in the bidding and management of DoD contracts.
It is nice to sue all of those companies for colluding. But can't you just import those drugs for less from India or other cheap drug producing country?
I am not sure the problem lies in manufacturing. The system is rigged between the insurance companies and the medical system and the middle men!!
Offering a cheaper cost, means more money for the middle men probably
Well its not all about insurance companies but also where government drops the ball. Example, doctors will prescribe Eliquis because if you have insurance and not medicare its downright cheap but if you are on medicare your cost is four hundred plus.
Even insulin prices get distorted because you are limited to which types you can buy in you are under medicare.
maybe with their majority the Democrats can finally tell their union buddies to bugger off and pass a single payer or tax high value insurance policies; one major reason ACA was so limited as many of those policies which were going to be taxed were all on the side of public employee union benefits.
I've heard this mentioned a lot and I have always wanted to ask: How does tasking high value insurance policies address this issue? Does the government take the additional tax money and use it to subsidize the drug cost? What would prevent the drug company from raising the price to capture the subsidy?
I have imported Colchicine from overseas pharmacies with regularity and never had an issue with it being seized. The prices I get are significantly cheaper because of the patent issue on that 2000 year old drug. For uncontrolled legacy drugs affected by patent issues this is probably viable for the tech savvy (and for those who can afford to wait quite a while). It would be nice if it could be done on an industrial scale instead of as an individual.
It is not guaranteed that a regular American can get drugs from another country. In the past few years, you have been able to legally bring a few months of drugs back from Canada if you visited in person. But if you order drugs online, the drugs are at risk of being seized. Sometimes they get through fine, sometimes they are seized for things as silly as improper labeling (or the drug being straight up illegal to import). You can still save money on many drugs if you can accept the risk or you can order far enough in advance to be able to reorder if one of your packages gets seized. Ordering drugs from another country is a slightly better plan to save money than making friends with a veterinarian. But most people should just go to the local pharmacy and work with their insurance provider or state aid programs if they can't afford their prescriptions.
Ironically, the Trump administration recently allowed states to import drugs from other countries to enable them to offer lower cost drugs through state run programs, but was still seizing the same products if they were ordered by individuals. While I can't really complain about an initiative to lower drug costs, the mental gymnastics needed to come up with this plan are pretty incredible. "We don't think price controls are compatible with a capitalist society, so we won't implement them. But we campaigned on lower drug prices (since that will increase our appeal among the elderly), so we have to do something. Let's import drugs from countries that do have price controls. But people can't order the drugs themselves, we have to protect them from themselves. We have to order the drugs and repackage them with new labels, because we need American instructions and American warning labels, not the instructions and warnings that the Canadian government is fine with."
Right now, it's better/easier for most people to get their drugs from a local pharmacist with our current system. If Mark Cuban is willing to throw a lot of capital and break up the price collusion between established drug companies, then I suppose it's a step in the right direction. We should be happy to accept lower prices and get to work on fixing other important problems with our healthcare system.
Those drugs need to be tested and certified by the FDA before they're legal in the US. For a lot of lower volume drugs, the cost and time to go do that ishigh enough (vs the potential gain) that companies don't bother.
I know it's trendy to hate on billionaires, and by no means do I think this step makes Mark Cuban the new "Mother Teresa" or anything. But I have to say, by and large, I feel like Cuban is legitimately a "good guy" as billionaires go. Yes he's rich, and he's unabashed about it, but he seems like a normal and reasonable human being nonetheless.
Ever since he joined Shark Tank that show has become one of
the best things to happen to our economy in the 2000's.
He's exposing millions of Americans to the long term
benefits of a value creation, non-linear thinking, honesty
is the best policy, builder/craftmanship mindset.
When I was a kid growing up far away from Silicon Valley we
had "The Apprentice" to learn from. Shark Tank (especially
Cuban, but really the whole cast), is orders of magnitude
better.
I believe there was a point when Shark Tank would take some amount of equity from every business that came on the show regardless of if one of the sharks invested or not. Cuban called BS and said he wouldn't be on the show if that was the case. The policy was removed as a result.
Smart move too, since you will probably get better companies on the show without that sort of policy.
I too had a lot of respect for Cuban regarding this.
Article from Inc:
Mark Cuban Made Shark Tank Change Its Contracts After threatening not to return until an equity clause was removed from contestants' contracts, Mark Cuban finally got his way.
Just for appearing on the show, owners agree to give up 5% of their company or 2% of future royalties.
...
Cuban said the clause was removed retroactively, meaning every contestant who's appeared on the show since Season One will be relieved of the commitment. However, how that will work out logistically remains unclear.
I love when "medical" products with incredible claims show upon Shark Tank because Cuban usually shreds the owner's claims in about 2 seconds. He doesn't seem to tolerate grifters very well.
This venture seems like a shot across the bow of anyone trying to squeeze an unfair percentage on top of generic drugs. Kudos to Cuban for launching this but it is something the US government should have been doing decades ago through drug price negotiation for medicare.
Yes. I can confirm this is exactly what happened (roommate almost went on the show, pre-Cuban. though I'm sure theres a lot more to the story that insiders would know).
No. The negotiations are real, and while there is a follow-up due diligence to close (or not) the deal, that is it. Note that anywhere from 1/3 to 2/3 of deals fall through in the due diligence phase, depending on the shark.
The first season, before they brought on Marc Cuban, the show took a percentage just for appearing on the show (so even if you didn't get a deal, you still gave up equity). The second season, Marc Cuban came on and insisted they remove that rule.
I have attended a few presentations where Phil Dumas, founder of UniKey, described his experience winning an investment on Shark Tank. He explained that there were many unattractive terms in the agreement he received after the recording that made him ultimately decline the investment. My takeaway was that it doesn't matter what happens on the show, the real offer is more complicated.
(I have never seen the show, so I don't know how the offers are described. As an investor, I cannot imagine any offer that can be made verbally in the timespan of a television episode being meaningful.)
The shows are edited for time. Each negotiation, which airs for about ~10 minutes on the show, takes an average of 2 hours to shoot (with a surprisingly wide variance).
It's meaningful in getting future guests/contestants to be willing to appear on the show. If all of the sharks only ever said no, nobody would want to go on the show. They have to at least make the audience think deals are happening to keep an audience. After that, if the deal actually completes or not are not relavent to the producers of the show. They just need to line up the next round of chum to bring out in front of the sharks.
You have a rather charitable interpretation of the show. I saw 4 powerful combative "investors" holding ordinary folks in their fists, playing with their lives, and sometimes even verbally abusing them. The show offers a lottery ticket on top of the lottery ticket out of day-to-day work that is creating a new business. What invention the participants bring is commodified a second time, a double grotesquerie. I absolutely can't stand it, and the show, in teaching viewers to hold unsuccessful contestants in contempt, also promotes a sort of circus-like misanthropy.
Yup, my mom and I watched it together for years. At least it was worth it for that QT (now somtimes we still watch Shark Tank together). This is back when I was still a script kiddy and lemonade stand entrepreneur.
I also read "Art of the Deal" or whatever that crap was called.
Sometime I can tell you the story of how I sued a Fortune 50 company after a minor disagreement because I thought that's how business was done.
I can only laugh about all that now, and shout "thank you" to Cuban that we have at least one highly entertaining business show that also teaches mathematically correct ways of thinking about business.
I think at certain levels of wealth, being "normal" is simply impossible. But there are people who use their fortunes for altruistic causes and that should be celebrated. Unfortunately, most of these cases simply highlight fundamental issues in other areas of our society.
He's a major investor in my company, and can 100% attest that's true. What's most astonishing about him is how responsive he is even two years after making that investment. He must have so many companies and he's still always showing up and encouraging and providing value. He's pretty direct when he thinks we are doing the wrong things, but that's always appreciated. His super power is handling all that over email (mostly).
I second that sentiment. I was in business with Cuban for many years, he always responded quickly and could always be reached via email / messaging in a matter of minutes in most cases if something came up. An almost ideal investor for an entrepreneur and his terms are very unusual in the industry, he often takes common shares with no strings, he's on the same playing field as the founders.
This is awesome. I’ve been daydreaming for years that Bezos would launch some kind of “CostCo, but drugs” operation, as I figured he had the infrastructure… but this will do just fine.
He should get insulin and epipen factories running ASAP, those are very high profile scams in the US right now.
Amazon usually waits until it can clone the operations before it dives into a new territory. Even though they would be set up for it quite easily as you say, they’re approach in the past has been more EEE...or more politely adopt and optimize.
They sell generics, but I don't believe they actually make them.
Allow me to clarify: CostCo sells everything at a fixed profit margin (I believe it's around 18% but I could be mistaken). I have no idea where their generics come from, I doubt they manufacture themselves, so before the CostCo markup they are subject to the same inflated prices you'll find anywhere else before the pill reaches the drugstore or your doctor or whatever.
What I've been imagining, specifically, is generics manufacturer that applied a fixed profit margin — "cost plus" — to their products. I guess that's not precisely the CostCo model, but you get my drift now.
Most in my state (CA) also have fully functional pharmacies, and the prescription drug prices are much cheaper much of the time. I shopped around when I went through a period of poor insurance (years ago) and my monthly medication costs were $25 at Costco, and the nearest competitor I could find was just over $100 when paying cash. Also, I believe that California, you do not need a Costco membership to purchase from the Costco pharmacy.
I think this is only true in a handful of states. In California, there's apparently an old law that you can't have members-only alcohol clubs, so Costco technically has to let you buy alcohol.
I tried this once last year before I had a membership, and the person at the entrance told me they would need to get an employee to escort me, and it might take an hour, because they're busy.
Presumably this is the kind of thing that a court would smack down, since I'm pretty sure they're required to actually provide reasonable access, but I was just trying it for fun and didn't make a fuss about it.
> I tried this once last year before I had a membership, and the person at the entrance told me they would need to get an employee to escort me, and it might take an hour, because they're busy.
> Presumably this is the kind of thing that a court would smack down, since I'm pretty sure they're required to actually provide reasonable access, but I was just trying it for fun and didn't make a fuss about it.
Also it makes no sense for them to need to escort you. They scan your card on checkout so how would you buy stuff other than alcohol anyway?
Anyway I've never heard of anyone being told that before. I understand not making a fuss (we are social animals after all), but it probably should be done so they don't keep trying BS like that.
I'm surprised they said that, but probably your mistake was in asking. :) Even with a membership, I'll occasionally be too lazy to bother pulling my card out at the door, and will just tell (not ask) the person there that I'm going to the pharmacy. They let me go right on by. Once in, you can go anywhere you want. As CogitoCogito said, the real check is at the register, where you can only buy certain items without a card. Apparently that also includes alcohol - never knew that.
The person at the door was very diligently checking. This was the SF Costco, in the early days of the pandemic lockdowns, so perhaps it's unique to that specific location or those specific circumstances. Indeed, just a few weeks ago I went to another Bay Area Costco intending to inquire about membership, and the person at the door was just handing out promotional flyers, so I helped myself to a quick self-guided tour of the store to see if I thought membership made sense for my household (I did decide to buy a membership, for what it's worth).
What is good besides the vodka being a near identical done of Grey Goose? I feel like I got kind of burned with their tequila, which was extremely mediocre.
Their scotch can be good, but look up the specific bottling. Sometimes it'll be something like a "factory second" of MacCallan 18... not the prime barrels, not as good as the stuff actually sold by macallan, but also about 1/3rd the price.
Not sure if their supplier has changed in the past few years, but their bourbon is pretty good for the price. There was speculation it was from Jim Beam, some kind of Knob Creek barrels.
I think a lot of that comes down to his background. Mark Cuban is from a very blue collar background. Compare that to Bezos/Musk/Gates/Zuckerberg, all of whom were from money.
From what I understand generic drugs are currently often made overseas, and then sold back to American market. Although he may not be a bad guy, he simply knows how to make money, and there are many billions left for the taking in this market. Definite not Mother Theresa, but better done locally, at the least.
I don't know the man either way, and you may be spot on, but outside folks whose work is largely charitable and etc, how does anyone feel they know these things?
My impression of Mark Cuban has been built up over the years from a variety of sources, ranging from a brief in-person encounter[1] with him, to reading his book, his blog posts, etc., to seeing him on TV in various forms, interviews he's done, etc. There isn't exactly one specific thing that stands out by itself.
All of that said, it's a very subjective thing, and for all I know Mark works very hard to cultivate that specific image for his own ends. I have no problem saying that my impression could be wrong. But based on the limited evidence I have available, that's where I'm at with it at the moment.
[1]: I don't typically hang out with billionaires or anything. The only reason I've met Cuban is because he was once a keynote speaker at an event I attended. After his speech he hung out with the hoi polloi and mingled and interacted with people. I spent maybe 3 minutes chatting with him personally about my business, and maybe another 10-15 minutes listening to him talk to a small crowd that gathered around him. To be fair, that encounter probably went as far in shaping my impression of him as anything. I think the single biggest thing was that he displayed no condescension or smug superiority or anything towards people who weren't on his financial level. He was respectful, attentive, and reasonable even when talking with some rando like me.
When I found out the a-hole on Silicon Valley was partially based on him, I had to do a little research
Couldn't find one negative experience. There are several threads on Quora for instance detailing how he treats everyone with respect and is a genuinely good dude.
Isnt he the one who returned a bunch of Covid stimulus money after being called out on not needing it? Perhaps an oversite in his business empire, or perhaps damage control?
By and large this country is very lucky with the billionaires it continues to produce: Bezos, Cuba, Buffet, Gates, Paul Allen, Zuckerberg, Dorsey, Musk, etc, all seem to be incredible people who are committed to do good. I think it has something to do with the fact that these people are self-made and for the most part made their billions without having to sell their souls to the devil.
I legitimately can't tell if this is satire, particularly the "self-made" part.
Bezos' parents loaned him a quarter-million dollars in 1995 [1].
Gates' mother, while on the board of directors of United Way, convinced IBM to invest in MS in 1980 [2].
Zuckerberg's parents sent him to the crazy selective and expensive boarding school Philips Exeter Academy and was privately tutored in comp sci before college [3].
It's a long way from quarter of a million to Amazon.
How many people get quarter of a million in inheritance or have rich parents? It's silly to call out "self made" just because someone got a loan. Bezos did not inherit billions of dollars, he is a billionaire now. By any metric he is a self made billionaire.
It's a lot longer from zero (or negative, in you have student loans) to a quarter million if you're working outside the SV/software engineer salary bubble.
The point isn't that it wasn't hard work to grow from $250,000 to billions. The point is that there's a big difference between saying "anyone who works hard can build a company like Amazon" and "anyone who works hard and got $250,000 from their parents can build a company like Amazon."
Anyone who says that (anyone who works had can build a company like Amazon) is a fool. Most likely suffering from survivorship bias.
You cannot. But Bezos did not inherit billions and living on them. He is self made, maybe he did not start at zero, but he did 1000x or 10000x (or even more) what he received. If someone had received a loan of 1000 dollars, I doubt anyone would say he isn't self made when he reached a million.
This is a straw man. Nobody thinks that "self-made" means that you literally had no help whatsoever. Bezos was a hedge-fund SVP before starting Amazon, so it's not as if he was particularly hurting for more funding.
It's not a straw man if the first commenter was intending to use "self-made" to actually mean something to a reader anywhere close to an average reader. To an average reader, even on this website which probably skews American and wealthy, it's just not reasonable to refer to someone as a "self-made billionaire" when they received a loan from their parents that's well over 3 times the median household income in the United States.
Self-made just means that you made the money with your own effort as opposed to inherited it. There's nothing in that comment that attempts to paint them as relatable. If they wanted to do that, they would talk about Bezo's teenage mother and adoptive Cuban-immigrant father. For all we know, that $250,000 could have been money gifted to Bezo's parents while he was employed at DE Shaw.
> Self-made just means that you made the money with your own effort as opposed to inherited it. There's nothing in that comment that attempts to paint them as relatable.
I disagree. The point of the term is not to describe a financial technicality. If someone inherited $900m and worked really hard to earn another $100m, I think most people would be confused to hear them described as a self-made billionaire. On the other hand, of course, people wouldn't tend to be confused if you described some billionaire as self-made if they grew up lower-middle-class and their parents gave them $100 when they turned 18.
So, yes, it's not an "all or nothing" thing, but it is absolutely about conveying relatability to a certain audience. We can reasonably disagree about whether describing Bezos as self-made is appropriate for the HN audience, but I tend to think the $250k "business loan" from his parents should at the bare minimum accompany the inspiring anecdotes about making a desk from a door (which, from what I have read, was literally done to symbolize the imaginary need for extreme frugality).
I am conflicted about Zuckerberg, I think I understand where you are coming from, but Zuckerberg contributes heavily to charity and perhaps might not have realized the monster he was creating in Facebook. Similarly Dorsey. I do not get the Bezos hate.
One of the big issues with Zuckerberg's optics are the circumstances around Facebook's creation. An app to rate people's attractiveness, laughing in chat logs that people would trust him with their personal information, etc. Combined with the externalities and immense power they now have, it's not a great look.
However, I agree that he's probably a better person than most give him credit for, and I think he's really stuck between a rock and a hard place on a lot of these issues. Especially things relating to politics, mis/disinformation, and free speech. I consider the proliferation of non-paid online services (who therefore can only survive by making money in other ways) the true bane of humanity; not any particular executive. (That said, I'm also not going to let anyone off the hook once they deliberately choose to create such a service.)
I had a high opinion of Bezos until the disclosure of Amazon's poor working conditions. His making the minimum wage for workers $15/hour is a good step, but I think they're going to need to do a lot more before that reputation changes. Other than that, I admire him.
Dorsey seems to be the least hated of the bunch, and I like him, personally. He seems like he still has a kind of hacker mindset, and I believe he genuinely wants to make Twitter a force for good in the world. I'm not sure if he'll be able to accomplish it, though.
I'm just looking at what Wikipedia says Zuckerberg is worth but it's $69B. Looking at what Forbes said his charity (which does not mean 100% his money) they donated $410 million in 2018. That's ~0.006% of his wealth meaning it's not even giving away a penny out of $100. It's close to half a penny out of $100.
I understand net worth of $69B is on paper but none of these guys are philanthropic.
I would separate here, Bezos is evil because he is just amassing wealth, avoids taxes and pretty much is focused only on himself.
Contrast that with Cuban who is also amassing wealth, but also is trying to do what is good for the community.
Bezos has donated a lot to charity, including $10 billion to fight climate change and $100 million to food banks in 2020. Sure, he could donate more, but % wise that's probably more than many people reading this have donated in 2020. And I don't want to start a debate over it, but I do believe that the primary intention behind Blue Origin is to benefit humanity.
The main issue with Bezos is worker conditions at Amazon, I think.
How many more billionaires than those that you've named has it produced?
What about Exxon, AT&T, Aetna, AIG, Goldman, DuPont Chemical, Lockheed, McKinsey?
There's a pretty obvious bias there: the ones you name do good because you named the ones who do good. (which, really, you could examine: how much of that perception is PR?)
We're not lucky to have billionaires. We'd be just as well if there were none at all.
not sure if the world can count on his moral value, but more competition is always good. If the narrative of generic drug pricing fixing is true, it would be a wonderful business opportunity as well.
There are two options when you're rich like Cuban is (clearly there's more but to dumb it down).
You can acknowledge that while it took hard work, and luck to get where you are, you likely would not have done it if you hadn't been born into a society that fosters the ability to move up the social ranks. If Mark Cuban were born in Libya there's almost no chance he becomes a billionaire for instance.
Or you can pretend like the reason you're rich is solely of your own doing, and that the world owes you something.
Cuban seems to be the former, and while he's not going to volunteer to just give all his money away, he is trying to help society collectively improve. It's a stark contrast between his approach and say, the Koch brothers.
I guess the best way I'd put it is Cuban is a capitalist who believes in the social contract.
Off topic. What do you mean by "if he was born to Libya"? Does it imply prior existence? The official theory is that we are created during those 9 months, assembled like cars, and if so, he couldn't be born to libya because the body assembled in libya would be completely different. In the unofficial theory, e.g. buddhism, prior existence is a thing, but even then Mark couldn't be born to Libya: there were only few choices for him matching his prior achievements and every path would lead to a billionaire status.
Imagine you and I share an apartment and we split the rent between us. It's not a great apartment. There's mould in the bathroom caused by a lack of ventilation. The carpet is a mess. The power keeps cutting out if we plug too many things in.
Now imagine I tell the landlord I'm going to move out unless he fixes these issues and he then offers me a 50% discount on the rent. Now imagine he recoups that discount by putting your rent up by the same amount. And now imagine that I use those savings to buy a nice big TV for the two of us. The bathroom is still covered in mould. The carpet is still a mess. The power still cuts out all the time. And you pay more rent than me.
But I bought an awesome TV for us. So I'm the good guy right?
This analogy would work if you were already paying 10000x more than the roommate in the first place.
Remember, all of the talk of billionaires “paying less in taxes than their assistants” is not based on raw collected amounts, it’s based on percentages. A billionaire with an effective federal tax rate of 15% on 50 million income is paying 7.5 million in taxes, which is more than all of the federal tax collected from the bottom 10% of income combined.
What an unrealistic comparison. No landlord would ever do that, nor would the roommate agree to the changes that the landlord would attempt to make even if that is something the landlord would do.
Aren't you in Vancouver? I've had landlords here that would absolutely do something like that. Many slumlords would do anything they think they can get away with.
Nope. I've never been to Canuckistan. If you're saying this is typical behaviour of landlords in Canadia, then it makes me have second thoughts if universal health care is worth it.
Make no mistake Mark Cuban is a snake if you ever lookup his past business dealings. He made his money by basically pushing out fellow founders at paypal.
“ The first product we are producing is Albendazole. Albendazole is an antiparasitic drug that currently has a list price of approximately $225 per tablet (currently listed average cash price per tablet on goodrx.com).”
I bought this in Canada for maybe $30 last year. And not just one pill. An entire course of it.
People in the US can afford to pay a lot more for healthcare than in India. They just can't afford to pay twice as much as other industrialized countries.
Mebendazole (functionally equivalent to albendazole, as I understand it) is 4 USD a tablet here in Ontario. So even with this you're still paying 3x as much.
compare price of labor between usa and india. Outsourcing everything to asia will be beneficial for company (and probably consumers since lower prices), but not for americans who work for cuban rn
Indian doctor here. We give Albendazole tablets away for free. Maybe you can take a flight, buy a bunch of these tablets from the local pharmacy, and go sell them for half the price you are putting on your low-cost website.
Looks like Mr. Cuban is demonstrating that, sometimes, a superior business plan is the shorter path to justice than waiting for the Courts and the Legislature to catch up.
Wiping out their businesses financially might be the most effective way to fight them, in the short term.
If I am not mistaken, the biggest challenge as I see it is that according to the FDA abandoned (generic drug) program, the Cost Plus Drug company will not be able to advertise many of its drugs to advertising monopolies that the FDA has handed out to companies (e.g. Shkreli, but also many bigger pharma companies), which according to a doctor friend of mine is a business killer. However, it's entirely likely that through sheer force of personality and name recognition, Cuban can force through a program of "check our company first", without advertising any particular drug, that gets popular among doctors. Hopefully that will drive eyes to the company without running afoul of the FDA's well intentioned but horribly gone wrong rule.
How do you practically ban lobbying without removing the ability of private citizens to directly interact with the legislature? There are good reasons to allow groups of people to get together and pay someone to go hassle congress on their behalf. Regular people are busy with their own lives after all, and most of them live far away from Washington. And sometimes you want to complain to a representative from outside of you own district, because they're sponsoring legislation that would hurt you, or blocking legislation that would help you.
You could limit the amount of money you can make via lobbying. If it was illegal to make more than $1 MM a year through lobbying, suddenly the playing field would be significantly more level. If a corporation can pay you $1 MM and a group of citizens can pay you the same, suddenly you care more about the message than the receipt. And the majority of ultra-rich lobbyists will do something else, because that's not nearly enough money to interest them.
I'm not a fan of limiting salaries in general and I do not believe this is a good solution, but I believe it's likely to be better than the current situation. This is just me spitballing on a whim, having put approximately 60 seconds of thought into a solution. Hopefully people more informed will reply with better solutions or an informed explanation of what's wrong with my idea.
You write the laws to apply to companies but not private citizens. A major owner of a pharma company could still lobby privately as themselves, but at least they'd be paying taxes on that expense rather than having it hidden as a corporate writeoff.
(And before anyone chimes in with "but corporations are just groups of private citizens" - they're explicitly not. Corporations are fundamentally defined by having a charter from the government to reduce the owners' liability, and thus we would expect them to incur additional regulations)
I imagine CEOs would just lobby privately and in person then, but pay a team to do all of the other leg work. This is trickier issue than people popularly imagine.
Influencing the leaders of a global super power is incredibly valuable, and lots of people want to do it for a lot of reasons.
In your proposal, would you ban NGOs, non-profits, and unions from lobbying? Why or why not?
If the CEO were paid an extra $10M salary so they could turn around and personally spend it on a lobbying firm, that would at least reduce the efficiency of said lobbying by 37%.
The biggest issue is the complete lack of reporting, and anything that pushes the money flows more into the open (your hypothetical CEO is then personally responsible) is a step forward. Take a look at the stark difference between campaign finance reporting for individual candidates, and everything else.
Your last bit is a loaded question. If an entity's business is lobbying, then obviously they can engage in lobbying. But they could only be funded by individuals, not companies whose business is other-than-lobbying.
My point is that NGOs, non-profits, unions, and other voluntary groups aren’t primarily about lobbying but may want to increase their members’ voice by lobbying, e.g. environmental groups.
I did get your point. The obvious solution is to split into two entities, one that does the lobbying and can only accept personal dollars and one that accepts corporate donations and does no lobbying. This is the third non-issue you've brought up as if it were some kind of blocker. Prohibiting corporations from donating to individual campaigns is something that is already done. It just needs to be expanded to all lobbying.
My point is that lobbying isn’t some magical activity, it’s just petitioning the government. Anyone being governed should probably be able to voice comply about how they’re being governed. Corporations aren’t some magical thing,and most aren’t the giant entities people imagine.
Do I think lobbyists should write legislation? No. Do I think congress should be able to break encryption without ever tech company sending someone to educate them on their stupidity? Also no.
I think there are some controls we could put on lobbying but it’s useful.
If Congress still allowed floor votes and amendments to bills, lobbying would be far less clandestine and effective. Right now lobbyists just have to target congressional leadership and key committees. Congress in an effort to clamp down on the legislative process and protect its members from controversial ores has made the process more vulnerable.
You're the one referencing "magic". The main thing I'm getting from your response is the standard retort whenever anybody complains about the problems arising from corporate scale - "but anyone can start a corporation". This is technically true, but completely dodges that issue of scale. If there were non-incorporated groups of thousands of people coming together and doing similar things we would need different criteria, but there are not.
As for the encryption topic, then perhaps the scope of anti-lobbying should include government agencies as well. I certainly don't trust big tech to defend my personal digital rights, and the fact that we're looking to them to be our saviors is itself a major problem. They seem to be aligned with us at the moment, but ultimately mandated communications escrow would be another competitive moat for them. I expect that to shift if there is a serious move (back) to p2p apps.
I agree on the congressional process, but not to the exclusion of other approaches.
We could start by banning political campaign funding from corporations and unions.
I took a look at a handful of western democracies and they all either banned or drastically curtailed this. People need to be in control of their government, and that includes campaign funding.
"Lobbying" is legitimising bribes from corporations politicians. It is as simple as that.
If USA wants to change the game (they don't) they can ban all corporate donations (aka legalized bribing), allow only donations by individuals, and then impose/enforce a limit of $10-25-50k per person (or something reasonable). Anyone playing tricks to game that rule get a penalty of x20 the excessive amount donated (e.g. via others). Also put all donations in public record. As simple as that.
It makes no sense to me that you (USA) spent $14bn [0] on this election.
If by "Lobby" you mean bring their arguments forward in a discussion, well that's the objective of freedom and democracy (you speak - you are heard - majority decides).
If you mean that EFF will donate $5m which will inadvertently alter what logic dictates and demands.. then yes block EFF too from bribing politicians and political parties in the guise of "lobbying".
It's not really an innovative business model till California tries to pass a proposition in few years to screw over your business plan because it's not "equitable" or something.
If by market you mean "for profit companies", that's correct. But if "market" is taken to mean "marketplace of ideas"... In free market philosphy there is a lot of sunlight in the gap between corporate behemoths and government, ranging from individual action through mutual benefit associations all the way up to pbcs and ngos. The point is government should also not be relied upon to correct injustice. In the end justice is up to the people, and if a for-profit takes the banner of justice that's decentralization of power at work.
Also, as an employee having a company that has to actually compete can really eliminate a lot of BS. If you're in the 800-lb gorilla, there can be a lot of dysfunction. If you're in a company with an 800-lb gorilla, there's a good chance what you do may not matter (unless its really good).
Robust competition doesn’t exist without strong regulation, because the natural state of competition is monopoly even with a medium barrier to entry. Almost all of our companies nowadays are high barrier to entry.
In this case, isn't the barrier to entry itself regulatory? The drug approval process stops new entrants and federal law stops consumers from buying drugs from other countries. Otherwise, I imagine there would be a pretty robust market, given that these are generics and there's no R&D involved.
Capital costs are the barrier for a new generic drug maker, since the approval process is already done. Hense, Cuban starting a new one with his huge capital. But I’ll bet it will take lots of capital and well, they’ll find that there is no incentive to lower the price unless they want to gain market share. I suspect that pharma factories are quite expensive especially given the chemical reagent supply chain already being heavily owned or partnered with the incumbents.
From a quick search, it seems that in the US, generic drugs still go through an approval process called ANDA, but it's simpler because there are no clinical trials. When one drug manufacturer raises prices on its generic, a lengthy approval process still inhibits other drug manufacturers from quickly introducing competing generics, even if they have the capabilities.
Given the name and positioning of this business, I would say it's partly a PR stunt and partly an act of charity (a non-charitable approach would be to undercut by only 30-50% instead of 90%).
So yeah... it's great that billionaires occasionally step up to "fix" issues created by corruption and inadequate regulation/oversight, but I think if you're going to take a position that this is somehow better than waiting for the system to fix it, it might be more instructive to look at how this works in countries with a functioning bureaucracy. For example the drug given on the homepage is Albendazole, which they're selling for $20— well guess what, that pill is $2 in the UK and has been since the patent expired in the 90s:
> "In other countries, there are price control methods. The government steps in to ensure drug prices do not increase by a certain amount," Alpern says. "There are no price control mechanisms in the U.S."
> a non-charitable approach would be to undercut by only 30-50% instead of 90%
Not if you're fighting deeply entrenched incumbents. Switching costs are huge, financially and politically. You need patients to hammer their providers to give them access to these drugs through this channel.
50% off is big, but it's something incumbents could match. 90% off leaves you with a profit margin, gets you PR points and holds the hounds at bay. Bonus: if you work out your competitors' debt loads and price at a level that they couldn't, financially, sustain.
If the incumbent is a large scale pharmaceutical company with thousands of drugs in its portfolio, then it can most definitely afford to lose money under-cutting you when you only make a small handful.
And I think that really just underscores why this approach is the Google Fiber of the US pharma market— it may be able to force prices down for a handful of select customers, and may be helpful for proving a point about true costs and the need for regulation, but its existence is most certainly not some kind of proof of the invisible hand stepping in to solve this problem on its own and that regulation is therefore unnecessary.
Of course not— it argues for not bothering to enter this space at all unless you're doing so with ulterior motives, for example as a PR stunt.
As for antitrust laws, isn't the whole point that we're in this mess because the incumbents are all conspiring to fix prices and the existing consumer protection systems which should be preventing that have been failing Americans for decades and thank goodness for the free market which created the necessary incentives for Mark Cuban to swoop in and start this business?
> incumbents are all conspiring to fix prices and the existing consumer protection systems which should be preventing that have been failing Americans for decades
The Sherman Act prohibits monopolies or cartels damaging competitors. As a competitor, you have standing. As a consumer, you do not.
I think this business could be phenomenally cash-flow positive in short order. It's not dissimilar from the way Teva started, just further down the pipeline.
> Looks like Mr. Cuban is demonstrating that, sometimes, a superior business plan is the shorter path to justice than waiting for the Courts and the Legislature to catch up.
This is a very bold claim, that we do not currently have the data to evaluate.
In ten or twenty years, we can revisit it, and conclude whether or not it is actually true.
Albendazole is given as an example on the page. Last time I was in China, I purchased a pack of these pills just in a grocery store pharmacy, no prescription needed. It was something under a dollar per pill. How does Albendazole still cost $13 / pill to produce?
Some actual competition on generics from a US company, with a much higher salary cost?
Also, from the web site:
- "We are hoping to introduce over 100 additional drugs by the end of 2021."
- "By 2022, building a pharmaceutical factory of our own in Dallas, TX"
I can't shake the feeling it's just a shallow rebranding play using a billionaire's personal brand. Perhaps many americans don't trust non-US brands, even when it comes to generics?
Is there a quality problem with generics in the US? There doesn't seem to one in Europe (or at least Sweden). I assume you also have regulations and testing protocols etc?
It's extremely hard to enforce GMP and QA/QC from across the world and there's a strong incentive to cheat and lie when it comes to these costly procedures. Whether it'll be any better in a US manufacturing facility is of course up for debate.
> Because the FDA requires very specific GMP requirements that differ from those of the EU and other countries, drugs approved or synthesized without US FDA certification cannot be legally sold in the U.S.
Sounds a bit like trade protectionism - but I assume that goes both ways between e.g. EU and US.
Mark Cuban must have my conversations bugged. I recently was talking to a friend about how the rich should realign how they do large charity spending.
In previous decades a rich industrialist may have built a library or a university building. This made sense when education was for the rich, and knowledge was inaccessible the wider public. But now knowledge is cheap, and large gifts like this are disconnected from today's average public person. Also putting a name on a hospital that still puts people into debt isn't a good image either.
Now the wider public needs cheaper pharmaceuticals. In order of the rich to stay in power for extended periods, they need to give some amount of handouts. Nuevo rich don't understand this, so they look to predecessors, and look on how they spent their money (hospitals, universities, etc), without realizing why they spent it. Expect to see more charity capitalism aligned with today's needs: generic drugs, taxi services, even phones and internet access.
This is cool, but what they're claiming is puzzling. Perhaps someone here can clarify.
Making generic drugs is non-trivial. The medicinal chemistry may be decades old, but you still need to do trials to demonstrate efficacy equivalency to the non-generic version. Are they really saying they'll do 100 of these trials by the end of the year?
While this is cool, I'm thinking that this type of initiative should be done by the federal government. A generic drug "mint" if you will.
Why does this generic have to be retested if it's the same as the existing generic? Can't they just do composition(?) testing to very it meets manufacturing standards?
I don’t have the best answer for you, but there are a number of considerations apart from the synthesis of the active molecule itself. Delivery vehicle can alter the physiological impact of the active substantially, and so the overall “package” needs to be tested even though the active is already approved.
To my knowledge, generic trials aren’t as involved as their non-generic counterparts for obvious reasons. But they are still non-trivial logistical undertakings.
That makes sense! This is where I feel like I have a disconnect between what I think applied science is and what it looks like in practice. It seems like they should know enough about the molecule, delivery vehicle, etc, to know that it will work the same. A medical "proof" if you will. I guess we're not quite there yet? Is there work pushing in this direction?
You're right. If it was just one drug, I'd think they were manufacturing it themselves. Apparently, they plan to have a single factory in 2022. Most likely, significantly all of their formulary will be copacked.
For those interested... I thought this was a pretty good book going over the creation and evolution of the US Healthcare system. It's equal parts fascinating and infuriating.
An American Sickness: How Healthcare Became Big Business and How You Can Take It Back
I don't understand the criticism here. A customer of this company is not reliant on Cuban at all--if Cuban's company raises prices, the customer can switch to another company or move to a country with cheaper drugs.
I also don't get the "goodwill" argument. This is designed to be a profitable, sustainable business built on the classic mantra "your margin is my opportunity".
I think it's ridiculous that someone has to consider moving countries, which is no small task and out of reach for many, just to be able to afford their healthcare.
is this sort of the “free market” example of disruptions in healthcare space that could may be move healthcare in US towards a model where you pay for what it actually costs instead of the inflated and opaque pricing that private health insurance thrives on ?
In spite of the missing question mark, I think the answer is yes
I'm not even particularly bullish about companies being able to improve transparency (it's a really complicated system, the incumbents stand to make/lose enormous sums of money, even when lower cost alternatives exist doctors might be contractually obligated not to discuss them)
But I think that this is a really good step
Similar to toasttab or chownow in the food ordering space
> There are no hidden costs, no middlemen, no rebates only available to insurance companies. Everybody gets the same low price for every drug we make.
While this sounds good in practice, will it work in reality? I remember a pharma sales guy explaining that one of the ways his company got away with being more expensive than the competition was to practically give the medicine away to hospitals, so that the hospital would be more likely to prescribe it than the cheap generics, after which point the patients would just keep refilling the same meds (with the higher price then picked up by insurance)
In any case, I wish this company good luck! The US really could use more "maverick competitors" in the medical space
Old coder here...multiple environments ... I've kept up, still making enough to live comfortably ... hope to retire soon.
Couple of thoughts:
1) Not a bad idea, been proposed before,
drugs at a fair market value ... a little over cost ... good if true ... keeping in mind current restrictions.
2)Is this a springboard for a 2024 Cuban run at the presidency?
>> There are no hidden costs, no middlemen, no rebates only available to insurance companies. Everybody gets the same low price for every drug we make.
I've been advocating this for a while. Any given provider should have the same price for a given drug or procedure, regardless of insurance concerns. Putting this in law would probably help a lot.
Just saying, in some countries you don't need to buy the whole packet (of pills) it's more ecological(less use of packaging, less unused stuff) and cheaper for the consumer...is this illegal in the US (or other countries) also what are the downsides ? (Theoretically the usage paper could be photocopied, found on the net)
My French brain frequently struggles to parse English titles. But this one takes the cake! Before opening the link, I was expecting something about drug addictions and Cuban cigars. (It's about a company that goes under the overly complicated name of Mark Cuban Cost Plus.)
It turns out markets are a great solution to some kinds of problems and not so much for others. There's a lot of reasons why healthcare doesn't approximate a free market very well, and why government intervention here tends to do better than the US system. Yes I know there is plenty of government intervention in the US healthcare system - it's just not the right kind of intervention.
The US is actually the only developed nation without a public healthcare system, it also has the highest healthcare costs of any nation on earth. Coincidence?
You are assuming that healthcare is a free market. There is tremendous regulation, encouraged by incumbants, to keep away the competition.
You should look at historical healthcare expenditure by the US.
The problem isn't providing healthcare for all... it is the method and the cost. Universal payer is one way. It is not the best way and in fact Medicare is one reason costs are currently high. It is a bit like a car that used to get 30MPG and now gets 15MPG, and getting worse, and the solution being offered is for all of us to collectively chip in and buy gas for those who can't -- which is not tenable in the longterm because you're spending more and more of the GDP on transportation.
There are other ways of giving everyone coverage. One scheme, would be giving people money. Enough to cover average cost of healthcare plans and say education plans. The individual is then responsible for their own healthcare and has the funds to purchase health insurance. Then you have a healthy market and have mechanisms for the costs to come down.
A free market involves a customer that has the option to simply not buy what is on offer. Healthcare can never be a free market in this sense, because the customer is faced with a choice of "buy service and/or product" or "be dead".
That is entirely unlike the choice involved in buying something like a refrigerator and seriously skews the applicability of traditional free market thinking to the problem.
> Healthcare can never be a free market in this sense, because the customer is faced with a choice of "buy service and/or product" or "be dead".
What you're referring to here is a high "price elasticity of demand", and markets are used to provision all sorts of goods for which this is true. Food, for example, is predominately provisioned by the market, and consumers are constantly faced with a choice of "buy food" or "starve to death".
> consumers are constantly faced with a choice of "buy food" or "starve to death".
And funnily enough, food is heavily government-subsidized and regulated. It's not really a free market either.
Also starving to death isn't really the same level of urgency as dying of a heart attack. There's a couple orders of magnitudes difference in the amount of time available to make a purchase decision, and the level of physical and mental stress you're under while making that decision.
> And funnily enough, food is heavily government-subsidized and regulated. It's not really a free market either.
Sure, but by this metric, there exists no free market on the planet. If your argument is that the healthcare market should look exactly like the food market does today (with subsidies and FDA regulations), most adherents of private healthcare would agree with you.
Privatization != "no welfare".
> Also starving to death isn't really the same level of urgency as dying of a heart attack. There's a couple orders of magnitudes difference in the amount of time available to make a purchase decision, and the level of physical and mental stress you're under while making that decision.
Okay, but not all healthcare is "dying of a heart attack". Obviously it's impossible to shop around for healthcare when you're having a heart attack, and that's exactly what insurance is for. After EMTALA, emergency care is free if you can't pay for it. This isn't really controversial. What's controversial is whether the same framework needs to be applied for planned care, like MRIs, colonoscopies, annual physicals, tonsillectomies, vaccines, prescription drugs, etc.
Different types of food are fungible goods. If broccoli is expensive I can instead purchase carrots and still survive. If I think chemotherapy is too pricey, I can't take an aspirin instead to treat the cancer (at least not with the same prognosis).
This is very true, and not at all what I mean when I say "choice". In free market choice means alternative vendors. Do you have other choices for getting chemo besides the one hospital?
You may be surprised to know that 80% of hospitals in the US are non-profit. The evil profit motive isn't the reason their bills are so outrages.
In the 60's US healthcare expenditure was 5% of the economy and it is close to 20% right now.
I'm curious (you don't come out one way or the other on this from your comment, but this will help me make sense of where you're coming from) do you think there are any domains where a free market doesn't work? Or is your position that free markets work universally (or less absolutely, that free markets work for almost all practical purposes and fail only in very artificial environments).
Free markets don't work when the cost of the transaction isn't paid by the two sides of the transaction but by a third party. For example the environment where I can buy a gas guzzler from you and drive away polluting the environment. There you need intervention but the framework of intervention and has to meet some specific criteria. I don't want to digress.
Other than that I have yet to see a problem that isn't solved by this scheme: increase the set of choices available to the person, and in some corner cases give them money so they are free to choose.
You have to bear in mind that the alternative to the free market approach is for someone else to come in an constrain either the buyer and seller in some way. Ths may work for a limited time and for a specific set of buyers and sellers but it won't work beyond that. Given that people have diverse and evolving needs the forced solution causes long term harm. Then you'll need some kind of propoganda machine to either exagerate the good or down play the harm.
To be clear I do not believe that we have a free market in the US in a lot of areas and what people conceive of as free market -- or rather what has been shoved down their throat as free market is anything but that.
I think you and I probably would have different notions of what it means to "solve a problem." In this case I suspect you have a notion that a free market in many ways nicely sidesteps needing to even resolve this question in the first place. It frees one from having to commit to overarching, centralized value systems and instead allows for gestalt value systems to arise naturally from the behavior of people. This nicely avoids the issue of needing to impose a higher authority's will on a population and all the authoritarianism that that entails as well as the inevitable schism between a centralized value system and what people actually want. (I happen to disagree with this take and can expand on why if you're curious, but if this accurately reflects your views, there's enough commonality at least for me to make the next point.)
> increase the set of choices available to the person
This view abstracts behavior into that which is governed by "choice" and "coercion." I think this binary distinction is a fine model for a lot of domains, but a poor one for healthcare.
Choice feels much more like a spectrum in the domain of healthcare than it does in other domains. For a rough sample of points along this spectrum, you have "do this or die immediately," "do this or die in the next several months," "do this or suffer permanent disability," "do this or suffer great pain," "do this or suffer some probability of some amount of disability," "do this or suffer mild discomfort," "do this or be slightly annoyed."
The far-"left" part of this spectrum cannot ever realistically expand its set of choices. The most extreme version of this is that you're literally incapacitated and so can never make a choice of e.g. what hospital to go to and what treatment to administer no matter how many hospitals or treatments exist.
However, I think the same problem persists in less extreme states as well. Health ailments can directly impact a person's ability to choose to begin with in a variety of ways apart from just physical or mental incapacitation or degradation. Various treatments and healthcare choices impose switching costs that reduce a person's choice even when they are nominally capable of making one. For example, if a patient chooses a single hospital for a bout of appendicitis (when they are in such pain that they cannot make a choice in that moment other than to dial 911), even once the acute problem of surgery passes, they are unlikely to be able to choose a separate hospital for their post-surgery hospital stay without jeopardizing their health due to movement and continuity of care concerns.
Even in non-emergency cases there is an extreme information asymmetry and unpredictable path dependence (certain choices lock into other choices down the line but the nature of how they lock in may not be apparent at the beginning) that make it hard to formulate what "choice" would even look like.
In some ways, I personally view the need for coercion in the healthcare space as precisely a way to return to a world where modelling things as a binary distinction of "choice" vs "coercion" makes sense again.
Any plan for regulation of healthcare always must deal with a distinction between "elective" and "necessary," "non-essential" and "essential," "covered" and "not covered." That line is drawn precisely where we have a best guess that the model of a binary "choice" vs "coercion" holds vs the model of a spectrum of choice; the ideal is that care is provided to boost a patient back into a universe where the binary "choice" model is a reasonably good approximation.
More generally there is the problem that healthcare has a weird squeeze of monopolistic and non-monopolistic needs.
At a base level, in almost all domains including healthcare you need some amount of a regulatory framework to counteract the problem that market participants generally have an incentive to decrease the number of choices to the other side. I think you probably agree with "coercion" at this level (stuff like preventing collusion among players, certain stances on breaking up certain kinds of monopolies, etc.).
But the problem is that in healthcare you do want powerful players because there are benefits we want to reap from large players. Large drug makers are the only ones capable of performing substantial R&D and regional hospital and transportation networks are really the only ways you can get the necessary infrastructure and expertise to treat a lot of things. On the buyer side you want large insurance pools to even out risk for people.
But those all have inherent monopolistic tendencies that are exacerbated by the problems of choice that I mentioned.
Different types of healthcare are also fungible. And not all healthcare is cancer! I think the biggest problem with having any discussion around healthcare policy is that we automatically assume that we should treat routine treatments and visits the same way we treat catastrophic accidents like cancer and brain surgery.
Food is much more fungible than healthcare. The loss of any number of food items can be substituted by an overwhelming number of any other food items without the consumer ending up dead.
Healthcare is not as fungible. Most medications have single-digit or even no effective alternatives.
For an illustrative example and the flip side of the coin, water is a good example of where unregulated markets do terribly (since you really do need water and can't substitute it with something else and it's also geographically heavily monopolistic). Potable water production and pricing in all developed countries is heavily regulated for good reason.
The vast majority of healthcare expenditure is preventive or planned care, which is largely fungible. MRIs are fungible. Primary care is fungible. Antibiotics are fungible.
To the extent that healthcare isn't fungible, it's in very specific cases like end-of-life care, cancer, catastrophic surgery, and rare patented drugs. They also account for a tiny minority of overall health expenditure.
We can use different tools across both of those problems.
> The vast majority of healthcare expenditure is preventive or planned care
I don't think that's true for the U.S. Preventive care and planned care (if understood to be stuff like physicals, blood checks, screening, etc. including your examples of MRIs and primary care) as far as I remember is actually a small minority of healthcare expenditures (< 20% is a number I recall). I can try to root around for sources if you're curious, but I'm also curious where you're getting the impression of "vast majority."
> Antibiotics are fungible.
Not really. Definitely not in the same way that food is fungible. I assume you're talking about generics here? But generics again actually make up a startlingly small minority of healthcare expenditure costs despite making up the majority of prescriptions IIRC (again I'm going off memory but I think it was something like 75% of medication expenditures are due to medicines with no allowed generic alternatives).
Basically the places that you're suggesting the free market should best apply to are already the smallest slices of the healthcare expenditure pie (and also already quite effective in that limited domain).
Ah, I don't ever remember reading numbers for those so I can't comment on that (I'd be curious if anyone has a breakdown of surgery costs by elective, semi-elective, and emergency).
But even stuff like hip replacement kind of is on a sliding scale. How much choice do you have if the alternative is death? What about cognitive impairment? What about blindness? What about impaired range of motion? What about mild discomfort? What about pure annoyance?
Not accurate and the car insurance market provides the model health insurance should be based on. In car insurance you have multiple providers you are free to choose from with different coverage levels and service options. If your bad driving history prevents you from getting standard insurance, government programs provide a backstop alternative way to get coverage. Yes the alternative costs more, as it should, because you are responsible for your driving habits. But there are also government programs on top of that for low income drivers.
The point is, the free market should be plan A, and government programs should only exist to cover the gaps. Ultimately, people should be responsible for their own health, but in special cases, for no fault of their own issues, government should provide a backstop because it is the right thing to do.
Most taxpayers would agree with that. What they don't want is to be forced into something that is inferior and on top of that be penalized to subsidize someone else's premium.
That's not entirely accurate and that's not even the meaning of free market.
Water is also a necessity as is food and you can have a free market for those.
The questions are:
1. Does the buyer have enough choices or alternatives to choose from when it comes to healthcare?
2. Do those who offer services have a monopoly on the service?
When you look at the US market you'll find that it doesn't meet those criterias. Market forces are prevented from acting and being able to reduce costs.
The fact that there is a captive audience, as you suggest, means that we cannot just shovel money into it. You end up exactly where you are. Costs go up because it is a necessity. Same reason food prices go up when there is a shortage. It is not a luxury.
I think you are making a more articulate defense of private/market based health care than i usually hear. but i think fundamentally health care has too many forces that make it untenable for a market. there is no real satiation point in care, people are price inelastic, many services cannot be priced before delivery, there is little opportunity to do repeated business for most of the costliest services, comparison between providers is very difficult, most of the choice happens under incredible duress when you are your weakest point. health care is just not a consumer good that responds well to market mechanisms.
I suppose it all depends on how you define market mechanisms. What I've found -- after personally studying the subject -- is what a lot of people consider free market is the opposite of what the literature considers it to be.
To answer your point:
Most/all of the issues you raised are met by "pooling" aka insurance. The need arises at random and when it does there is a massive cost and you urgently need the service. This is what insurance is for.
What I was suggesting isn't that people go and pay the doctor out of pocket -- although they can. Rather that they purchase insurance. Those who can't get $$ indexed to some national average or whatever scheme you prefer. The point is everyone gets to purchase insurance if they so prefer.
The problem is that choice of insurance providers is artifically limited right now and the choice of healthcare providers is as well. So you have a system where you are captive to the need and those who provide the service have a monpoly. Naturally costs will rise. Putting political preassure on government to increase spending is easy way out but that will only shovel more money from the pockets of the many into the pockets of the few. In fact this was predicted when Medicare was first introduced, and here we are. It is not like doctors and providers magically became greedy capitalists in the last 40 years.
Also to be very clear this isn't an issue of "profits". Insurance companies don't have huge profit margins. They make their "wealth" by being a monopoly. The execs make their money on the rise in stock prices which isn't sensitive to their 3-5% profit margin.
so you are arguing that many small insurers, with insurance not bound to employment, would create a healthy price-quality structure in us health care? akin to the german model?
i think that has some merit, but its hard for me to imagine that having the payer, be disconnected from the consumer can really create a stable market without heavy handed regulation.
i dont think insurance can really get you to an efficient market. health care is simply not a good where price and substitution apply as in many other markets. and rather than jumping through hoops to invent such a market lets agree that this an ethical part of social contract and manage it with the best technocratic solutions that our society can offer. E.G. NHS and NICE
Sure but that single payer has political motivations and sources of influence which ensure that won't happen.
If concentration of power was good we'd just find a few wise persons to run the country and leave it all up to them. Other than the little snag, the sinle buyer argument would work.
Giving the individual the money to make their choices is a better way to ensure that people get what they want. A universal healthcare plan (irrespective of how it is funded) because different people -- or even the same person at different stages of their life -- don't have the same needs and the same risk profiles.
I'm not assuming anything. I'm starting that even in theory healthcare isn't very amenable to a market solution. I think you disagree with that. It's possible to have a reasonable position on both sides, I don't think it's a solved problem.
Where I think we both agree is that the current disastrous mix of regulation and free markets in the present US system is a terrible solution.
> The US is actually the only developed nation without a public healthcare system,
That's false on multiple counts. First of all, the US does have a public healthcare system, Medicare and Medicaid. Second of all, there exists other developed nations with fantastic healthcare systems that are driven by purely private systems: namely Switzerland (widely regarded to be one of the best healthcare systems on the planet) and the Netherlands. Even more perfectly fine developed nations operate on public/private mixes, including Germany and Belgium.
> it also has the highest healthcare costs of any nation on earth. Coincidence?
There's an excellent book (well it had bad reviews, actually, because it was perhaps overly detailed and tedious, but I enjoyed it) about the Gemini project called On The Shoulders of Titans. Reading through the notes of how NASA interacted with contractors was terrifying: here's some money to study something. Turns out it was very subtly different from what NASA had intended them to study. Here's more money to do another study. Now here's money to build a prototype. Oh you're 90% done and out of money? Here's twice as much money. Oh now you're 99% done and out of money? He's the same amount again. Oh it doesn't work but you can argue it's NASA's fault? Here's more money to start over. You're done? Actually we're gonna scrap this particular mission objective now.
Space X owns something much close to an end-to-end objective: it's not a study, or a build, it's getting the thing to orbit, end of story. I think if you could set up the situation so that a company owns the end-to-end story of your health, things might be better off. That sounds more like Kaiser Permanente and my impression is that's exactly what happened. In reality our healthcare system is typically more like Gemini: contractors, tons of regulations, but none of them really own the end result so it's a public/private mix of bureaucratic mess, misaligned incentives, and buck-passing.
Part of that is it was very very hard to know back then what was needed and what would work. Now a lot of the fundamentals are well hammered out and the big challenge for SpaceX was the landing not figuring out how to build rockets in the first place.
Also the ACA did have some successes in doing kind of what you're talking about. There were incentives in there to avoid readmittance before 30 days and to all appearances it's been a success.
one is a necessity and other one is not. If it's too expensive to launch stuff to space, most companies won't. If it's expensive to get a drug, well you will either pay up or suffer until you die.
I had forgotten those terms.. yea nothing mysterious going on here. This is well understood situation. Everyone should take micro-economics not matter the profession.
I think the space successes have far less to do with privatization, and far more to do with Space X, specifically the combination of a massive amount of capital sloshing about, Elon Musk being good at getting his hands on that capital, and there being an absolute army of engineers who would walk over coals to build rockets.
That NASA hasn't been able to capitalize on this situation is more about NASA's failures than anything else.
Privatization doesn't make costs plummet, competition does. In most cases, our healthcare system is not competitive even when it is private. e.g. emergency rooms. You will just go to the closest one. If you look at areas where healthcare actually is a competitive market, e.g. Lasik surgery, the situation is very different.
Actually, throughout history (at least 500 years in the UK, since the end of the guild system) people have paid what was essentially a premium in order to access medical care at the point of need - effectively insurance, if not always named as such.
Most of these organisations were mutuals, eg, member owned, and would have pre-existing relationships with doctors etc that would control costs.
In this way, there were no perverse incentives - people had "insurance", and they wanted that money to cover as many eventualities as possible. The bigger the pot of money, the more resilient the community.
So actually, health insurance has a long legacy. The problem, I would suggest, is shareholders who are not the principal beneficiaries of the service.
FWIW, in the UK we found that a system of mutuals and municipally owned hospitals was sufficiently imperfect that we created the NHS anyway. Probably best to skip to single-payer in the US, imo.
Not really though. Not in the way it does today. Medicine up to 1900 was largely ineffective. And most of what we consider modern medicine has its roots in the 1940s. Which coincidentally is about the same time employer provided health insurance started becoming common.
Many procedures that are common between today and circa 1960s have grown exponentially in cost. It was about this time that public insurance became a thing, and private insurance approximately the same time, in terms of actual usage. The median cost to individuals has gone up significantly since any insurance was mandated.
Manufacture of rockets and space travel has always been privatized.
It is really a testament to spacex PR that that there is so much confusion on this topic.
They SpaceX is "private" in the sense that they are not listed on the stock exchanges. Previous manufactures were all "public" in the sense that they had gone through an IPO and you could buy stock.
People confuse this with public, as in the the government owned public pool.
Except...it's not obvious that the root cause of the US's current healthcare disaster is "privatization". I work in the industry, and by far the #1 most jarring misconceptions I see floating around forums like this is conflating of "privatized" with "employer sponsored because of decades of tax incentives and mandates". The US is not the only country that has a public-private mix of healthcare, but it is pretty much the only developed country where private health insurance is predominately received through employers rather than on the individual market.
If you want a true apples-to-apples cost of public vs private healthcare, you should look at Medicare Advantage vs Original Medicare. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare, also cover Part D prescription drug benefits, and often include supplemental benefits that Original Medicare doesn't already cover. There are some interesting findings so far:
- 39% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly, that we expect by 2025, more seniors to be on a private plan than the public one. There's also great variance by State. In Florida, Pennsylvania, Wisconsin, Michigan, Minnesota, Oregon, Alabama, Hawaii, and Connecticut — nearly 50% of beneficiaries are on Medicare Advantage. By 2022, we expect more seniors in those States to be on a private plan than a public one. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about...
- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan. https://www.commonwealthfund.org/publications/issue-briefs/2...
Albendazole - retail price in Russia is $2 per pill... How in the world it may cost $13 per pill to manufacture and sell? OK you can factor in Russia vs USA ~2.5x PPP factor, it's still $5 per pill retail then - how come it comes out 4x more expensive?
It’s pretty insane how big of a marketshare CVS owns. They can make or break small pharmacies. Either you accept their terms or they refuse to let hospitals and doctors to work with you.
I really hope this works out. We need more public corps companies like this.
I dont know if manufacturing is the problem. Cant you import drugs from India or other country with cheap off label drugs?
The system is built to prey on the sick, it has nothing to do with manufacturing.
I like his idea, but doubt it will work
Well if this is supposed to be an eye-opener, than it might work. Otherwise the prices listed are still insane, and comparing them to non-existent prices doesn't help the case to make it trustworthy.
Sure, that's what patents are for: to guarantee exclusivity to whoever bore the R&D cost so they can charge a lot for long enough to recoup their investment. This service is selling generics, though, so they'll be off-patent at this point.
Mark Cuban is selling Albendazole, the well-known anthelmintic that has been at market since 1975.
Current sticker price of Albenzazole in US: several hundred dollars. Cost in the developing world: a few pennies, according to Wikipedia.
Is this a joke? Would the government rouse itself to negotiate prices with manufacturers, like it does in the developed world? We'll have to wait four more years, with Mr Joe "Nothing will fundamentally change" Biden.
The government isn't just the executive branch, there's also the legislative. The courts just interpret current laws. It's Congress and the Senate that need to act, but they won't. They are financed by people like Marc Cuban who buy politicians to increase their wealth even further, as seen here.
A common anthelmintic is somewhere north of 400 dollars in US but in Britain it's something like 5 pounds. Profits for the well-connected, pinworm for those that can't afford it. Pharma markets are funny, of course there is a monopolist, given the size and entry requirements, consequently you need a monopoly buyer. Can the government please wake up and govern?
Can we just appreciate the level of moral depravity needed to price fix medication? In my opinion something this repugnant and egregious needs personal executive accountability. I'm willing to wager that many human lives have been altered for the worse because of this, and there's nobody taking personal accountability.
Imagine if Epstein wasn't personally charged, instead just his business was fined. To me, that's actually the level of crime we're approaching here. If you think this is tenuous, at least consider the fact that it is proven that poverty is correlated with human trafficking (due to desperation and vulnerability) and illegally high medical bills force people into poverty.
Price doesn't even have to be fixed for it to be depraved!
Good time to remind everyone that Shkreli is in prison for financial crimes largely unrelated to the pharma side of his businesses, the rest of the pharma industry continued doing the same things as him as usual.
That was kinda the point, no? Shkreli was made into a bogeyman, but he was just doing in the open what every other pharma was smart enough to keep secret (pricing things higher than necessary). He also did it an excessively bombastic way.
"Don't hate the player" is the kind of thing you say about people scraping by at a day job, who hold no real power over the business practices. He wouldn't have gone hungry if he'd behaved acceptably, so he had a choice free of influence by the immediate need to survive. I wouldn't characterize Shkreli's moral failure as a symptom of "the game," but rather one of several root causes of its perpetuation to begin with. In my view, fixing the problem includes denouncing powerful people who fail to abide by the ethical standards that we want them to hold.
I made no statement about "objective" morality. I explained my own morals, and why I'm comfortable encouraging people to blame the wealthy for the harms they perpetuate. Could you please elaborate on how you think this reply is relevant to that?
As slow as it seems to be, my perception is that societal attitudes towards wealth have been shifting over the past few decades. I'm hopeful that one day, the tolerance for their misdeeds continue to dropbenough to inspire progressively more social and legal change, as you suggested.
Public witch hunts are called "witch hunts" for a reason, and it's not a pretty one. It's also known as "mob justice", which despite the name is generally considered to be not justice at all.
It seems poorly considered to characterize social pressure as a witch hunt. It is acceptable to encourage others to share your moral convictions, there is a vast gulf between that and a pitchfork mob.
I definitely would, since the response to Shkreli has been primarily online ranting. He's never been at significant risk for physical harm as a result of the public discourse as far as I can see. I don't consider negative public opinion and castigation for unethical behaviour to be unwarranted or undesirable, so I can't see that rising to the level of vigilantism either.
In my view, society would become severely dysfunctional if we are expected to withhold our negative views of someone's choices, from fear that too many people will share those views.
This is something people often forget, nothing is objectively good or bad as they are social/individual constructs. Even things like killing or theft could be seen as good looking through the right lens.
This is a game theory problem with perverse incentives where regulation and law enforcement are needed. If CEO A (in this case Martin Shkreli) were to take the "moral high ground" and behave acceptably, the board of directors would look at similar companies performing 10x better, fire him and replace him with someone less moral.
If the board were to take the "moral high ground" the shareholders would value the company many times lower, and they'd be bought out for pennies by an acquirer willing to take the low road because that would be a super profitable move.
If moral shareholders refuse to buy the shares of low-road companies, the value of the shares fall, but the profits don't, and suddenly being "amoral" is super profitable for stock investors, and there are always some, and they will be richer than moral shareholders. As amoral investors amass riches, they will deploy greater amounts of capital using amoral valuations, which will then dominate.
So the whole system is broken, and personal ethics does nothing to fix the game. In a nutshell, this is also why libertarianism is broken.
I see what you're saying from a business perspective. From a social perspective though, I don't consider that a reason to withhold my ire towards people like Shkreli. Choosing to be a bad person because someone else might be worse is still a choice to be a bad person, so while your pragmatic reasoning might work well when it comes time to determine a legal response, I don't feel that encouraging people not to hate Shkreli is helpful in encouraging good social norms.
Your ire is not necessarily directed at a personal preference to be a bad person, though. Attributing it to him "wanting to be evil" is easy, especially because he is abrasive.
Due to the incentives above, it might be said we are annoyed by their lack of willingness to be fired in a futile effort to obstruct a system which will carry on regardless--we are annoyed they won't do something pointless.
I have a feeling most people would have trouble taking food out of their family's mouth and literally becoming unemployed in order to tilt at a windmill where your effort cannot win. That's a pretty impossible standard to expect. If Shkreli found morals and got fired, Shkreli2 would take over.
So instead, I say, the problem is the system. Pretending it is about moral failing enables the system to go on by wasting time blaming moral failings instead of fixing it. The system produces bad behavior. We can tut tut each individual person it produces, or we can change the incentives and fix the system.
I really appreciate your reply, you've definitely got the gears turning in my head.
Something to clarify, I'm not really trying to say that people like that want to be evil. People like Shkreli make bad choices not because they like to be bad, but because they're indifferent to the indirect consequences of their choices. I'm extremely skeptical that someone in a position like Shkreli was would be in any serious risk of losing access to essentials like food and shelter if they were to behave more ethically, so I think it's important to set the standard that choosing a job like that when you have alternatives is wrong.
All that being said, I do agree with you that the primary problem by far is the exploitative structure that enables these people to exist in these positions, in the first place. If someone's analysis of the situation ended at Shkreli, I'd encourage them to think deeper. However, I do strongly believe that we don't have to choose between one or the other -- encouraging others to look down on those who choose to be a part of this system can have a significant influence by discouraging others from entering it, themselves. The more voices we have saying "this is not something to aspire to," the more pressure we can build to effect meaningful systemic change.
I appreciate your open-minded approach. In terms of turning gears, I find that a surprising amount of the time, the evil people (greedy bankers, landlords, unions, execs, VCs police) are caricatures held by outsiders who don't see the full set of incentive structures driving their behavior.
Instead, from afar, they become cartoon bad-guys. When this happens, most people take the easy route and decide they are all "evil" rather than looking at the incentive structure of the system, and the behavior it encourages.
Next time you see one of these, see if you can instead see it as a bunch of people in roles mostly acting in their own self interest, and think on whether policy, institutional organization, or law could alter the incentives and change what is in their self-interest in a better way.
There are many root causes, one of them being execs with decision making abilities, like Shkreli, making greedy decisions at the cost of people's health. It's ok to hold them accountable.
The root cause, in that, medicine is a for-profit endeavor and people are not only profiting, but seeking to maximize their profits on other people's basic needs?
Pretty much. Other things that don't help (somewhat US specific):
1. Layer of indirection created by the entire insurance system, which at this point is clearly not a good model for healthcare. Everyone needs/should have some amount of healthcare, so a system built entirely around the idea that only a minority of people should need to take advantage of the system is silly.
2. The half-assed government intervention of Medicare/Medicaid/ACA/etc – worst of both worlds in that when a government just injects shittons of money into the private sector (without very strong controls on price and behavior), what you end up with is ballooning costs... and that's about it. See also the govt. guaranteeing student loans for another example of the same. Or the Military Industrial Complex. And so on.
It's a bit more complicated than that. Health care costs have skyrocketed in the US. One of the big contributors to that has been the explosion in testing, both routine and diagnostic. These large costs aren't always shared to the same degree with other countries that have socialized medicine.
One example is with MRI scans. MRI machines, and the technicians and doctors who work with them, are insanely expensive. The US is, of course, not the only country with MRI machines. However, in countries with socialized medicine there may be a much longer wait for people to get an MRI scan for a non-critical issue. What about in the US? If you've got the money, you can get one right away. As a Canadian, I've seen tons of advertisements over the years targeting Canadians for MRIs as a cross-border service.
So the question is: is getting an MRI now instead of waiting 6 months a basic need? Private MRI clinics are definitely profiting from it. It definitely seems frustrating for people on the waiting list who can't afford to cross the border and pay out of pocket. However, it doesn't seem nearly as bad as a company price-gouging people on life-saving insulin, for example.
Too much of that is markup. The cost of MRI machines is down, and the cost of CT scanners is way down. But charges for those services have not dropped to match.
You could say the same about bakeries ("seeking to maximize their profits on other people's basic needs").
IMO the problem is more about (very) imperfect competition. Also medicine is very special in many ways (desperate buyers, doctors making decisions for them, moral and emotional weight, etc.), so it's hard to have incentives aligned.
The entire food pipeline is heavily subsidized by the government, from advantageous loans to crop price insurance to direct cash subsidies to a sales tax exemption, to SNAP to people who can't afford food. I agree wholeheartedly with the bakery comment, that they try to maximize profits, but, bread is less than a dollar a loaf and significant expense and effort is taken to ensure everyone is fed. There seems to be no will to do the same for healthcare.
Maybe people would have less problems with "corporations are just groups of people working together" if the people of a corporation were ever held accountable.
In evolution adaptation prevails over customary behaviors thought of as morals. The question is why have the generic makers continued to cooperate instead of defect? How is the cartel protected?
In this thought I am reminded of the Econtalk podcast’s discussion of Martin Shkreli in the interview about the High Cost of Cancer Drugs with Vincent Rajkumar.
One tactic pharma companies use is playing games so generic makers can't get samples of the medication. These samples are required for making a generic version.
> least consider the fact that it is proven that poverty is correlated with human trafficking (due to desperation and vulnerability) and illegally high medical bills force people into poverty.
This is pretty tenuous and would implicate a lot of other behaviors. You know what else causes poverty?
- the ability to hire based on skill and lay off people when you don’t need them
- alcohol
- charging for housing
- charging for food
- charging for utilities
- property taxes
- charging for transportation
If, “does something that could cause poverty” is the bar, then a huge chunk of market exchange of goods and services needs to stop.
You’re comparing the basics of a capitalism based society to a large company actively breaking the law (price fixing) on products that affect people’s lives and health directly.
Please don't take HN threads into ideological flamewar or nationalistic flamewar (this is a bit of both). Those paths just lead to internet hell, and we're clinging to little clumps of grass and the occasional rock trying to stave off the downward slide into that abyss.
Part of it may be lack of compassion but that it certainly not all. Part of it is that Americans have been led to believe that government can do nothing right and that the free market is all that is needed to solve the problem. Which is incorrect, but here we are.
Certainly government is competent in many places, but the performance of the American national and many state governments throughout the pandemic hasn't exactly been confidence inspiring. I don't think Americans who believe that their government isn't capable of many simple tasks are delusional.
They aren't delusional about the government. But there is some delusion that private business or the "free market" can necessarily handle all these same problems entirely better.
My friend recently got admitted to the hospital. There must be 10 people during the intake who didn’t seem to be doing anything. Some “nurses” were just observers. There were two admin people who came into to take personal information. 2 medical techs who just took temperatures and nothing else and finally a real nurse who did all the vitals and finally the doctor after 2 1/2 hours. Imagine the efficiencies that could be extracted and passed on to the patients.
This is hilariously bizarre from a non-US perspective, but your country is so primitive in this area that a "Mark Cuban" branded solution is probably the most viable path out of the mess.
“Can’t argue with the benefits of the trickle down effect of wealth”... yes I think decades of economic doctrine have covered the benefits. Probably should keep in mind other things like the consequences
I'm a bit too cynical to believe a benevolent billionaire will save us.
Me thinks theirs something else at work here. I could see Mark Cuban building this company up , selling it for billions at which point we're back were we started
I believe Mark Cuban is an altruist, but as you alluded to, the empires he builds are not inherently benevolent and could eventually end up in the same place over time as ownership changes.
I agree, either there's something else going on or he's entirely genuine about the mission -- in which case it's unlikely to thrive.
While this business model can work in some industries, in this particular heavily regulated industry, Cuban is either going to discover that it's harder than it looks and fold in a few years, or he's trying to sell a grand vision and offload it for a profit before the cracks in the foundation are discovered.
I would be more inclined to see the mission as genuine if this were launched as a public benefit corporation or B corp (but even then, the promises such companies make of serving the public good can be overblown).
I'm not usually a "market" guy, but some good competition in generic drug production might actually save us. Presumably, he sees large potential profits by aggressively undercutting the non-competitive overpriced generics. If that takes off, it could be a good thing overall.
It’s easy pickings but putting your name on a generic drug company seems like an oxymoron. This and the thing in the news recently with Delonte West’s rehab that Mark Cuban sponsored - not even an attempt to get the stink of PR off of it which rubs me the wrong way
We're planning to introduce a lot more drugs with transparent prices later this year, cutting out monopolistic middlemen in the supply chain and alleviating pharma drug shortages, particularly for rare and orphan disease conditions.
We are looking for a few devs (fullstack, frontend, and backend). If anybody is interested, drop me a line at alex@costplusdrugs.com
In the meantime, happy to answer questions if anyone is interested!