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Comment by sharemywin | Hacker News Reader

I just kind put together why this isn't free market.

There's no incentive for anyone to push back on price. There's plenty of money to be made doctors make the same either way. People don't notice because they just want the best healthcare available regardless of cost. Pharmacy make more money with gouging. Drug companies do. Insurance companies make more with higher prices. Companies just pay what they have to show it as a benefit.

Who in the entire system looks out for costs?

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One thing that's always bothered me is that companies can make a ton of medications, such as those that treat depression and anxiety, that are incredibly difficult to get off of once you start with the medication. None of these companies are required to make any lower doses to help people "taper off" what's supposed to be a temporary medication. Most of the time your only option is to quit "cold turkey" which is straight up awful with brain zaps, nausea, trouble focusing, and often a complete spike in your previous symptoms from 0 to 100. Oftentimes quitting this way can make you feel like you need the drug to survive.

I get it is not profitable to make doses that are only used temporarily when people quit your product, but this is definitely harmful to the consumer.

I was stuck with one and I tried everything to find a lower dose. I had tried quitting cold turkey 3 separate times and I ended up a sobbing mess each time. Given that was just not working, I tried different pharmacies, I talked to them about liquid suspension ($200+ not covered) and more. I was fed up. Eventually, against the advice of my doctors, I just started cutting my pills into 1/4s and taking a 1/4 less every 2-4 weeks until I was off it. Doing it this way was utterly painless and I was able to continue working throughout. After that I didn't need it anymore. But this is a terrible practice, and won't work with all drugs -- especially delayed ones.

This is why I think so many people are on these types of drugs. They are amazing short term and can help people work through some really difficult issues to get to a better place mentally -- but not everyone needs them long term. However when faced with the withdrawal symptoms, many people start to think they can't survive without it.

Im not claiming some conspiracy, but the current strategy isn't the best for patients, that's for sure.

Don't be so sure. These companies have hidden the addictiveness and side effects of these pills for years: https://www.karger.com/Article/Pdf/501215

In fact, using anti-depressants is more likely to make you relapse after you are off of them, rather than if you got over the depression without drugs: https://www.karger.com/Article/Abstract/110056

There is definitely an interest from these companies to have people be on these drugs pretty much indefinitely. They have a host of side effects which the companies will also benefit from treating (obesity, sexual dysfunction, liver damage, etc...).

It's pretty clear from what's coming out of the opioid trials that these companies conspire on a regular basis to do what's right for their bottom line, not what's right for people...

It's amazing how often folks forget that pharmacists are licensed professionals trained in the algebra of medication -- even doctors neglect this. I recently had a doctor tell me he could only write a prescription for a daily dose of either 15mg or 50mg doses without realizing that one could theoretically take two 15mg doses a day. (He probably did realize this, but it would be significantly more paper work).

Compounding pharmacies are able to remix manufactured dosages into what you desire. I know folks who, with the assistance of their doctor, crafted finely tuned taper schedules.

You bring the drugs, they remix to your prescription.

Yes, cutting pills works for some formats (tablets). Liquid suspension can somewhat be done yourself if you have suitable input medication and buy a mortar and pestle. It's of course harder with capsules or extended-release formats, but rarely are those the _only_ format a drug is available in.

> companies are required to make any lower doses to help people "taper off"

pharmacists are trained, allowed and encouraged to prepare different doses of drugs when needed for the specific needs of their individual patients. Not sure why you expect pharma companies to take on their role here.

Evidentially these often aren't covered under insurance plans. Maybe the med I was on was just particularly difficult, but it was going to cost me quite a bit of money to do the liquid suspension.

I don't expect pharma companies to take any role, as I understand their position. I was hoping that I had made that clear. I simply believe it as a current short fall of the system.

I don't attribute any blame, it's just something that could possibly be improved. Honestly, the change would likely have to be more on an insurance / governmental level. It shouldn't be an ordeal to get a lower dose -- it should be just as easy and cost-effective as the original medication.

The insurance part is the most important. The more things cost, the more value insurance provides, which is especially valuable to insurance providers because they pay for things at a discounted cost. The more value it provides, the more they can charge.

The economically rational consumer is best off getting drugs through insurance, but in doing so, builds a system that makes any alternative less affordable.

I think you assume that the insurance market is competitive. In the U.S. it is not.

I’m not sure how that follows.

As an FYI, this phenomenon is called the third-party payer problem in economics.

https://mises.org/library/how-third-party-payers-drive-medic...

Also, there's literally a government regulator that controls entry.

It isn't just patents either, the FDA will grant exclusivity periods for other reasons, and so on, but it then doesn't have much power to examine pricing. It's because our Congress is stupid (I mean, that's the terse summary of it).

They aren't stupid. It's completely on purpose and virtually anyone who has had a lengthy career in congress or the senate has voted in favor of this system many many times. That includes anyone you like.

"I mean, that's the terse summary of it."

You can't paint the entire pharmaceutical market as non-competitive. It really depends on the drug.

Most of the egregious examples of raising prices happens in specific markets - ones where there are significant barriers to competition even in the absence of patent protection. These markets also tend to be on the smaller side - big enough to make a good profit, but not so big that it attracts a ton of competitors.

There are examples of drug prices coming down because of competition. Hepatitis C drugs are a great example. Launched at almost $90K, they now hover around $40K because there are multiple companies competing on price (the drugs are all very effective).

The other thing driving prices down are the insurance companies. Amgen dropped the price of their cholesterol drug Repatha by 60% because insurance companies said "yeah, we're not going to pay for that at that price".[1]

[1]https://www.biopharmadive.com/news/amgen-cuts-us-repatha-pri...

> There are examples of drug prices coming down because of competition. Hepatitis C drugs are a great example. Launched at almost $90K, they now hover around $40K because there are multiple companies competing on price (the drugs are all very effective).

That price is less than $500 in India. Generics in the US are estimated to cost the consumer $200[1].

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4946692/

That's because the drug is priced based on relative purchasing power.

If the drug cost $500 in the US, it would have been a net loss investment in the first place.

The producers don’t have market access and the middlemen have inverted normal market powers. If a producer lowers price, that means the PBMs percentage cut goes down. So they cut away market access. So the lower the price the less you sell. The higher the price the more you sell...

The people in the middle of this getting shafted are uninsured who are forced to pay imaginary list prices and don’t get any rebates. Now the producers are trying to just sell generics at the post-rebate level, but the media field by lobbyist are calling them out like it’s a bad thing. Because it threatens the con game of the PBM/Insurance/Pharmacy cabal (yes they often end up all owned by the same corporation), while they are pointing fingers at the producers who just want market access and fair competition.

At least in theory insurance companies should look out for price, because they want to be cheaper than other companies.

But, free market just doesn't work for health care. In a life or death situation people would pay anything.

Yep, also I think the barriers to entry for the insurance market are extremely high. Not only is there a huge fixed cost of actually negotiating rates with every individual doctor/hospital, there's also the fixed cost of getting individual employers to consider you for their business. These and some other factors leave the insurance market with just a few insurance providers, who can let prices run away and simply charge higher premiums/deductibles without fear of competition from a "start-up" insurance provider.

FYI, in the US insurance companies are regulated such that: "No more than 20 percent of premium revenue can be spent on total administrative costs, including profits and salaries."[1]

So the difficult thing is they are incentivized to increase revenue to increase profits, and cutting costs won't result in more profit.

[1] - https://www.verywellhealth.com/health-insurance-companies-un...

Yep. And a lot of big companies are self-insured, so the "insurance company" is actually just an administrator for the big company's insurance pool. Thus reducing the cost incentive even more. Competition could help, but there just aren't a lot of insurance administrators that can run plans for the biggest companies, so there is little competitive pressure on price.

That sounds somewhat inelastic. Like gas or basic needs, people will often still use/need healthcare regardless of price, at least as long as it is high quality care. If, say, knocked unconscious in an accident, you'll wake up in the ER regardless of price.

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