
Treat Medicines Like Netflix Treats Shows - katiey
https://www.nytimes.com/2019/03/05/opinion/can-netflix-show-americans-how-to-cut-the-cost-of-drugs.html
======
KaiserPro
This is insurance. Literally insurance.

You pay a monthly fee in return for a good, service or cash payment should
something happen.

however in the USA, something odd has happened. For what ever reason, be it
legal, cultural or other, copay, crippling buerocracy and down right greed has
stopped the health system working properly.

The problem with a "netflix" model, is that doctors can currently prescribe
anything, regardless of cost or efficacy. There are legions of people around
the USA bribing doctors to prescribe expensive generics. Until that practise
is stopped the US system is sunk.

For insurance to work, US doctors must follow national guidelines laid out by
a scientific body (ie NICE in the UK) any deviation without justification
would/should lead to fines and censure. They would set out a list of drugs
that work for certain conditions, anything else is either poor value for
money, or the wrong drug.

The very fact that medicare is legally barred from negotiating volume discount
tells you that some deeply wrong has happened.

~~~
will_brown
>The problem with a "netflix" model, is that doctors can currently prescribe
anything, regardless of cost or efficacy

Unknown to almost everyone in the US is that if you are a Medicare patient,
when you go to fill a Rx before the pharmacist fills the therapy, insurance
software suggests cheaper generics to the pharmacist and requires the
pharmacist to do the leg work of asking the doctor to change the Rx based on
what the insurance company wants (ie the cheaper medication).

So the question might be..why would a pharmacist do what the insurance company
software tells them... or why would a doctor second guess their initial Rx at
the request of an insurance company trying to minimize their costs? Because if
the pharmacist/pharmacy doesn’t do what insurance says or if the doctor
doesn’t do what insurance says, they get dropped from the insurance network.

~~~
vonmoltke
> insurance software suggests cheaper generics to the pharmacist

I have never heard of pharmacists using "insurance software". The pharmacy
system requests coverage from the patient's insurance, and it is either
accepted or rejected.

Additionally, if there _is_ a generic they just fill it, assuming the patient
consents. In fact, pharmacists in many states are _required_ to point out
generic alternatives if they exist.

> requires the pharmacist to do the leg work of asking the doctor to change
> the Rx based on what the insurance company wants (ie the cheaper medication)

If a prescription requires modification, the _patient_ is required to go back
to their doctor. Pharmacists cannot just ask doctors for prescription
modifications.

Where are you getting these ideas from?

~~~
lostapathy
>If a prescription requires modification, the patient is required to go back
to their doctor. Pharmacists cannot just ask doctors for prescription
modifications.

>Where are you getting these ideas from?

This is not strictly true, at least in the US. I have had to wait while
pharmacists contact the doctor to modify a prescription to sub something in
due to availability issues.

The mail order service through my insurer will also do this to have doctors to
order a 90 day supply rather than the usual shorter supply.

~~~
vonmoltke
You're right, my statement was too absolute. What I meant to convey is that
pharmacists cannot just ask for modifications without the knowledge and
consent of the patient.

------
IMTDb
> For 1 billion Australian dollars — $766 million U.S. — Australia gets, for
> five years, all the hep C medicine it can use.

What will happen in five years ? If we follow the Netflix model, a _lot_ of
what used to be available will simply stop being there because the producer
will markup the price significantly. In Netflix case, I don't really care
since I can download the movies from other sources anyway, but for drugs ? No
thanks. The consequence of getting a fake product from the black market are
orders of magnitude worse than downloading some porn.

~~~
BurningFrog
> _What will happen in five years ?_

According to the article, Australia is on track to have hep C eradicated by
2026.

~~~
aidenn0
That's 7 years away...

------
jedberg
A great theory but one major flaw. The utility value of most tv and movies
comes when they are brand new with quickly diminishing returns afterwards.

Drugs on the other hand have equal utility for their lifetimes (until replaced
by something better, which can in some cases take centuries). In fact
sometimes a secondary use for a drug is found and its utility goes up.

Entertainment rarely has increasing utility. Even the biggest sleeper hits
have a short peak of utility until returning to baseline.

It’s two totally different utility models and I don’t think the cost models
are transferable.

~~~
VikingCoder
I don't understand how you're measuring.

Hep C medicine has zero utility value for me right now.

And I'm enjoying watching Brooklyn 99 from the beginning right now, because
I'd never seen it. My wife is watching series after series on Netflix that are
all old.

My daughter is enjoying the entire archive of Disney movies. Snow White is
what, 82 years old?

When Incredibles 2 is coming out, you can bet the utility of Incredibles 1
went way up.

That said, I think you're being entirely too specific and literal. It's a bad,
clickbait analogy. And? Buy medicine in bulk. Not a huge leap to make.

~~~
kakaorka
Maybe because that’s just you, a unique individual.

For a different unique case, such as someone who has Hep C, the utility value
for the medicine could literally be everything for the person.

So, if we average the utility value for a whole population, the utility value
would actually be pretty high, especially if a lot of people have Hep C.

~~~
VikingCoder
I'm sorry, can you explain how we "average" the utility?

For me, it has zero value.

For another person, it saves their life, and they would pay literally anything
they could.

How do we average that?

My hot take: We can't. Buy medicine in bulk, give it to people for free,
progressive taxes to pay for it.

~~~
rexpop
I like your take, but how are we going to enforce progressive taxation? The
wealthiest firms escape taxation, at the moment.

~~~
djakjxnanjak
We ought to tax wealth instead of income, and tax individuals instead of
corporations. The nature of corporate wealth is that the generation of value
is disconnected from the generation of cash. It’s impossible to fairly
regulate the infinite shell games that result from this. The problem we are
trying to fix is inequality of wealth, so we should tax wealth directly and
not via proxies like corporate profits.

------
pyedpiper
I'll just leave this here:

[https://en.m.wikipedia.org/wiki/Cost_of_drug_development#Res...](https://en.m.wikipedia.org/wiki/Cost_of_drug_development#Research_and_development)

~~~
bencoder
Not sure if you're posting this as a disagreement with the suggested model, or
agreeing.

From the link, it looks like it costs ~$10bn per successful drug, at the top
end of that list.

Australia paid $750m for 5 years access.

Australia has ~1/10th the population of the United States. and ~1/3rd the
population of the UK.

If just the UK, USA and Australia paid at that same rate (per capita) then
they would cover that 10bn average development cost in 5 years.

Seems like it's a good suggestion

~~~
ummonk
I imagine the Hep C drugs are some of the more monetizable drugs though and
will need to rake in more money to subsidize the development of niche drugs.

------
3into10power5
I went to PAMF in Palo Alto, california yesterday for a "group diagnosis
session" with the dermatologist. It seems dermatologist appointments are hard
to get, so they came up with this method. You sit in a circle with other
patients and doctor comes to each of you and quickly checks what happened to
you and prescribes medicines. If she thinks it requires deeper consultation,
she will scheduler private visits.

I thought this is a good system, especially if you are young and kind of know
that what you have is one off fever or some such thing.

What am I missing? Why are more hospitals not following this? Why is no one
applying to YC with this idea?

~~~
okmokmz
I would not be comfortable with that method, and would definitely find a new
doctor if I was presented with that situation

~~~
3into10power5
Well big ailments I would mind too. But small ones like fever or flu, I am ok
particularly because its much less time consuming and much cheaper.

~~~
xkcd-sucks
Ah, a reverse quarantine

------
keiferski
Maybe I’m missing something, but discussions on the cost of medicine never
seem to question whether using prescription drugs is the right choice to begin
with.

IMO, it would be far preferable to treat pharmaceuticals as a last resort,
focusing instead on preventative medicine and addressing the underlying social
issues that cause the medicine to be prescribed in the first place. From the
article:

 _Hep C kills more people in the United States than all other infectious
diseases combined. Cases are soaring, largely caused by injection of heroin
and opiates; it’s a blood-borne virus spread by sharing needles._

Surely the solution to this epidemic is to address the underlying drug
problems first?

Edit: I’m not suggesting that the treatments be ignored or that people who
already have the disease aren’t helped. But rather that if X disease has an
increase in cases, the only solution shouldn’t be to treat it - it should also
be to figure out why it’s increasing and then try to prevent it.

~~~
lkbm
> Maybe I’m missing something, but discussions on the cost of medicine never
> seem to question whether using prescription drugs is the right choice to
> begin with.

Because it's pretty darn obvious that once you have Hep C, yes, prescription
drugs are the right choice. No one's pumping Hep C drugs into people who don't
have Hep C.

> Surely the solution to this epidemic is to address the underlying drug
> problems first?

I'd recommend addressing both problems at the same time. There's no reason we
can only do one.

~~~
Anon84
> No one's pumping Hep C drugs into people who don't have Hep C

However, that is what is being done with HIV drugs under the guise of PrEP

[https://en.wikipedia.org/wiki/Pre-
exposure_prophylaxis](https://en.wikipedia.org/wiki/Pre-exposure_prophylaxis)

So I wouldn't be so quick to rule it out, specially if Pharma companies see a
way to profit out of it.

~~~
fwip
> Under the guise of

I thought y'all were all about prevention? Now you're acting like preventing
acquisition of a lifetime disease is a bad thing.

~~~
Anon84
Prevention is great, and I'm certainly a big fan of it...

but by overexposing people to the drugs that are actually effective against
HIV we're both helping the virus evolve around them and having to deal with
whatever adverse side effects the drugs have on healthy patients.

------
zebrafish
Seems like Ben Thompson's aggregation theory could be useful to look at here.

Netflix & Spotify are aggregators, they own the consumer and distribution.
Acquisition of movies costs either royalties to a studio or cost to produce
the movie (actor salaries, etc.) Royalties are probably negotiated and the
aggregator has leverage in negotiations because they own the consumer and
distribution to them.

Insurance owns the patient, but the patient doesn't necessarily get to choose
the medication. Their condition plus the doctor's prescription dictates what
medication they can use. You're also not allowed to shop around for doctors
who will prescribe what you ask for. Pharmacies own the distribution of
medication. Drug companies need to recoup the massive R&D costs of developing
drugs and thus are granted 20 year patents. This is somewhat similar to
studios producing content and the copyrights afforded to those studios.

Not sure how to put all of this together but I think a big difference is that
the consumer doesn't have discretion like they do in the Netflix/Spotify
space. Maybe a good parallel would be Friends/Garth Brooks. If I want to watch
Friends, I have to use Netflix or if I want to listen to Garth, I have to use
Amazon Music. But despite the fact that I enjoy Garth's music, I can live
without it or I can get it through other means (youtube, buying an album
direct from a studio-owned distribution channel, etc.) People literally cannot
live without some of these medications so consumer discretion is removed
there.

Also, consumers don't have the ability to self-diagnose and self-prescribe.
There are also no other distribution channels for medication. All of it must
come through a pharmacy. There is no distribution done by the owner of the
consumer(insurance companies), although PBMs may be a similar model?

Maybe somebody else could help me fill in the gaps with how the aggregator
model is different from the pharmaceutical model or identify mistakes in my
assumptions.

------
mnm1
It really boils down to what a society values. Does it value caring for people
and health or does it value hurting people for profit? We have the tools to be
caring but in America, we generally don't use them because we value companies'
profits above all else. We let corporations profit as much as they want off
the suffering of others. We used not to, as the article points out. We can
override patents. We can see drug users as human. We can try to eradicate
diseases like hep c. Or we can go our current path and let corporations profit
while millions die. It's really a cultural issue. Do we want to be
compassionate or do we want to exploit our own people? That is the question
being asked when we talk about reducing drug prices and having national
healthcare instead of the vile insurance and drug industries we support now.
It's not looking too hopeful for compassion at the moment.

------
Scoundreller
Cool, I’d love to share my insurance with 3 people strategically distributed
across time zones to avoid contention.

But please don’t send me emails about my insurance being suddenly used in
Egypt. Those false alarms are really worrying.

~~~
selimthegrim
The pop up alerts when your friend’s ex’s mother gets an abnormal blood result
can be a real drag.

------
bitxbit
The system is too entrenched especially after all the unchecked consolidations
disguised under the ACA. Put it bluntly it’s disgusting. The drug pricing
trends we are seeing is a form of regulation arbitrage. We need to overhaul
the FDA and the way new and old drugs are approved.

------
refurb
The reason why Gilead is doing this is because their hepatitis C franchise has
already slowed and will likely be much smaller in a few years. Far better to
negotiate a deal like this and lock a country into buying your treatment than
to lose market share against competitors.

------
snappyTertle
If only we had private companies that can freely experiment with different
business models...

------
jacknews
This seems quite important, and raises questions about whether free market
capitalism is actually the best or only model to spur innovation (spoiler: I
don't think it is, at all).

~~~
ahoy
Especially when lives are at stake! Market capitalism is probably fine for
coffee shops, less so for insulin pumps.

~~~
Mirioron
The part of medicine that's often overlooked is the creation of new medicine.
Usually the discussion goes along the lines of "we can make pill X for $0.1
each, but these greedy pharmaceutical companies just want profits". But what
they're missing is that without those pharmaceutical companies we probably
would have far fewer treatments/drugs in the first place. Doctors and labs
need money to run. Investors help with that. If you chase investors out then
less research will be done. You won't feel it immediately but after a decade
or two it will catch up with us.

~~~
jopsen
> If you chase investors out then less research will be done. You won't feel
> it immediately but after a decade or two it will catch up with us.

I don't think you'll feel it... BUT, if we keep investing in drug research
we'll feel it :)

You don't have to look far to fine an article like "Cancer Statistics Report:
Death Rate Down 23% in 21 Years"

I'm not sure we'll notice if the improvements don't keep coming, but we will
notice if the improvements keep coming :)

Today, we're keenly aware how HIV isn't a death sentence anymore.

------
alsadi
We are big pharam, give us tons of money and hope that we cure you! We don't!
we just treat you.

------
guelo
We desperately need a socialist pharmaceutical industry: The same researchers
that work for Gilead Science could work for the NIH. Instead of directing
research at the most profitable niches it could be directed at the guidance of
the CDC.

------
peteretep
Line 2 of the article is:

> Why can’t the United States?

The answer is either “regulatory capture masquerading as capitalism” or “but
that’d be socialism!” depending on how snarky you’re feeling.

~~~
kurthr
I don't think most people have fully internalized the fact that insurance
companies are fully invested in rising medical costs since their margins are
regulated and their BoD are looking for rising profits. Their "everybody
wins!" means everyone who pays for medical care loses.

They would rather drive lower cost independent doctors into a higher cost
hospital systems as long as all of their competitors pay the same... and they
do.

------
mr_spothawk
So, I should binge on them?

------
anjc
Am I missing something:

>A study just published in The New England Journal of Medicine found that on
average, Australia pays $7,352 (U.S.) per course of treatment. It has been
able to treat seven times as many patients as it would without the agreements.

I guess the reason we don't treat medicine like Netflix is because most people
don't want to spend $7352 for a course of penicillin....?

~~~
vonmoltke
What does penicillin have to do with this?

~~~
Jwarder
I don't want to put words in their mouth, but I think it might be a bundle vs
a la carte argument. For issues that tend towards short term treatments (eg a
handful of antibiotic pills to mitigate the risk of wound infection) then you
don't want to pay the same total price as someone who is treating some chronic
condition.

I can't find statistics on comparing one-off and routine prescription drug
use. CDC data from 2014 shows that when asking about a 30 day period 47% of
the population used >1 prescription drugs, 21% used >3 drugs, and 11% used >5
drugs. That suggests to me that there is a large population of people who
could be bundled together, but for the context of the article this would all
depend on the specific treatments.

[https://www.cdc.gov/nchs/data/hus/2017/079.pdf](https://www.cdc.gov/nchs/data/hus/2017/079.pdf)

~~~
anjc
> I don't want to put words in their mouth, but I think it might be a bundle
> vs a la carte argument. For issues that tend towards short term treatments
> (eg a handful of antibiotic pills to mitigate the risk of wound infection)
> then you don't want to pay the same total price as someone who is treating
> some chronic condition.

Yeah this is what I meant. The article says that the Australian government
offset the high cost of new Hep-C drugs by negotiating a flat rate of $7.5k
per person per year for any Hep-C drugs, and then talks about the high cost of
penicillin and epipens.

Nobody would use Netflix if the subscription fee had to account for films that
cost billions in R&D and only 10 people were going to watch.

