BiggerBoat posted:Ok, real quick, explain THIS: The "Chantix corporation" (Pfizer) isn't making you get a prior auth. Why would a drug company but any barriers in your way to purchasing their product? A prior auth is something used by insurance companies to control costs. It'll typically ask you basic information about you, your treatment history, and why the doctor thinks you need this medication. In many instances it's simply a formality or a data collection tool. In other cases it's used to verify that you've tried other less expensive therapies first (e.g., generics) before going to a more expensive therapy. In some cases certain insurers have step edits on the formulary. A formulary puts drugs into various tiers based on whether the insurance carrier prefers them/wants to be used and often is tied to the out of pocket cost for the patient. Formulary placement is negotiated between pharma and insurers. If two pharma companies have similar drugs and have list price of $1k each the pharma company may offer a 25% discount for them to be placed in a preferred tier. Access to the less preferred treatment requires you to "step through" the preferred treatment. Generally this is all good because it lowers the actual cost of the drug and those savings are passed on to patients. While the terminology may be different in a UHC or single payer system, the general process still applies -- if not more so. This is good in the sense that it helps constrain costs. It's bad in that it gives HCPs less power over how they treat their patients because guidelines / treatment pathways are more strictly enforced. This is why you'll typically see a lot more use of new, novel therapies in the US relative to other countries that require you to step through older therapies/generics even if they're less efficacious. That is also why the concept of off label treatment (using a drug outside its approved indication) exists in the US and doesn't occur in Europe like with NHS/NICE in UK. They're not going to pay for a patient that lacks other options based on possibility of efficacy in 1) similar disease area (e.g., approved in one type of leukemia but not another) or 2) phase 1/2 studies. It also introduces the dreaded DEATH PANELS because MD has run out of approved options and sends you to hospice. KingNastidon fucked around with this message at 00:12 on Aug 6, 2020 |
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Aug 5, 2020 23:56
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My goal isn't to tell you anything is good or bad. Just talk about why things are the way they are and discuss upsides/downsides to changes.BiggerBoat posted:But all that's a petty complicated, convoluted and stupid way for my Insurance to ask for "prior authorization" for a scrip I got written yesterday and when the obvious reason it was "authorized" is "I would like to quit smoking please and heard this might help" along with a WELL documented "this person is rapidly losing weight and may have cancer" additional reason. Prior auths are annoying for patients and MDs. To the poster above, some of this is just an annoyance factor to ensure that 1) patients are actually committed to getting the therapy and will be adherent/compliant and 2) MDs aren't just pill mills that are haphazardly giving out drugs. This seems silly in your example with smoking and Chantix, but there are obvious examples where these hoops make sense. BiggerBoat posted:My insurance company ALREADY HAS this information, believe me. They might or might not. People change jobs and get different insurance. Maybe they have your full history but still want additional information that they don't have visibility into. One example is lab values or scan results. Again, seems absurd in your specific case, but less so in a $10k/month cancer therapy. BiggerBoat posted:You totally skimmed over about how "yesterday" is "prior" to today (when I went to pick it up) and how "authorization" is "has a prescription from a loving doctor". Unless I loving forgot how to speak English or something. Any doctor can write a prescription. Given your insurance is paying for it they may want more information to fill it. This is annoying, but a cost saving measure. Plus plenty of doctors are overworked, greedy, and/or cranks. BiggerBoat posted:I totally skimmed over the completely reasonable and not at all idiotic "formulary" and "step edit" procedures that exist because "reasons" that might be less "efficacious" after already REPEATEDLY having to do other tests before I do the ones my PCP ordered. You'd think "this guy needs to quit smoking" would...uh...be a decent and basic enough place to start with what ails me. But maybe I'm being overly cromulent and not factoring in the hypotenuse and the bilateral precipitation involved in this carefully calculated decision to basically require my doctor to re-authorize a legit prescription he already loving wrote. I'll never say the US health system is easy for patients/caregivers. The easiest argument against for-profit insurance companies is they're incentivized to not give you care. Restricting access to healthcare would still occur in a single payer system (e.g., are we really giving this 85 year old with major comorbidities an expensive cancer treatment that won't meaningful extend quality adjusted life years?). But at least people could rationalize that as a data driven, democratic choice in how to allocate finite healthcare spend across its population rather than for-profit corporation maximizing earnings per share.
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Aug 6, 2020 01:01
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Apologize if I skip things.BiggerBoat posted:Wouldn't ALL this stuff be less complicated and make more sense without marketing and advertising? Or worrying about which hospital or doctor is "in network" in the event I'm barely out of a coma? Marketing and advertising by insurance companies, hospitals, drug companies, med device companies, patient advocacy groups is its own thing. There are certain aspects where the US is a clear outlier and should be addressed (e.g., direct to consumer advertising on TV). Devil's advocate in me would say there are benefits to DTC advertising for things like viagra because it makes topics like erectile dysfunction less taboo. Men are notorious about not procrastinating on healthcare issues or being shy about bringing ailments up with their doctor. The in and out of network thing is a pain of the rear end for patients and why I pay more for a plan that won't potentially leave me in a bad spot even if I'll never use it. The rationale behind it is that insurance companies make deals with providers. Easiest example is with dentists. Dental insurance companies will say: "Hey, there are X number of people in your area with our dental insurance. Our insurance will cover you and send you business from these patients, but you have to agree to a 20% discount off your normal rates." This allows the dentist to determine whether access to those incremental patients, albeit at a reduced cost, makes sense to them. This is all fine and good with something like a dentist where people can typically investigate benefits in advance, but less so when your accidentally chopped your finger off cooking dinner and need treatment ASAP. BiggerBoat posted:Also, you said, "given my insurance is paying for it". That's the point. They're NOT. I'm being denied tests and medicine at every turn and I'm "one of the good ones" who WORKS for my super duper private insurance. This is a crass way to look things given healthcare, but think about it like a car insurance assessor/adjuster. They're doing additional work to make sure they aren't paying for repairs that aren't needed or overpaying for services that are rendered. From the perspective of the patient or car owner this looks like they're just loving you and only you. The alternative is they're more permissive of outright fraud and those costs are passed onto you via higher premiums. Tomberforce posted:Have you ever considered that forcing someone to provide you a service is called slavery so publically funded medical care mesns making doctors into slaves. But this doesn't apply to any other public sector job for reasons. I see where you're coming from and this underpins the debate around healthcare being a "right" vs. a service that a humane society provides to its people. Likening it to slavery is unhelpful because anyone involved in providing healthcare can simply opt out of doing so. If some future single payer legislation caps reimbursement such that healthcare provider pay goes down significantly or biopharma/med devices can't breakeven then so be it. People will just leave to more interesting/lucrative careers, but this isn't chattel slavery. DC Murderverse posted:when is this an issue for things that aren't painkillers/abusable drugs? Many hospitals, clinics, etc use buy and bill. This gets very into the weeds in an area I don't focus on, but tl;dr is healthcare practices make money for each drug prescribed/infused. Doctor isn't going to care if they make 10% mark-up on giving Chantix, but they might if that 10% is applied against a $200k/year cancer treatment. Griefor posted:This is just plain false. Huge pharma coorporations have been buying up smaller companies that just developed an effective new treatment, jacking up the prices and slashing the R&D department because there is no short term profit in R&D. Even though that R&D department researched the treatment they are now making bank on. Dozens of smaller companies that still did research have been gobbled up by big pharma for the patents and had their R&D shut down. This is just one way the industry works. Big pharma does their own R&D, but much of the work is done at smaller biotechs. This is because outside investors will have significantly more influence on how the company is run (e.g., seats on the board) and greater upside if their bet is successful. Any biopharma R&D is highly speculative in terms of discovered drugs -> Phase 1 success -> Phase 2 success -> Phase 3 success -> FDA approval. What typically happens is that big pharma will jump in at Phase 3/FDA approval stage to buy out the company because it's less risky. Big pharma gets cash flow, employees and investors at small biotech get payout. Each side is happy otherwise shareholders on both sides wouldn't have done the deal. The value of that ongoing R&D (e.g., Phase 1/2 trials) is priced into the deal. When or if R&D associated with the small biotech is eliminated it's because the new big pharma co has decided it's not worth pursuing relative to other options. Kreeblah posted:It also incentivizes finding ongoing treatments rather than cures. Why let somebody pay $200,000 for a cure when they could be paying you $10,000/month for years? Conspiracy theory bullshit. Trust me, enough doctors and VCs and biotech founders/CEOs are megalomaniacs in that they'd rather be on Time Magazine for curing X than increase their already high net worth. People aren't letting The Miracle Cancer/Alzheimer's Cure die on the vine in the clinic because treating the disease is more profitable than curing it, maaaann. You can't simultaneously believe that corporations only care about maximizing next quarter's revenue and that they're walking away from 100% market share at essentially any price for a cure. Also while clinical trials are sponsored and paid for by pharma, major academic hospitals/doctors are the principal investigators. They diagnose the patient, administer the therapy, and see the results. They want to present the data at the plenary session at ASCO and have their name on the NEJM publication. The conspiracy doesn't run so deep that everyone is hiding The Cure. KingNastidon fucked around with this message at 02:04 on Aug 8, 2020 |
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Aug 8, 2020 01:31
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wins32767 posted:You realize that there are multiple Hep C cures on the market and that's what another big factor driving the cratering value for Gilead, right? Right. Gilead didn't just have Sovaldi magically fall into their lap from the NSF. They spent $11B to acquire it from smaller biotech Pharmasset almost 10 years ago. Since then other companies like Abbvie and Merck have gotten similar therapies approved albeit with slightly different indications. Additional competitors allows payors to apply more pricing pressure, thus diminished revenue for all players involved.
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Aug 8, 2020 02:57
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Seems like extreme focus on the $3k/patient cost of remdesivir is misplaced when it's potentially 0.3% of the costs in this example.
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Aug 15, 2020 19:23
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You're always going to have some segment of the population that genuinely believes each individual should be fully responsible for their own healthcare. Even if some are born with a condition that requires out-sized health expenditures, are eventually diagnosed with a disease that is not really linked to any personal behavior (e.g., hematologic cancers), or suffer a random tragic accident. These are people that you will never reach and shouldn't worry about. My minimum acceptable situation is UHC with personal mandate. In any given year top 1% of the population contributes to 22% of health expenditures (avg per capita: >$110k), top 5% of the population contributes 50% (avg: $50k), and the bottom 50% of the population contributes 3% (avg: $276). There is massive financial incentive for people to not want to pay for sick people -- premiums certainly higher than $276/year for those that fall into the bottom 50% of healthcare use! But who falls into the high spend groups changes constantly and often randomly. I find opposition to UHC and a personal mandate unquestionably immoral because it's just a roll of the dice, especially with moral hazard where HCPs will not refuse care even if you willingly choose to not be insured. I also don't really understand opposition to making insurers non-profits along the lines of Switzerland since they aren't driving much innovation. The good faith arguments against full single payer generally fall along the lines of "better the devil you know..." Everyone is aware the various for-profit market incentives that lead to higher costs and bad care in some circumstances. The three major questions that single payer advocates need to address and have good answers for are 1) what do you pay for 2) how much do you pay for those services and 3) how do you pay for cost of total program. #1 introduces questions around abortion, trans healthcare, homeopathic/herbal medicine, chiropractics/sports medicine, therapy and mental health, on and on. One may assume that any country that is able to pass single payer will make the right policy choices, but the political winds change (see: Trump and USPS). Also introduces the dreaded death panels because the easiest way to constrain costs is not pay for old, sick people. #2 determines how much providers (HCPs, hospitals, pharma/med device, etc) get paid. To the discussion earlier, no one is forced to work in the healthcare industry but financial incentives + influence over one's day-to-day work will drive who stays/leaves. This also applies to any private, for-profit entity interacting with the public healthcare system. There will be no private funds invested if it's a guaranteed loss. #3 is probably the easiest question since it's just a mathematical exercise, but tax incidence will have influence on where you draw support. None of these questions are unsolvable otherwise you wouldn't have NHS/NICE in UK. But now every single minute aspect of healthcare for consumers and providers becomes an issue of federal politics. I can understand why those that are risk averse or have sincere local government or anti-authoritarian beliefs would want no part of single payer even if they support UHC or medicare/medicaid in their current form.
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Aug 15, 2020 23:21
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knox_harrington posted:It is particularly acute in the US though. I don't live in the States, but doing US-based medical research for a US company I do find that lots of people are simply unaware of what is happening globally, even in their own field at a global company. To revive this dead healthcare thread that always dies because it strays from interesting/hard policy discussions, tell us more about your work in Switzerland and US vs. Ex-US dynamics. Basel is lovely 
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Aug 24, 2020 04:34
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fool of sound posted:Get the primary relitigation/electoralism stuff out of this threads except where is directly pertains to stated healthcare plans. Absolutely no one accuse each other of brown-nosing the democratic establishment or loving trump and wanting him to be re-elected. The thread is already pretty dead so don't see what this sort of discussion hurts. You aren't going to find much substantial disagreement on various healthcare policies [or those disagreements won't be permitted]. If we're going on assumption that Bernie style single payer is unequivocally best and healthcare always polls as one of the most important issues for voters then it's useful to discuss why those voters didn't choose Bernie. Potential flaws in Sanders' messaging and how other candidates were able to counter-message (e.g., muddy waters on what M4A is) is important if others want to do better in the future.
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Sep 2, 2020 16:41
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FizFashizzle posted:Is there a concise argument/research against capping healthcare costs at x% of income? Phone posted:With the solution of “raising taxes” and the response of “that’s a make-believe answer” in the context of the recent feedback thread that outlined that doomposting and doomerism is a problem within D&D. It's important to separate debate on the initial question under the conditions as they exist today vs. possible future. Today, capping healthcare costs at % of income is just a band aid. You're solving for the acute affordability issues of an individual. The supply side costs of providing care to that patient is the same regardless of whether their personal healthcare expenditures are capped in that fiscal year. The real world implications of a %income cap are a combination of 1) that individual's premiums increase in other years where they don't hit the cap and 2) other people's premiums are increased to make up for the difference in lost revenue from the patient whose expenditures are capped. You can't just "tax the rich more" because cost of employer provided healthcare plans are not pinned to the income of the employee. Even if all insurers were non profit then they'd still need to balance inflows (premiums) vs. outflows (health expenditures). In Bernie M4A world this whole problem is solved via progressive income taxes because premiums and out of pocket costs like deductibles, co-insurance, and co-pays don't exist. You can change the progressivity of taxes based on your own personal preferences. This is still quite complicated depending on nuances of how you adjust for COL (e.g. $100k in NYC vs. Omaha means different things) and how family members are accounted for (e.g., does a single income household pay more healthcare related income taxes based on marital status, number of dependents, etc) The consumer side of single payer is pretty boring, to be honest. If you tell people in isolation they'll get free everything then they'll support it. The real challenge from electoral perspective is 1) details around tax incidence such that they know whether they'll come out ahead from personal finance perspective and 2) downstream implications of supply side policy necessary to contain costs.
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Oct 20, 2020 23:19
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Sharks Eat Bear posted:Huh? I had a different reading of that post, I thought the OP was saying that under the current healthcare system in the US, trying to implement a %income cap as an incremental change would be extremely complicated due to the profit motives of insurance companies. Which is another argument in favor of UHC/M4A, it would actually be "easier" to operationalize at least in this specific regard It really has nothing to do with profit motives of insurance companies. Right now insurance companies may need to bring in $1.03 in revenue per $1.00 in expenditures to show profit or give dividend to stockholders or whatever. If they were non profit then the only thing that changes is they only need to bring in $1.00 in revenue. So let's say we turn them into non profits and their baseline revenue is $1.00. You implement an cap on health expenditures for individuals at a certain income level. This causes revenue to drop to $0.90. You need to collect the incremental $0.10 somewhere else to break even. This will be captured via increasing premiums by ~11% on the pool of patients not subject to the cap. You can't selectively tax higher income individuals higher because the cost of employer provided insurance is not linked to the income of any given employee. The root problem with US healthcare expenditures is our supply slide costs exceed other countries. Some portion of this is due to for profit insurance but larger portion due to hospitals and HCPs that work for them, unaffiliated support staff (e.g., paid caregivers), and other providers (e.g., pharma, med device, diagnostic/testing companies). The cost savings associated with single payer aren't realized simply through eliminating for profit insurance, but rather job cuts, lower salaries, and rationing on the other three sectors. Any serious single payer advocate needs to full-throatedly acknowledge that reality and potential trade-offs because otherwise their opponents will. They also need to tell people what they'll actually pay rather than rely on some sort of moral argument or principle. People are very much aware of how much they pay for their family's healthcare each year because everyone deals with benefit changes around this time of year. One of the many reasons democrats do not talk about this is because their voter base are college educated urbanites. What are the demographics of anyone that touches healthcare provider system? Where in the country are these companies typically located? Now that Bernie is out of the picture, the left has yet another 4 years to construct concrete plans and refine messaging rather than talk to an abstract framework. KingNastidon fucked around with this message at 01:12 on Oct 21, 2020 |
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Oct 21, 2020 01:05
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Dumper Humper posted:Won't somebody, anybody, think about Aetna Hospitals and long term care centers are where the vast majority of healthcare dollars are currently being spent. You can burn for profit insurance companies to the ground, cool, but that alone isn't going to make a meaningful dent in aggregate healthcare expenditures per capita relative to other countries.
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Oct 21, 2020 01:24
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Jaxyon posted:Don't vast majorities generally total vastly more than 50%, instead of around 40% combined as your link shows? They do sum to >50%? Here's another source from CMS. I don't know what hospitals being profit centers has to do with this discussion. I don't care if they go non profit, but the existing profit margin is likely a drop in the bucket relative to aggregate infrastructure spend, salaries+benefits, etc. US salaries in the healthcare sector generally outpace peer countries and US requires more small, regional clinics/hospitals because population density is lower than Europe.
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Oct 21, 2020 01:41
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Dumper Humper posted:That source also does not add up to more than 50% Hospital Care (33 percent share) Physician and Clinical Services (20 percent share): Other Health, Residential, and Personal Care Services (5 percent share) Nursing Care Facilities and Continuing Care Retirement Communities (5 percent share): Dental Services (4 percent share) Home Health Care (3 percent share) Other Professional Services (3 percent share) Other Non-durable Medical Products (2 percent share) Total: 75% Retail Prescription Drugs (10 percent share) Durable Medical Equipment (2 percent share) Total: 12% I can't tell you why the publication doesn't sum up to 100%, but hey you want to entrust federal orgs like CDC and CMS with your family's healthcare. Go wild with this KFF dashboard if you want. The point being is that you aren't going to realize all these savings by burning for profit insurance and pharma to the ground. There will need to be cuts elsewhere to realize the 50-60% cuts to be inline with UK and NHS and honest advocates shouldn't shy away from that. Doctors are rich people and you should want to eat them, too. Jaxyon posted:Hospitals + long term care facilities is about 38% on your second link, matching your first link. What percent of the total population of Australia, Iceland, and Canada are centered around a few major metros? I'm not saying US having a sizeable rural population is the primary barrier to lowering healthcare costs, but it's a unique consideration when comparing us against peer countries.
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Oct 21, 2020 01:56
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Jaxyon posted:OH I see if you include things that aren't what you claim like dental, non-hospital doctor visits, "other services" and devices", you make the number go up! I'm was assumption that "physician and clinical services" are provided in some sort of hospital, clinic, or other healthcare center. I apologize for not being more precise. Jaxyon posted:I'd imagine that if you were making the argument that it's a major obstacle(which is not one that most experts on single payer plans in the US make), you'd have knowledge of your own argument. Do you want some time to go gather that? Don't think I ever said that the United States' lower population density was a "major obstacle" to adoption of single payer. It's actually irrelevant to whether we maintain our current for-profit multi-payer system or transition to single payer. Rather, the need for small regional hospitals/clinics may limit how far we can drive down costs relative to peer countries even under a future single payer system. KingNastidon posted:I don't know what hospitals being profit centers has to do with this discussion. I don't care if they go non profit, but the existing profit margin is likely a drop in the bucket relative to aggregate infrastructure spend, salaries+benefits, etc. US salaries in the healthcare sector generally outpace peer countries and US requires more small, regional clinics/hospitals because population density is lower than Europe.
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Oct 21, 2020 02:10
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Jaxyon posted:Literally no other nation in the world bases their UHC system around a for-profit system. But you don't think that's relevant? I'm...I'm not arguing in support of the for-profit system in the US. My first post today was pointing out why capping personal expenditures in our current for-profit multi-payer system has its limitations. And how moving to a single payer system funded directly by progressive income taxes is a much more straight forward way to address individual healthcare costs vs. ability to pay. You could switch every single entity that touches the US healthcare system over to non profits and it wouldn't solve the problem. You're going to need cuts in infrastructure, headcounts, salaries, price controls on reimbursement, rationing, etc. I'm not saying that's a bad thing, for reasons many people here have pointed out, but just be honest about it.
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Oct 21, 2020 02:22
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Phone posted:You’re not saying it’s a bad thing, you’re just pointing it out as some sort of counter for no particular reason at all. If I don't talk about it and present these arguments, someone else certainly will. Presumably someone with much more money and reach than a C-tier somethingawful poster. I'm but a log in the river, floating along with the current of 150 million voters I have no influence over. Restructuring US healthcare system will be painful because so many people are getting a taste of that 18% of GDP. And not just individual voters, but the democratic party as I mentioned earlier. They need to convince their base college educated urban voters to lose their careers, accept lower salaries, and/or pay more income taxes [given high income/cost of living cities] potentially to their own financial detriment. They also need to sway some moderates/republicans to gain enough votes in the House/Senate to cede power to the federal government and its college educated shitlib bureaucrats that see them as backwater nazis. It's a hard problem that I enjoy talking about! You're quite smart, well versed on the subject, and always welcome your contributions. As long as they're talking about the issue itself vs. an attempt to stifle discussion.
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Oct 21, 2020 02:41
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silence_kit posted:I don't think this is true. I think you are talking out of your rear end here. If it was really this easy, then why do so many drug trials fail? It's not true. There are multiple sources that point to very low success rates for Ph1 -> Ph2 -> Ph3 -> FDA approval. When the external research partners (e.g., academic institutions) hand off the drug it's typically very early because they don't have the in-house trial design, regulatory, commercial expertise to move it through the process. That's why they're willing to give it up in the first place. No one is forcing these PhDs/MDs to out-license their research, they must know it's not just a "walk through the approval process."
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Oct 21, 2020 03:27
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Jaxyon posted:You disagreed because of your belief, restated here, that the US drug imbalance funds the innovation of other countries as well. Drug R&D is largely an international project where revenues are pooled together and used to meet clinical development and regulatory approval needs across the world. Clinical trials predominately run in the US can be used as the basis for approval in Europe. Only certain countries like Japan require clinical trials in their own population for approval. You can look at quarterly earnings statements or the Roche/Genentech finance dashboard to see split of US vs. Europe or US vs. ex-US. For example, US revenues in 2019 were 20B CHF vs. 6B CHF in Europe. US does not have >3x the population of Europe. Jaxyon posted:However, if that were the case you'd think that US drug companies would disproportionately benefit from the arrangement(via political proximity to the regulatory apparatus and revenue streams) Can you explain what you mean by "benefit" here? Novel therapies are almost always approved in the US first followed by EU-5 followed by Switzerland/Austria, Nordics, etc. Companies are going to prioritize approval in countries based on revenue potential because it funds expenses, R&D and otherwise. Jaxyon posted:yet the US is more or less exactly in proportion with it's wealth and population, while several countries on that list perform disproportionately better than the US. Maybe? It depends on what specific metric you're talking about. For example, UK has lower cancer survival rates than peer countries based on a Lancet study. Is this because NHS/NICE rations care and fewer patients receive expensive novel therapies compared to peer countries that spend more per capita? Maybe, maybe not, but it's dangerous to fall into univariate explanations on these things. Jaxyon posted:Right now pharma R&D is a distant second fiddle to marketing, acquisitions, and stock buybacks, financially speaking. And pretty much all drug innovation has come from basic research done on the public dime, including basically every novel drug in the past 10 years(see my earlier citation). R&D may be developing new products, but it's not developing innovation. There are too many things to unpack here, some of which others have already been addressed. "R&D may be developing new products, but it's not developing innovation" doesn't make much sense. A Ph3 trial that doesn't meet its endpoints (e.g., statistically superior efficacy/safety) isn't going to spend money on regulatory approval and commercialization because it won't be used.
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Oct 22, 2020 20:29
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Jaxyon posted:I am pointing out, with a study to back me up, that one would expect any disproportionate contribution to innovation to be going to the US int hat situation. Yet it's not. The US is in proportion, and other countries with less access to the US government and market are disproportionately better. Sharks Eat Bear already pointed out the limitations of that study. It's silly to attribute R&D achievements as US or ex-US. Sanofi/Ipsen are headquartered in France, Novo/Lundbeck in Denmark, Takeda/Astellas/Eisai in Japan, Roche/Novartis in Switzerland, AstraZeneca/GSK in UK, Bayer/BI in Germany. All of these companies employ hundreds of thousands of people in the US, working on R&D and whatever else. Biopharmaceutical R&D is a global project, of which the US contributes an outsized share of funding because of the outsized revenue due to the outsized costs. Jaxyon posted:By this logic, the US, which spends around TWICE as much as similar OECD nations, would be perhaps a top 3 in many or most metrics. But it isn't. It's above average in some metrics, at best. As an overall healthcare system. it's ranked below most developed nations. Sure maybe, but it's extremely dangerous and often intentionally misleading to do a correlation analysis between one random healthcare measure and per capita healthcare costs if you aren't controlling for confounding variables. The high obesity rate in the US is a good example of this. Jaxyon posted:Also, you describe the NHS as rationing care, which they do. The US also does, and moreso than the NHS. Agree. The US rations care based on who can personally afford premiums/out of pocket costs. NHS rations care by setting a fixed pool of healthcare dollars and trying to optimize for aggregate outcomes. There's absolutely nothing wrong with NHS approach, but I wish US single payer advocates would at least honestly acknowledge there are trade-offs. The NHS is plenty popular and I'm sure a well-implemented US single payer plan would be too. Jaxyon posted:The pharma industry funded the study I cited above which says that just about every novel drug in the past decade is due to publicly funded research. I don't know how much to unpack there is there. knox_harrington and wins32767 already explained the difference between initial drug discovery (research) and clinical development. KingNastidon fucked around with this message at 21:35 on Oct 22, 2020 |
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Oct 22, 2020 21:22
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We aren't making much progress here. Let's try a thought experiment. If both US and Ex-US decided to not reimburse pharmaceutical companies for their existing therapies do you believe this would have any future impact on the number of therapies progressing to Ph3 studies or eventually approved by the FDA/EMA/NICE?
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Oct 22, 2020 21:58
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Jaxyon posted:I see youve dropped the part of the discussion where you were talking about actual researchable metrics and focused on thought experiments. Okay, if you're willing to concede that reimbursing pharmaceutical companies 0% of US and ex-US status quo, what about 25%? 50%? 75% 90%? At what point do you think there is non-zero future impact on clinical development or the number of novel approvals? Absolutely no one here is saying that US costs shouldn't be reduced in some way. It's pushing back on magical thinking that there cannot be downstream impacts by making that change. If you're convinced that publicly funded NIH research is all that's needed to bring therapies to market then I can understand why you believe there's little correlation between biopharmaceutical revenues and number of novel therapies approved by FDA/NICE/EMA.
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Oct 22, 2020 22:12
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Jaxyon posted:I know what theyr'e doing and why they have to do that. I understand how validations work. The point is they're taking a ton of their R&D budget, most of it in fact, and using that to prove that they can use that same drug they already came up with on other types of cancer, because every single usage has to be researched and proven. And they didn't come up with it. It's an acquisition from a EU company. What is the problem with running additional trials in new indications for a drug that's already approved? Arguably this is a more effective use of R&D spend because you don't need to run largeish Ph1/Ph2 studies to evaluate dosing/safety. BLA/NDA submission process is easier. Need to hire fewer office or field staff given adding new indication to existing PI takes less time/effort than a new product. Who cares whether Merck acquired Keytruda from another company? Multiple people have acknowledged that much of R&D today is done at smaller biotechs. Big pharma's acquisition costs aren't reflected in their own R&D spend, but they're eventually paying investors back for the now de-risked R&D spend at the target company up to that point. Oldie but goodie article on the twists and turns of Keytruda development that highlights the uncertainty in R&D despite Keytruda being a blockbuster today. KingNastidon fucked around with this message at 02:50 on Oct 23, 2020 |
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Oct 23, 2020 02:43
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The current US single payer plans don't change the relationship between privately run biopharmaceutical companies and payor(s), especially in terms of how R&D is funded. The only difference is who that payor is -- currently a mix of commercial (Aetna, BCBS) and public (Medicare, Medicaid) vs. whatever the single payor entity is called. From the pharmaceutical company's perspective there are only two things that single payer directly changes for them in regards to novel therapies: 1) expected reimbursement after discounts and 2) market share. Reimbursement rates will definitely go down because otherwise what's the point of consolidating buying power. Market share could go up in some limited circumstances, but much more likely to go down because the easiest way to constrain costs is establish more rigid pathways through lower price generics/biosimilars or older, inferior branded therapies. Both of these changes result in reduced revenue. Single payer doesn't tell private biopharmaceutical companies what to do with this revenue. There's no direction on how much profit they recognize and what's done with it (e.g., normal dividends, stock buybacks to appeal to investors) nor is any government bureaucrat deciding whether an illness is worthy of a private company to research (your b example). The same internal decision process applies to R&D spend where pharma/investors build an risk-adjusted cashflow to determine break-even on an individual clinical development program. Probability of technical (Ph1/Ph2/Ph3) and regulatory (BLA/NDA acceptance, FDA approval) success at each development stage remain the same. Revenue goes down due to lower reimbursement and market share per above. Pre-approval clinical, regulatory, and SG&A costs remain the same because the work still has to get done. Post-approval SG&A spend may go down, but all of these expenses in the cashflow are gated on technical and regulatory success. Some SG&A spend will persist depending on role. Need for finance/accounting, forecasting, analytics, etc. still necessary for basic investor relations, demand/expense estimation, performance tracking. To use your MCL example, marketing isn't developing an expensive ad campaign right now for a disease with 10k incident patients per year and relatively few HCP targets (heme oncs as opposed to GPs) and won't do so in the future, either. They're still going to need to spend money on basic HCP/Patient websites, education materials, etc. that exist in non-US countries today. Field sales spending should go down, but only to the point where the marginal ROI of an additional rep is <0%. You could lower expenses at all stages of the cashflow by just taking a 25% wack at compensation or whatever, but don't know why this would disproportionately apply to SG&A rather than R&D. Ultimately the relative split of R&D vs. other spend should remain fairly similar, just lower aggregate spend amount on both. The cashflow math and investment decision making process is pretty straightforward. I don't see any reason to believe that lower expected revenues would make more clinical development programs RA NPV positive. Single payer isn't going to force private entities in the healthcare system, pharma or otherwise, to operate at a perpetual loss to maintain status quo R&D. And maybe status quo R&D isn't terribly important or should at least be deprioritized relative to other things, but that's a separate discussion vs. aligning on directionality of expected changes. KingNastidon fucked around with this message at 15:27 on Oct 23, 2020 |
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Oct 23, 2020 15:25
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Jaxyon posted:I am arguing against the idea that single payer would necessarily reduce innovation. What would be the mechanisms for which single payer would increase innovation if that's defined as any are sent through clinical development and eventually approved? If we believe that clinical development is largely done at small biotechs with no revenue stream or profits, what is going to cause VC's to invest more in this sector when clinical outlays are the same, but the future revenue stream is lower? No one is going to be able to provide specific evidence that single payer, which could be implemented in various ways, will produce some specific quantifiable negative outcome. But there's value in at least aligning on the likelihood of up/down/flat and drivers for each.
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Oct 23, 2020 19:30
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Jaxyon posted:Sounds like the development stream should be nationalized because, like in healthCARE, the profit motive is at odds with people wanting to live. The process of nationalizing drug development and commercialization currently handled by multinationals headquartered in different countries would be a really interesting discussion, but it's not part of any US single payer proposal. It's not fair to assert clinical development levels will remain at status quo under single payer when that claim will actually require additional legislation or government action. I'd like more single payer advocates to be honest about the likely vacuum such that voters don't feel burned by false promises.
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Oct 24, 2020 17:03
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Jaxyon posted:Oh now the international nature of drug development matters, when before it was all essentially irrelevant because the US was the source. You're combining a bunch of separate discussions. The US contributes and outsized portion to drug development because it's an outsized source of revenues because our reimbursement rates and out of pocket costs are higher than other countries. You can believe that while also questioning how the US nationalizing massive ex-US companies like AstraZeneca, Roche/Genentech, or Bayer. If the goal is not nationalize those companies but rather build up the capabilities within the US federal government then that's fine, but it's not part of the current single payer proposals. Jaxyon posted:No, what you have is what you think will be a failing of single payer, that you can't actually prove and you've admitted that. Voters are literally dying because of our current system. I think this is less about your concern for voters and more about your personal reservations. There are only three ways pharmaceutical innovation can go after US does single payer -- up, down, flat. I and others have provided the potential reasons why innovation would go down if US implements single payer in line with the current proposals. I've asked you to provide potential drivers to explain how innovation would go up or at least stay flat and your response is to nationalize clinical development, which is not part of the single payer proposal we're discussing. It's both my concern for voters and personal reservations. Meaningful healthcare reform beyond ACA, single payer or otherwise, should be a layup for either liberals or leftists. The US is a clear outlier on the issue and healthcare touches every single person in the country. They can't gently caress this up and overpromise/underdeliver because it will cause a backlash that results in dismantling those reforms and/or limiting progress to similar changes in other sectors. I'm wary of individuals or groups that seek to gain power/influence based on disingenuous or misleading claims even even if I generally agree with their end goal. Jaxyon posted:Single payer isn't some sort of pie in the sky overpromised nirvana, it's literally a common public policy that is working fine all over the world and works fine here. I agree. If I was appointed god king of US healthcare then some flavor of single payer would be my preferred choice to maximize aggregate outcomes. Doesn't mean there shouldn't be an honest discussion of the second order supply side effects. We've spent a lot of time the past few pages on the pharmaceutical industry that comprises 10-15% of total healthcare spend. Anyone with personal/financial exposure to the healthcare sector is going to take a bath here if you want to meaningfully lower healthcare spend. If advocates don't acknowledge that and explain why it's still better than the status quo then someone else is going to do it.
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Oct 24, 2020 19:19
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Jaxyon posted:I said the process, not the companies. I don't know what this means. Jaxyon posted:This is something we already do, or do you think that NIH spending only goes to products US companies make? I'm positive some NIH funding for basic drug discovery goes towards pre clinical drugs that are ultimately out-licensed to companies not based in the US. You keep bringing up the NIH but it's not at all relevant to clinical development and commercialization at private healthcare entities, which is what single payer would affect. Current single payer proposals aren't changing NIH funding nor the scope of what they do. Jaxyon posted:You have claimed concerns for voters that are very specific and focused. The current system kills 40k people a year. Republicans have literally tried to remove preexisting coverage and then just lied and said they're not doing that and it has worked on millions. There are no republicans on this forum so I don't feel the need to criticize republican healthcare proposals, or lack there of. Jaxyon posted:You don't spend any time on drugs that aren't innovated on because there's no market incentive. Our current system reduces innovation and that's something you haven't even mentioned, despite a professed concern for voters and innovation. Don't know what this means. What's a specific example of a drug that isn't innovated because there's no market incentive? The existing system has plenty of incentives to produce novel drugs. Orphan disease act, fast track, breakthrough therapy, accelerated approval, priority review, real-time oncology review. But most critically, no hard cap on WAC cost or reimbursement. The cost of therapies is almost always inversely correlated with the number of patients it could treat. You aren't going to have private companies spending money on ultra orphan diseases if they're not reimbursed at a level to at least break-even given the low number of patients. Jaxyon posted:So let me again provide another research paper relevant to this topic. It even partly agrees with you! What's your takeaway from this? I'm not going to read 55 pages if I don't know what you're trying to prove/refute. Jaxyon posted:Oh no what if all the money going to the blackhole of a few healthcare companies was being spent on aggregate demand. Who/what is the blackhole? Where are these dollars going? What is aggregate demand in this context?
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Oct 24, 2020 19:56
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Jaxyon posted:KingNastidon, for one. Think this is a pretty uncharitable representation of the back-and-forth. Going back to page 4-5, we were discussing how much various entities contribute to total healthcare spend in the US and where cuts would come from. There were posts rejecting that cuts would touch sectors that contribute the most to total healthcare spend. Transitioning to a single payer system and reducing costs to be in-line with somewhere like UK is going to require more than eliminating CEO salaries and I find it interesting to talk about that because politicians and media rarely do, for better or worse. This eventually led to pharma, as these conversations often do, as a target of these cuts. We've talked about the different scopes of NIH and pharma. The likely effects of lower drug reimbursement rates on how pharma companies would respond as private for-profit entities. How innovation should be defined and whether any reduction in innovation is an acceptable trade off of lower healthcare spend. And lastly potential approaches to replacing these entities in the future as to minimize any downsides that could exist. Good discussion! But we're getting hung up on some topics (NIH vs. pharma, rationale behind why drugs are moved through clinical programs under status quo, feasibility of nationalizing global entities) because it relies on a level of alignment aren't getting to and end up talking past each other. What do you want me to reconsider or respond to? I'd love for the conversation to diversify from pharma and talk more about insurers, hospitals, long-term care centers, HCPs, etc. I know very little about the structure and finances of these orgs and would be interesting to hear about hot button issues or their perceptions of a transition to a single payer system.
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Oct 27, 2020 00:31
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Let's bump this nice long-term policy thread to have something else to talk about other than the impending US civil war [that is definitely going to happen and not just people obsessing over social media coverage of the fringes in a country of 330 million people]Ytlaya posted:When it comes to all this talk about "innovation," I think it's necessary to actually translate that to lives saved (or other direct benefits to people). For example, there's a certain percentage (though I'm not sure how high that percentage is) of R&D that doesn't actually translate to anything meaningful for patients and is just intended to replace medications that might have patents ending soon. People have been talking about objective HEOR metrics like QALY from the very first page. It's important to distinguish between R&D done explicitly for the sake of creating a me too vs. the eventual pivotal Ph3 not being meaningfully differentiated from its competitors. What motivation does a company have to spend a bunch of money intentionally developing a mediocre therapy that 1) won't gain market share relative to established branded therapies or generics and 2) will face greater pressure from payors in terms of formulary placement or discounting? Ytlaya posted:At this point, benefits from medical "innovation" are likely experiencing significant diminishing returns relative to decades past, and the biggest actual determining factor in health outcomes is going to be simple access to care and resources available to provide care. I'm sure there were people saying the same things about diminishing returns of innovation in 2000 or 1975 or 1950. If you have a casual interest in the hematology/oncology space The Emperor of All Maladies is a nice pop sci book about how established standards of care have rapidly changed over short periods of time. I don't think anyone here has explicitly said that broader access to care will reap benefits. Rather, what the downstream impacts could be in order to realize that broader access at a lower aggregate cost. If you aren't interested in the second part of that discussion because you feel it's irrelevant or unimportant then don't participate in it. Ytlaya posted:I'm pretty sure that the difference in the actual impacts of "innovation" would be pretty small under a single-payer or NHS-like system (and might even be better if you increased funding to the NIH/NIDA/etc at the same time, since a lot of very important research is forced to be stingy with resources currently), and would unquestionably be dramatically eclipsed by the benefits to simply making healthcare easily accessible to everyone. The magnitude of impact is very hard to estimate until there's clearer direction in any policy proposal how they'll handle reimbursement rates. There's still disagreement about the direction of the impact under current proposals, which is probably important to agree upon first. Going back to log in the river analogy, private entities touching healthcare will adapt to whatever change comes through. The details do really matter from a long term planning perspective though.
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Nov 1, 2020 20:47
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