I believe we need to trudge further and further because even though we are creating new therapies that are wildly expensive, we are moving closer to truly cost effective therapies and best-in-class therapies. Though, we are certainly not there yet.
If someone can explain to me that my fears are unjustified about price controls diminishing capital invested into new treatments, I'd happily join the chorus of people calling for price controls in medicine (US citizen here with a chronic disease treated by TNF inhibitor which can cost 30K+ a year but through employer insurance, I pay nothing except for a copay which the manufacturer pays for).
That's not obvious at all; there's no reason creation of new drugs couldn't be financed by raising capital through either debt or equity issues, which are then paid back, in effect, by the profits from the drug itself; in fact, a fair amount of drug development is funded that way, because it's done by startups which are acquired by major firms, if at all, only after doing much of the development work; obviously, that's how every firm’s first drug is financed.
It may be that firms want to eventually shift business models, so at some point they take their existing stake of drugs and body prices so instead of paying off their own development, they are doing that and paying forward development, and after that switch to internal financing, but there is no reason that is obviously a necessity.
Secondly, if a publicly traded company already has a significant amount of equity in the hands of the public, issuing too much debt can mess with the balance sheet, right?
I hear you though, I still worry that price controls is attacking the issue in the wrong way. I don't know all the specifics, but I feel like protections to competition would be a better way to ensure the competitive market?
This is an area I'd really like to understand more from a non-partisan perspective, especially understanding the current nature of which countries actually do develop the most drugs. But every piece of information I find on this subject has a partisan bent. Anyone got a source they'd recommend?
So, basically someone bought the rights to the 5mg tabs, and now those are uninsured and would rack up 100s of euros per month. So instead you get the same prescription but in 2.5mg tabs, which is available as a generic brand and therefore just about free under Dutch healthcare. This may seem like a small difference, but we're talking about people with attention-deficit disorder, having to count and not get distracted twice as many pills, right at the moment the previous dose wears off. Taking them at a very precise regular schedule at the right dose really can make a huge difference in effectiveness. You don't want to get it wrong.
Sure it's not insulin, and it's mostly an inconvenience, but it's just so STUPID. I mean who the hell obtains the rights to 5mg dexamphetamine tablets? How? Why? And could the same happen to paracetamol?
1. The time horizons involved don't work well with government. The US can't get anything done over a 20 year time horizon, and the highly delayed ROI means projects would always be first on the chopping block when it came to cost cutting. As a side note, currently we can't even agree to adequately fund basic research in the country, let alone drug development.
2. R&D would inevitably be politicized. Some senator would want disease X researched because their kid has it etc. Some tax payers won't want to fund disease Y.
3. It places R&D and regulatory in the same high level entity. That sets up all sorts of conflicts of interest.
4. It complicates international trade. What if the US develops most drugs. What should Europe be charged for them? Surely products can't be open sourced because one group of tax payers paid for them and would want ROI etc.
5. Similarly, who decides pricing for all the US buyers? Get ready for massively complicated procurement based on tons of different rules.
I am ignorant of these things so I have to ask if it is assumed that your assertions are common knowledge. For example: "the US can't get anything done over a 20 year time horizon".
If international trade is a larger sticking point then I would suggest an international consortium? Like a WHO entity that collects dues from member states and member states in turn benefit from drugs produced?
Just spit balling here to be sure.
In the US, the policy agenda is (still) broadly defined by tribalism along polarizing issues (e.g. abortion). In other countries, it's slightly less bad but the phenomenon is similar. If less social goods were coupled to politics the world might be a better place, but it also might take a paradigm shift where we don't dualize social activity into two bins: stuff you do because you make money doing and stuff you get done by taking from your neighbors because they "owe it to everyone".
It's true that it is coercive: that the individual may not want to live in a society where that is the rule. But this is also true of all laws, including private property laws. The idea that property laws are natural and obvious, whereas other laws are impositions is utterly unhelpful and the source of a lot of issues, especially in the US where it seems pretty much all non-military public programs are underfunded.
> But this is also true of all laws,
Yes, that's true for all laws. It's funny that no one says it's part of the "social contract" when someone gets choked out and killed by the police for selling bootleg cigarettes on the corner.
I'm also going to point out that the central problem with income tax is that we think it's great because it's "punishes" the wealthy, but the equilibrium state is that due to bracket creep, it winds up screwing over the poor and middle class while the wealthy find escapes. Of note: I remember a year when I paid more in income taxes (as a proportion of my income) having made 30k than Bernie Sanders did.
The general paradigm among the liberal left is that the poor are screwed over by the political power because they are poor. I think it might be worth rethinking that - the poor are and continue to be poor because they don't have political power. The problem is that political power is a zero-sum game, so any solution that gives those in power more power will only make matters worse.
Anyone who says they believe in "small government". That small set of rules always happens to include property laws.
> when someone gets choked out and killed by the police
That's also illegal. I would also advocate enforcing the law against law enforcement officers. Stronger than against ordinary citizens if anything.
> we think it's great because it's "punishes" the wealthy
Actually, I think that (even assuming that it were enforced) it does little to no harm to the wealthy. They have sufficient wealth that having less has almost no impact on their well-being.
> The problem is that political power is a zero-sum game, so any solution that gives those in power more power will only make matters worse.
Giving money to the poor gives them political power. Or rather economic power, which is a good substitute, and often what the rich use to gain political power.
Ideally we'd have some kind of basic income which provides this function directly. But other socially funded initiatives such as healthcare and education are also helpful in this regard.
Legislation is stuck in the mud, but government is very much still getting things done.
Drugs, as a whole, aren't that expensive today compared to other healthcare. They make up 9.8% of US health care expenditure, which is pretty much middle of the pack compared to OECD countries. Hospitals, largely "non profit" (but sometimes massively profitable) make up 35%. But drugs feel more expensive bc copays are typically higher for drugs than for medical care
As it stands today the drug industry spends ~$200B a year to get 20-50 new FDA approved drugs a year. Virtually no fda approved drugs are developed solely by academia. NIH budget is $30-35B and on a steady long term decline. So you'd have a massive taxpayer expense just to build out that r&d function
Then you'd have to build out manufacturing. And some sales and marketing analog -- even if you aren't trying to profit, somebody needs to go out and tell doctors about your new drug and share with them very detailed data about how the drug works, what patients it works for, compared to the competition. Doctors can't stay on top of this themselves -- they are too busy and there's too much info
Then you'd need to build out some administrative function and some way to decide what projects move forward at what stage. This is where publicly funded drug research would probably massively underperform private for profit r&d
If you are making drugs for profit, you have a strong incentive to be efficient with your research. If not you go out of business. The more these decisions are driven by politics rather than profit motive, the less productive r&d is. And r&d cost and productivity is the reason drugs are expensive
There's evidence that startups are 10x more productive at r&d than pharma and it isn't crazy to attribute a lot of that to less politics
As of now something like 30-50% of published academic findings are thought to be false. 30%+ of all NIH money goes to "overhead", i.e. Profit to universities. And yields no fda approved drugs without private company investment
That sounds like a pretty interesting argument, but I notice that you didn’t actually make it. The rest of your post is full of claims sans evidence, and a lot of numbers out of context. For example how many of those newly approved drugs are novel therapies vs. rejiggered stereochemistry to keep a patent or compete in an existing field? How many are significant improvements over existing therapies and not just potential profit centers?
Those approvals are all for new molecular entities. In 2018 39% of those were first in class, i.e. Drugs with a new or unique mechanism of action. The percentage of first in class drugs approved among all NMEs has been trending upwards. My guess would be that most of the rest are second / third in class, not just "lifecycle management" plays
It's actually much harder to do lifecycle management bs in pharma these days compared to 20 years ago. Yeah you can get patents, some may be enforceable, but insurance companies will not put up with that unless the "new" drug provides a real clinical benefit
Can someone tell me how this patent extension works? If they improve on something, is that a new patent? Does the original patent expire or gets extended? Why couldn't someone else have discovered the new stereochemistry before the original inventor dose so? If the new discovery is not significant, wouldn't its be sufficient to use the generic form of the original chemistry?
As to why some other company didn’t snap up the patent, it’s an expensive proposition and not trivial to make enantiopure drugs, so a lot of the R&D budget touted by apologists and shills is entirely self-serving. Now sometimes an isomer is actually superior to a racemic mixture and there are plenty of cases where one isomer is therapeutic and the other is ineffective or toxic. Of course in those cases none of this patent fuckery applies, and there is no way to get a new patent issued or FDA writ because only one viable form of the drug exists.
It’s also true that a generic in the case of something like Esomeprazole vs. Omeprazole is viable, and that’s where the astronomical marketing budget that dwarfs R&D comes into play. Advertising directly to patients and doctors ensures that plenty of people won’t understsnd the value of a generic is they were even aware of it. You also get cases, as with Epi-pens, where supplies of the generic are scarce compared to the expensive branded version.
Good list of this kind of thing found here: https://en.m.wikipedia.org/wiki/Enantiopure_drug
Unless you provide a real clinical benefit, most payers will make docs write an rx for the 3x a day generic vs new 2x a day patent. So these lifecycle extension games certainly happen but it's not really that effective
Yes NIH is biggest single spender but pharma industry as a whole spends much more
Has this been successful anywhere? What purely run state enterprises that are charged with creating new and innovate things have been success stories?
I think that while private enterprise has had a jaded role in healthcare, I'm not sure what the better alternative is.
In countries where such care is provided by private insurance and not the state, I am wondering why this trade-off is not given as a choice to the consumer. Many people might be OK to get smaller premiums and better coverage throughout their life by explicitly rejecting coverage of end-of-life care.
Interesting enough the one thread that the folks pushing that concept picked out was a provision that paid doctors for consulting with people about what kind of end of life care they would like. That's all it was. There had been strides that showed individuals chose all on their own to refuse some of the most expensive late stage life care after having talked to a doctor about it. The result also meant there was significant cost savings, reduced stress for those dying and their families.
Sadly the BS surrounding "death panels" meant that provision was left out of Obamacare.
I don't know if there is an afterlife with any sort of destination based on people's choices, but I like to think if there is there's a special room in hell for folks who used that provision to score political points, and likely meant that some folks may have suffered more because of it.
Unfortunately the trade-offs don't go away, and we haven't figured out a way of making these trade offs that doesn't feel horribly statist (so called "death panels") or callous (private insurance denying care).
These already exist. Donor organs are a scarce resource and there aren't enough to go around, so some person(s) has to decide who lives and who dies. People already regularly die in the United States because it is uneconomical to have Level I/II trauma centers within emergency response distance of the entire country.
People have very different ethical standards for how people should act in advance planning scenarios versus in the moment. I think most people agree with the unreasonableness of arranging to have an on call neurosurgeon in a small town in the middle of nowhere. But I think people would have a very different reaction if the same neurosurgeon refused to skip a day of teaching medical students to instead walk across the hospital and carry out a 12 hour brain surgery on a 90 year old patient with dementia who will be dead from lung cancer in two months anyway.
I think people will just have to get over it. There aren't alternatives.
This never works out. Right now many people buy low quality high deductible health insurance expecting never to get sick and then balk when they suddenly get ill and end up paying a huge deductible. People don't assess correctly what they need later in life. When people are denied the health care later due to these decisions, the death panel rhetoric will be brought up.
* Drug companies have profit margins of 15% on average indicating there is room.
* many recent 'orphan drugs' were not newly developed, but off-label uses registered with the FDA for a whole new patent.
* these drugs rely heavily on research done by universities through public funding. It stands to reason the public should get to benefit.
* there is something morally wrong about setting the price of drugs purely based on demand. It is essentially blackmail: pay me or die / suffer.
It puts quite a dent in public health care resources.
People who are in this business to actually help the sick hate this system with a passion, and some national governments are now willing to allow hospitals and pharmacists to experiment with creating their own medicine again as a result.
There are maybe 15 pharma companies that commercialize a large portion of the drugs developed in the world. The vast vast majority of drug companies never make a penny in profit. They sell their products or companies to bigger, commercial companies
So the profits in the industry all accrue to a few big players, and the losses largely accrue to companies you've never heard of
Something like 65% of FDA approved drugs are developed by small companies that will never generate revenue. Bigger companies buy these drugs and plug them into their established sales forces
Virtually (probably literally in the last few years) no drugs emerge fully formed from academia. For profit companies bear the brunt of the r&d costs. 30% of public r&d goes to academic "overhead" and much goes to research that will never come close to informing drug r&d. The NIH spends $30-35B a year, the top 15 pharma companies spend $75B in r&d
Also don't know what criteria Bentley used to determine how much NIH research contributed to new drugs
This report provides another perspective and highlights the role of industry
The HBM partner report seems to somewhat confirm some of the findings in the report I linked and quoted:
- 50% of drugs come from outside “Big Pharma”
- Less than 50% drugs developed in-house (mostly coming from licensing and acquisition)
- 58% approved drugs are orphan drugs.
Orphan drugs may mean government incentives, funding, public policy.
Large sum of that money is wasted because incentives are perverse.
Developing new molecular entities (NME) that do the same thing as already approved new chemical entity (NCE) just for competitive reasons is wasted R&D from the public health perspective.
Evergreening and pay-for-delay costs additional billons for pharma companies and it's just zero-sum game between manufacturers.
I see a lot of expensive looking ads on TV. Those ads were made legal in my lifetime. Maybe it’s time to ban prescription ads again?
DTC ads would be in the marketing budget under SG&A
What is just one more reason for the government to bear that risk, from research up to distribution.
This seems to contradict itself. 15% profit margin is not that great compared to the opportunity cost. Someone working at a drug company could in theory switch (retraining etc.) to working at, say, Google which has a 22% profit margin. I realize it’s not apples to apples, but that’s not a huge, monopoly level profit.
There is only one producer of an approved formulation and they are charging too much.
The article mentions that the compound (lutetium octreotate) has been in use for a long time, suggesting that any patent term on the compound has lapsed. Novartis’ specific preparation has been approved for this use by the EMA. Compounding pharmacies have the right to prepare the drug without this approval, which they could not do if the compound was subject to a patent.
Theoretically another company could make a generic version of this but the market is probably too small to justify the approval costs.
Then, I read your link and had another WTF moment: why is a shipment from India to Brazil travelling through the Netherlands and thus subject to their customs? India->Netherlands->Brazil seems like an incredibly inefficient trade route.
Source: my wife is a pharmacist and could have worked in the UK after only completing 1/3rd of her study.
* 4 years undergrad, of which 90 credit hours must be a specific series of courses
* 4 years PharmD, doctorate program
* 1800 hours of internship
At this point a student has met all requirements to sit for the two license exams (NAPLEX and MPJE[^1]):).
Many students will elect for an additional period of education due to the competitive nature of pharmacist jobs in the USA. Those two extra opportunities are:
* 2 years of residency; followed by,
* 2-3 years of fellowship
Most pharmacists at a common drug store will not have the last 4 or 5 years of study. However most pharmacists in research or synthesis (including at both manufacturers and pharmacies) will have these two final steps of education due to just how competitive these jobs are.
Briefly there was also a 6 year accelerated pharmacy track (BS+) however this is no longer allowed and any practicing pharmacists with these credentials have to take a non-degree PharmD program to meet the new requirements. At this point in time I don't know if any practicing pharmacists still only hold the accelerated credentials.
[^1]: AK, CA, and VA have their own jurisprudence exams and do not accept the Multistate Pharmacy Jurisprudence Exam
Source: apotheek.nl e.a.
A doctorate* (nl: doctorandus) which takes 6 years to earn (3-4 years BSc then 1-2 years MSc to use the English terms) followed by a 1 year specialization for public pharmacist. Exactly the same as the MDs (also doctorandus) have to do.
It's not a PhD; although I assume that you'd want to go that route if you're more interested in the research (I'm assuming that a PhD in Pharmacology is a thing). I tried convincing my wife to do it but she feels that she helps others more by being more hands on.
I think the confusion comes because a doctorate and a PhD are different things and different countries and disciplines use different terminology. I just about understand the Dutch system now but I'll never understand the German system.
That doesn't seem to be true? This page says you need an MSc, in the UK, to register and be a licensed pharmacist: https://www.healthcareers.nhs.uk/explore-roles/pharmacy/stud...
Who funds this and what kind of shit lawyers and economists draw up the funding schemes that give away full intellectual property, only with a (historic) backstop for individual preparation?
We need risked based co-funding, co-profiting (irregardless of wether it's governments or, say, insurers investing), a backstop on prices via qualy-s, relatively short patents, no gaming of patents via arbitrarily small changes, governments creating generics, ... And now I wake up.
It says so in the first few paragraphs: Novartis licensed (bought) the right to sell the drug in Europe. The patents remain with the hospital.
The hospital that developed the drug is a public hospital associated with a public university. So the government paid for development, and (indirectly) to government is benefitting from the license fees paid by Novartis. That is co-profiting.
“Novartis bought the rights to Lutathera with a $3.9-billion-euro takeover of French company AAA last year.”
Where exactly does it say that the patents have remained with the hospital?
I don't think journalistic language necessarily so accurate.
I don't think we can say for sure what changed hands in the transaction, but it should not matter anyhow.
If they bought everything, then the total lifetime value of the asset would hopefully have been baked into the price.
> The producer (AAA, later bought by Novartis) gets exclusive rights to sell the drug, for ten years in the EU, and for seven in the US. The only exception is hospital pharmacies preparing the drug for their own patients.
While it may sound strange put that way, most universities spend a lot of time thinking about how spin off profitable companies from their research. It's a huge deal and public spending on research is often motivated like this. Universities and R&D companies have a codependent relationship and this is generally regarded as a good thing.
The morally dubious outcome of this is that a lot of research ends up locked away as intellectual property of some private entity, but it's not easy to question.
Is it? At best, I'd say it's seen as a "necessary evil," where "evil" is much more certain than "necessary."
Any sources on this, anyone?
Drugs don't emerge fully formed from academia, just waiting for pharma to patent them and jack up the price. Pharma spends more on r&d than academia
Currently they cost ~19 million each which is frankly not that big of a deal. A larger issue is only ~15% of drugs make it through the process. With ~20 new drugs a year this only adds up to 2.5 billion per year which a frankly a drop in the bucket compared to drug costs.
I think the answer is probably a little bit more grey FYI.
Saying funding would continue without any benifits seems to be the least likely outcome. Personally, I would be fine stopping all public drug research, but I suspect more people would want to continue...
In the end when you change one part of the process you need to assume other parts of a related system will change in some manor.
Honestly, this is simply not going to happen in the US so it’s hard to say what’s realistic.
Any yes, you can outsource running a trial, but you still need someone to design it, process the data, put together an NDA and submit for approval.
I can only imagine the complete clusterfuck that would be if it was all done by public employees.
Large drug companies are not bringing magic recipes to the mix here. Often it’s the same researchers who found the drug who end up starting drug a company to profit from their research.
As to advertising to doctors their is plenty of evidence this is harmful. It’s easy to for doctors to keep up with relevant drugs as so few are added each year and many are extremely specialized. Advertising results in over prescription which is known to be extremely harmful with opioids being an obvious example.
The flip critique of the drug industry is to suggest they're basically taking miracle cures developed in toto in publicly-funded labs and taking pure profits.
If that were the case, shouldn't one of the dozens of well-capitalized research institutions just go to market?
The reality is the drug companies take on a tremendous burden turning high-level research into a product that works, including:
+ Formulating a product that will work at scale,
+ In widely diverse populations,
+ While eliminating potential side effects,
+ Adapting for human UX limitations,
+ Exhaustively guarding against adverse reactions,
+ At the same time, building production capacity,
+ Creates marketing materials for patients, but also to educate doctors who don't have scads of time to study new treatments,
+ Physically distributing the product
+ Monitoring the product fastidiously once it's on the market for negative reactions,
+ Sending humans to almost every doctor's office to answer any questions about the product,
+ While staffing a 24/7 customer service number to sort out any problems
It's not as easy as it's made out to be!
This, so much. I'd add no gaming of orphan drug patents. It's through the patent system that pharmaceuticals get their pricing power.
They helped fund the development of the new CF drug by Vertex, which Vertex sells for $300k. Because of the success of the drug, they were able to resell their royalty rights to another investor for $3.3 billion.
Funds which they will use to drive massive amounts of additional R&D to make even better treatments at lower costs. In the process they have created therapies which did not previously exist, saving and improving people’s lives.
You can debate the profit motive (as your link mentions) but the Foundation considers this a massive win for their ability to fight CF and make CF sufferers lives better.
 Some economic reductionism here: if you know the cash flow, you can project the value and the other way around. So if someone offers you 3 billion and you know the effect of the medicine and the number of patients, you can infer the price of the medicine. This to establish the (moral) link between the selling of the IP and the price.
This is great for CF because it’s mostly the insurance companies (and therefore healthy people) who are bearing the costs of the treatment.
So the CF Foundation is “forcing donatations” from the healthy populace through increased insurance premiums to bankroll their continued investments in treatments and such.
I don’t know if that makes it any more or less ethical, but certainly if it were mostly individual CF patients on the hook for the $300k (in aggregate that is — I’m not saying that never happens) then it would make less sense for the CF Foundation as a strategy.
Don't we all bear the cost of treatment in the form of higher insurance costs because insurance companies are paying exorbitant prices on drugs (among other things)?
This is a _myth_
Big Pharma is an insanely inefficient structure for turning money into useful R&D results.
Big Pharma often spends on the order of 25-30% on marketing, vs 15% on R&D. From societal standpoint this is horribly inefficient considering that most medical costs are paid for communal money via taxes and/or insurance programs.
R&D should be paid by government funds. Testing should be transparent and open. Production should be done by private companies. This would be a significantly more efficient use of our money. It would also align R&D expenditures much better with actual costs to society for medical issues.
Are you contending that the non-profit CF Foundation is going to take their $3B and not do something useful with it to serve the CF population?
> For well over a decade, CFF has employed a venture philanthropy model that provides upfront funding to pharmaceutical companies to help reduce the financial risk associated with the development of drugs to treat CF. As a result, the organization has a pipeline of drugs in various phases of development and reinvests the funds from any royalties it owns to advance drug discovery and efforts to find a cure.
> The proceeds of the sale will dramatically accelerate and expand the foundation’s research, care, and patient programs and significantly boost its funding of research targeting the genetic cause of CF. The organization also plans to use the funds to strengthen the specialized care and support that people with CF and their families receive at more than one hundred and twenty centers across the country and to expand its resources for people with CF and their families.
The typical argument for justifying high drug costs is that it costs lots of money to do R&D. This argument loses weight when the marketing costs are twice the R&D costs. Further to this point is the fact that the actual discovers aren’t the ones getting the big rewards of their discoveries. So it all appears inefficient in ways that don’t matter when applied to Google due to the fact that ultimately we are talking about peoples’ financial and physical health.
Marketing includes the cost of bringing the new compound to the attention of medical professionals who might benefit from knowing about it. This means hosting conferences, having representation at conferences/trade shows/exhibitions, seminars and other educational material, etc. Medical professionals are busy people who don't have time to independently research every new compound being brought to market, so someone has to make it very easy for them to learn about new compounds and easy for them to determine if it's something they need to care about. Hospitals and pharmacies have to be convinced that it's something that should be stocked, insurance companies have to be convinced that the treatment is cost effective enough to justify covering.
> These drugs tend to be necessary for people in ways that Google is not. There are cases where people live in penury due to high drug costs. From the perspective of beneficial to society it seems from my perspective that this is inefficient.
The resources that are expended to create new drugs could in the short term be spent far more efficiently on saving lives were it all donated to the Bill and Melinda Gates Foundation. The benefit to society of drug research is not the well being of those people that a drug can treat when it is created, but rather that the drug now exists and will be available for all time. On the balance of the moral calculus, what happens during the 10-15 year window in which the drug is available and still protected by patent is totally negligible.
That is also a myth, perpetuated by people who do not understand how to read an income statement. Please provide a source for that, and if the source is or is using the SG&A line from an income statement, it's wrong.
If a company could increase its bottom line by cancelling marketing spend, that's an easy equation to figure out.
Or... maybe (profit after marketing - marketing spend) > (profit without marketing).
And as (in a reasonable stable company) the research spend will be related to profit... marketing spend likely does result in more money being available for research.
The current system seems to incentivize companies to hold on to patents by making minor, insignificant changes to drugs to maximize profits. They are incentivized to ignored exotic diseases that have too small of a market share for each individual disease but affect, collectively, a lot of people. There is also the fact that in a system like the U.S. where people have large out of pocket expenses at the point of contact with the health care system having companies maximize profits for a particular life saving drug causes some people to view said maximization with disgust.
Advertising direct to the public is banned in many countries, but not the US - I assume this is what you're referring to. However, pharma companies can and do spend billions on marketing to healthcare professionals within the EU.
> However, from a societal point of view it seems to me that it is much better for society for there to be no marketing of drugs.
Your point about the societal value of drug marketing is complex. In some cases, I totally agree with you that it's not money well spent - selling one beta blocker or statin against five others with broadly comparable data hardly helps the cause of humanity. However, in other cases the marketing/sales actually helps ensure that patients are given the drugs that they need - doctors aren't infallible, and not all doctors are created equally.
> The current system seems to incentivize companies to hold on to patents by making minor, insignificant changes to drugs to maximize profits.
This is actually relatively rare.
> They are incentivized to ignored exotic diseases that have too small of a market share for each individual disease but affect, collectively, a lot of people.
Like it or not, the overall cost of discovering a drug, then testing it all the way through the many phases over many years, is roughly billions. Rare diseases can be ignored because it's simply not sensible business to develop drugs for them. Unless a company can find a way of charging a very high price, or find short cuts to development, or the current system of regulations is eased, this won't change.
Companies are prohibited from advertising to doctors? I thought it was just direct-to-consumer.
From  it appears that U.S. sales for pharmaceuticals are double the figure for the EU. This suggests that advertising, lack of regulatory controls on pricing, and R&D account for this. Since medical costs are exspensive in the U.S. at the point of contact and the U.S. spends twice per capita GDP on healthcare people are indignant at the system and things like direct to consumer advertising is an easy target for our ire.
I don’t know if English is your native language but “marketing spend” is correct and “marketing spending” is not.