>the pharmas can create the appearance of innovation and modest new revenues nearly indefinitely even when their pipelines are in actuality quite sparse and breakthrough innovation is absent. this ability to churn old stuff buys them time to create new stuff to put into the pipeline using more complex therapeutics like immunotherapies, etc.

I agree with everything you said in that post but I think we disagree on the inevitability of the pipelines running dry. The mere fact that such strategies have become common industry practice points toward a structural decline in novel drug discovery. While such strategies buy time for new blockbuster drugs to be discovered, they simply are not being uncovered at a rate commiserate with the expectations of the existing pharma business model. What you are describing are what I consider to be patches on the hull of a sinking ship. When today's big pharma business model relies on $X profits and all the profitable drugs are going off patent and being replaced by tweaks and new indications, eventually $X becomes $X-25%+. Once that happens, all these enormously expensive shenanigans are no longer affordable.

Of course, this all comes at the cost of some potential drugs discoveries that could have been made if the business model was kept honest but that's the future we're left dealing with.