This was buried in the article, but is IMO a bigger deal. In the long run, this could really drive down drug prices.
Medicine prices are clearly inflated when you can buy at a huge discount using insurance, but then you can get apps like GoodRX, which is free and give you coupons that far exceed my insurance discount on every single time I had to fill a prescription. To the point that I don't even bother going through insurance anymore.
I saved thousands on medicine by just checking on GoodRx before buying it.
The coupons aren't unique or require a login, why go through all of this? All the services they use are "request demo / contact us for enterprise pricing", not free-to-sign-up SaaS either. Just who is paying for all this and with what?
As a company selling via the internet it would be handy to know what drugs/prescriptions a prospective client (via fingerprinting) is taking... it would certainly change what/if I marketed to them.
Of course the concept of retail companies having even the slightest access to a customer's medical/health/drug information for marketing purposes is a compelling plot for Black Mirror.
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As for all the bot countermeasures, the reason for that isn't immediately obvious to me, I assume it must be due to that competition.
There appears to be some tracking, as "Member ID" differs on each reload. I assume this is tied to cookies or fingerprints in the backend.
Personally, for me, the data they can collect off of me when I go to their site is worth the ~$2,000 I save every month. (actually I don't have to use them: I am prudent, and part of my contingency planning for losing my job is to know exactly what expenses I could strip away, and how (and for how long) I could continue to pay for the bare essentials. GoodRx is part of that planning for the healthcare end of things)
For a decent overview: https://www.pbs.org/newshour/economy/why-does-health-care-co...
"Just to give you one example, Duke University Hospital has 900 hospital beds and 1,300 billing clerks."
Don’t mistake what I’ve said as support for the current system.
[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511963/#:~:tex....
The "sticker price" of a drug is called the "usual and customary price" (U&C). This is supposed to be what you charge for a drug, and is generally based on the "average wholesale price" (AWP) of the drug plus a dispensing fee to cover other costs. The AWP, however, may or may not (usually not in the case of generic drugs) be related to the actual acquisition cost of the drug. It tends to be substantially higher.
The pharmacy bills its U&C price to the insurance company (or, more often, a pharmacy benefit manager (PBM) contracted by the insurance company), and the insurance company tells you what it will actually pay you—this can be negative—and how much to charge the patient. Usually the pharmacy gets paid whatever the insurance company/PBM thinks it should cost to fill the prescription, and the patient pays a standard copay/coinsurance. If the patient has a large deductible or doesn't have insurance, this is where GoodRx et al. come in. They act as a PBM, allowing the patient to pay a price lower than the U&C while pocketing ~$5 or so of the "copay" for themselves (plus whatever data they get). Often independent pharmacies will just cut out the middle man and give you a better cash price (although this may violate their PBM contracts), but the big chains will need the coupon.
Depending on the difference between the AWP and the actual acquisition cost of the drug(s), this can be a substantial savings for cash patients or people with large deductibles.
-edit-
I guess what I mean to say here is I'm not commenting on how drug prices work. It doesn't matter. I am commenting on the fact that somebody, somewhere has to pay for the drug, regardless of the price. I want to push back on this idea that drugs are "free" in Europe or elsewhere. Sure the healthcare programs appear to be better managed, higher taxes on the wealthy or corporations (although I don't know for sure) appear to be subsidizing costs for lower and middle classes, but the drugs still aren't free in any sense of the word to the society as a whole.
Now that you've clarified, it sounds like you're arguing against the idea that drugs have no cost of development or production, which is not an idea that anyone actually holds, so I'm sorry for wasting our time. I would point that "free at the point of service" does seem to be one sense of "free".
[0] https://www.rjhealth.com/2019/07/31/drug-pricing-101-reimbur...
Sure, and my contention (going back to the grandparent) is that is an illusion. I'd be more than happy to give you a car for free and then just charge you later if you thought you were getting it for free. I want people to continue to be aware that even drugs that are sensibly priced do still bear costs to society.
> which is not an idea that anyone actually holds
You'd be surprised. In fact, the language most people use is "healthcare is free in Europe and elsewhere" because they don't understand how things work. It's not free. Never has been and never will be.
> often that money doesn't need to come from anywhere.
I'd love to hear more. How is it that nobody has to pay for the drug? How does the drug come into existence without money?
This sounds like a great anti-account takeover program. I imagine with all of the various compliance programs they have to deal with and the legal risk, these are prudent measures.
Combine that with a culture that overvalues all university diplomas as equal, while disregarding the economic opportunities of at least half of them are almost nil, and you have a great recipe for massive failure for a big percentage of the young population.
The half baked social programs always do this. Same with how rent control in NYC and Toronto in the 1970s ended up significantly reducing the supply of low-income housing because it stopped incentivizing developers from building cheap houses in cities that had it (they just went elsewhere) while also ghettoizing a bunch of neighbourhoods because there was zero incentive to maintain buildings (which led to mass arsons in places like harlem).
If you're going to socialize it either go all the way and nationalize it/fully fund it or find a way that doesn't fuck the citizens over (like these glorified schemes to hand money over to politicially-connected middlemen like big pharma and diploma mills). OR in most cases just let the market do it's job. Like letting generic drug makers take over markets way sooner, without the multitude of government protection rackets that protect big pharma (including FDAs giant backlog). Meanwhile (social) media blames capitalism for every expensive drug or tuition price... like it actually makes sense for ANY market to charge a working class person $1000/pill.
These flaws seem so obvious to me but are repeated in so many western countries, not just the US. While blame goes in so many randomly misguided directions. Often heavily greased by the people who benefit from these schemes.
https://www.walmart.com/cp/4-prescriptions/1078664
Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some covered generic drugs at commonly prescribed dosages.
Amazon appears to be incentivizing customers to not use insurance to pay for their drugs. I’m not sure if Walmart does the same. If so, that’s also noteworthy.
In many cases, the discounts in the discount programs are subsidized by the drug companies for uninsured patients.
While discount programs focus on the uninsured, this is the first time I’m seeing the discount being framed in such a way that it effectively incentivizes paying out of pocket. It’s an important incentive if your goal is to decouple routine drugs from the third-party-payer model of insurance.
Health insurance in the US is actually 3 different services bundled into one: (1) risk sharing for catastrophic care, (2) access to low prices (called "fee schedules"), and (3) tax advantaged pre-payment for non-catastrophic care. 40-80% discount on drug prices essentially competes with insurance company fee schedules, i.e. service (2). By offering what amounts to insurance rates without charging insurance premiums, Amazon is essentially decoupling the fee schedules from risk sharing. That's a really underrated side effect of this product offering, and can have long run impacts on the industry (IMO for the better).
1) Age Rating Factors
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-In...
2) Out of pocket maximums for in network care
3) Elimination of pre-existing conditions, i.e. accepting all lives no matter how costly
4) The recently eliminated mandate to purchase health insurance.
The above conditions mean that premiums from healthy people that don't use healthcare is used to pay for the healthcare for sick people. It gets a little complicated with the ability for employers to silo their employees' lives from the rest of the population, but in general, US health insurance premiums are basically a tax on the healthy to pay for the healthcare for the sick.
Whereas, healthcare is a guaranteed expense, so the premiums are just prepaying for the coming expenses. But today, you're not paying for your healthcare expenses, but for the older, sicker person's healthcare, just like FICA taxes are paying for healthcare for those 65 years and older.
While FICA taxes (partially) pay for senior citizens' healthcare, your health insurance premiums both pay for your annual physical (especially on Platinum PPO plans) as well as care for sicker people that are not eligible for Medicare/Medicaid. I assure you that there are plenty of sick people that are under the age of 65, and actuaries price them in when computing premiums for private health insurance.
And as a minor point of order, even Medicare isn't "free" for seniors — the FICA taxes only cover Part A benefits, and seniors still need to pay monthly premiums to Medicare to cover Part B benefits. And even those benefits aren't 100% covered — Medicare only covers 80% of outpatient care.
While my auto insurance premiums will probably go up if the insurance company experiences losses much higher than expected, the insurance company will raise premiums on the people causing accidents more than myself (and maybe even drop them if they deem them uninsurable). If health insurance claims come in higher, the younger people will pay proportionally more even though they’re mostly going to just be getting a physical and flu shot.
Or implementing taxpayer funded healthcare.
yay
The US could very well institute their own price controls on drugs, but it wouldn’t invalidate the value in services like Amazon’s, especially if the price controls in question do not create a lower bound on prices, but instead focus on setting upper bounds.
EDIT: I removed an unrelated paragraph about Planned Parenthood and drug supply chain I thought was out of scope.
That’s effectively what government-enforced drug patents are for. I think it’s debatable whether that’s the best implementation of what you’re describing. Government sponsored “Prizes” are another approach that sounds promising -> https://marginalrevolution.com/marginalrevolution/2020/03/pr...
I donate to Planned Parenthood as well, and decoupling drug purchasing from insurance is a reliable way to make sure that everyone can get access to birth control or contraceptive, even if their employer feels strongly opposed to it (eg Hobby Lobby).
This presupposes that the US pharma market (and healthcare writ large) constitute an actual market. It's really not, by just about any measure. The only thing remotely resembling a "market" is the fact that insurance is predominately provided by the private sector for profit. Outside of that, the industry is ridden with the worst combination of distortionary incentives and regulations. The fact that healthcare is tied to employment didn't happen by accident, it's the net result of WW2-era wage ceilings, followed by 1970's tax deductibility for employer group plans, followed by the ACA employer mandate. I'd describe the US as combining the worst of public healthcare systems with the worst of privatized systems. PBMs and every other horrible inefficiency of US healthcare aren't some accident of a functioning market.
It really strikes me as a no-true-scotsman's analysis of our health system. Why not just adopt one of the competing alternatives wholesale and admit defeat?
It’s important to have that discussion because it has implications on what approach we take. I think there’s generally broad agreement that the status quo is bad...there’s just violent disagreement as to why it’s bad. There are a number of ways to fix it (and not just the one proposal you keep hearing about).
Simply decoupling healthcare from employment while keeping it private is one approach. We know that this is efficient, because it’s what Medicare Advantage is, and that’s actually cheaper and better than Original Medicare.
Providing universal catastrophic care with savings accounts is another approach that has shown empirical success. It’s how Singapore’s health care system works, and it is widely regarded to be the most efficient healthcare system among the advanced economies.
> Why not just adopt one of the competing alternatives wholesale and admit defeat?
I agree! If it were up to me, we would adopt Singapore’s system wholesale. Either that, or, Switzerland’s. Or we would just have everyone in the US be on Medicare Advantage.
You can say it's cheating when governments win lower prices for their citizens like this but I'm not much inclined to care. I don't want to subsidize the continuation of our more-market-based-than-usual health care experiment when the results have been clear for decades. Compared to our peers, we're in a hole. Let's stop digging.
If this is the case, I wonder what would happen to drug development if that goes away.
Note, I'm not saying there's not too much profit from drugs. These statements don't have anything to do with that.
Republicans would be hesitant due to “regulations bad,” and Democrats don’t want to improve our current system because they’d rather throw it out. And of course both sides get donations from pharma.
Initial discovery research is pretty much entirely tax payer funded. There's then a second phase, moving from that discovery to POC, that is extremely underfunded, and which a lot of charity and such funding goes toward. It's only the last phase, taking POCs -> product, that companies really invest in. https://www.ncbi.nlm.nih.gov/books/NBK50972/
Now, that capital investment is not a trivial amount of money (about 80 billion in 2018 - https://www.statista.com/statistics/265085/research-and-deve... ), but it still is only 17% of drug company revenues - https://www.investopedia.com/ask/answers/060115/how-much-dru...
Note, too, that private companies tend to fund research toward common first world diseases, since they're profit driven, and far less to niche and/or common third world diseases. So not only do they not fund early discovery (government does that), nor generally moving those discoveries to POCs ('valley of death', and charitable foundations and the like do that), they also leave plenty of potential meds untouched, since the likely profitability is low.
To be fair, the other side frequently tries to prove them right.
[1]https://www.canada.ca/en/patented-medicine-prices-review.htm...
If anything, Australia is quite generous to pharmaceutical companies. New Zealand's Pharmaceutical Management Agency has much less negotiating power but still manages to obtain substantially lower prices.
For myself I can't help but wonder if lump-sum licensing might not be more effective. Pharmaceuticals are a bit like software: very high R&D cost, but the marginal cost to manufacture is very small. A one-time payment to sink a large chunk of R&D for a drug might be quicker and easier than guessing at a price. On the other hand, I have no experience in health economics, so it's possible this is a terrible idea.
You're describing "Prizes", and that's a legit point of view -> https://www.mercatus.org/publications/covid-19-crisis-respon...
On reflection I like prizes better, especially if there are multiple tiers (first to reach the target gets the most prize money, second gets less, etc). You want to ensure that multiple pharmaceuticals are developed independently, in case one of them needs to be pulled from the market.
I see the benefit for things like a covid vaccine where the economic benefit is so large we can afford to drop exorbinant sums. But what's the right prize for a newer better lipitor or xanax, or a treatment for malaria or Huntington's?
A healthcare system will typically have a good idea what it needs, whereas a pharmaceutical company will rightly enough focus on what will make the most profit.
Put another way: you don't need to set prizes for every drug. A better treatment for malaria is not going to make much money, because most of the patients will be in less-developed countries. But if you produce a side-effect free drug to reverse baldness, you will absolutely mint it by first selling into wealthier countries at very high prices to "skim the market", then lowering it over time.
Prizes would work better for low-profit/high-impact, for the rest you can mostly rely on pharmaceutical companies to rationally pursue their best interests.
The real value of medical patents (and this is something we've strayed far from) is in incentivizing expensive R&D for ultra-rare diseases. There are diseases that afflict < 1% of the population, there's hardly any revenue to be made in serving that customer base, especially relative to the R&D input necessary. It's stuff like that which can really benefit from prizes. It also presupposes that the prize-awarding authority knows which types of R&D fall under that bucket and which do not, and you get into a quasi-central-planning territory, but that holds true even in a world where pharma patents were only awarded to inventors of such rare-disease drugs.
Competive forces only work while there's competition, the second competition declines, rest assured consumer pricing is the first to take a hit.
Why would it be different in other branch?
Lack of choice; the government has captured the "market", and "consumers" can't choose to go anywhere else. Compare to the service (and especially customer service) offered by your cable/internet provider where you have not choice. The cable companies vie for literally worst customer service of all businesses year in and year out.
And we know that the government is doing an awful job in regulation of healthcare. I've got kind of a front-row seat to this and see things that most might not, since my wife's whole career has been in healthcare finance, and in particular around how Medicare reimburses hospitals for services.
She's currently working with one client hospital for whom their Medicare cost report still hasn't been resolved for some years back even before 2010. How can a business operate efficiently when they don't know what their expenses are going to be - not just in the future, but even historically, more than 10 years into the past?
Worse, the way the government forces hospitals to report this stuff is extremely specific, and optimized for how Medicare wants to run things - which is why Medicare can claim to spend less on administration: they just force hospitals to do all the administration for them. And hospitals can't say "no", with Medicare (together with Medicaid, which generally rides on Medicare's regulatory coattails) comprising a plurality of the market, if not an outright majority. The result of this is that hospitals have a choice of either running two separate accounting systems (one for what Medicare demands, and another to do rational cost accounting), or more likely, to just do the one for Medicare and muddle along as best they can. And that's a major reason why hospitals can't operate more efficiently.
And my wife's currently involved in a battle with them over some detailed rules they posted early in the summer. She's been working all summer for her client hospitals based on what the government posted on their website. Last week they changed the rules posted (you can even see the "last changed" date). But the change was in a way that contradicts their previous statements, and invalidates much of what she did all summer - and worse, they're lying about it, not admitting to what the previous version of the page said. Unfortunately the wayback machine didn't track that site, and while she's got her own records quoting the page, the gov't won't acknowledge it.
So there's a clear explanation for why it can get bad, and tons of evidence that it really is bad.
In addition to this, it's worth pointing out that the idea that Medicare is the solution to all of our problems because of the cost savings of administration is way over-stated.
There's a pretty great breakdown of where per capita costs go in the US vs comparable OECD countries -> https://www.healthsystemtracker.org/brief/what-drives-health...
Administrative costs make up a tiny percentage of the overall cost differential. You could basically zero it out, and it would still hardly make a dent on the overall cost difference.
The US Military runs the VA, and that's also been a noteworthy embarrassment -> https://www.cnbc.com/2018/05/28/va-veterans-affairs-history-...
Outside of raw warfare, the military runs almost entirely on cost-plus, which results in over-spending of contract money for boondoggles that just entrench the military industrial complex.
Outside of the US military, you have systematic inefficiencies like this across most major agencies.
NASA's planned SLS moon mission is a bit of a disaster — way over budget and way behind schedule. Because the boosters aren't reusable, each launch is expected to cost $1B (with a B) dollars — EACH launch! Meanwhile SpaceX's target cost-per-launch is $50M.
In healthcare, Medicare has actually been running a fairly interesting A/B test. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Clover, etc. These plans replace Original Medicare, also cover Part D prescription drug benefits, and often include supplemental benefits that Original Medicare doesn't already cover. The outcomes are fairly interesting:
- 36% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly, that we expect by 2025, more seniors to be on a private plan than the public one. There's also great variance by State. In Florida, Pennsylvania, Wisconsin, Michigan, Minnesota, Oregon, Alabama, Hawaii, and Connecticut — over 40% of beneficiaries are on Medicare Advantage. By 2022, we expect more seniors in those States to be on a private plan than a public one. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about...
- For most beneficiaries, Medicare Advantage costs about 39% less than Original Medicare. https://healthpayerintelligence.com/news/medicare-advantage-...
- Medicare Advantage plans are, on average, of higher quality than the public "Original Medicare" https://healthpayerintelligence.com/news/medicare-advantage-...
- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan. https://www.commonwealthfund.org/publications/issue-briefs/2... From this same research, public "Original Medicare" is still cheaper in rural areas, but not by a whole lot.
So yeah, while the governments of a lot of countries are fairly robust and efficient, I think that suspicion is warranted, especially in the US.
Would you prefer the government to negotiate the price of your car for you? Markets are a powerful tool
Your website suggests you are American, so I recommend taking a look at the various healthcare systems on display in Europe, they're not all made equally (i.e. Some do more on behalf of their citizens than most). In my experience of watching American discussing healthcare in the EU, the subtleties are often lost, sadly.
There are merits to government price controls and there are certainly countries that have employed them successfully. That said, it isn’t the only solution to bending the cost curve, and there are also downsides to price controls. It’s complicated.
Yes? We already do this? For many years directly in the postwar period and now indirectly through agriculture subsidies and programs like SNAP. Making sure everyone has enough to eat is step one of having any kind of functioning society and why it’s always been a source of massive government intervention in the economy.
Making sure everyone has access to healthcare is, for the most part, a universally held goal. The disagreement is whether the only way to achieve that is through government price controls.
Food subsidies aren't targeted at the poor. The US government spends many billions of dollars subsidizing corn and soybeans and other crops that lower food prices for huge portions of America.
It's also not the same as price controls.
SNAP and ag subsidies are also just price controls with extra steps. We can argue about their efficacy, but they’re far closer to price controls than anything like free markets, especially given the increasing monopolistic control of industrial agriculture in the US.
I'm not sure who argued that "the right to not get surprise billed or screwed by your insurance company" is the optimum solution. The argument is that guaranteeing access to healthcare itself is attainable without price controls.
> SNAP and ag subsidies are also just price controls with extra steps
They're really not. The closest analog would be to institute a basic income that's earmarked for health insurance premiums. We don't have that today, at least in a uniform way (ACA subsidies come close).
No doublespeak vagaries here.
Healthcare is not just a demand-side issue. There is also constrained supply. I'd be happy to see the government subsidize supply production (building new medical schools etc) in a similar way that it subsidizes food production.
I'm by no means advocating government negotiation or single-payer or medicare-for-all as the thing the government must do on this issue. I'm fine with a form of intervention that allows the market forces to go the last mile in this.
Government does that in the US (and the EU and Canada and basically every first world nation that's not a city state). The department of agriculture and others spend somewhere between 10s and 100s of billions every year to make sure that food (and other crop) prices stay within carefully set, tightly defined limits.
Not being able to afford health care in no way condemns one to being killed. It's obviously not advisable, but plenty of people do just fine without regular doctor checkups because they keep healthy and live balanced lives. And, interestingly, given how many each year die in traffic accidents, it's not such a stretch that being _able_ to afford a car would kill you.
We all have really different reasons for wanting health insurance and owning a car. We have different components, considerations, and properties, which we value about these decisions. Given this, it seems ludicrously complex, inefficient, and cruel to subject all citizens of a nation to the same exact process of obtaining and using health care.
We all know how bad of an idea it is to centralize services, but because some linguistic jokesters have gotten the phrase "healthcare is a human right" to be passed around the globe enough times, people seem to drop context when it comes to this discussion.
As soon as youtube-dl got hit with its recent DMCA takedown request, GitHub obliged and the whole dang HN community lost their collective minds. "Decentralize your git repos" we all saw people writing - and they weren't wrong. But for reasons that continue to escape me during these awful lockdowns we're all facing, people don't seem to think that their government-provided healthcare workers and price negotiators will do anything of the sort.
I absolutely want the government to negotiate the cost of water, and electricity.
The concept of "markets" is not useful in a discussion about healthcare, because unlike other markets, a participant will often die unless they immediately purchase a good from the seller physically closest to them, regardless of price.
Saying the market can solve the problem of healthcare for everyone is a bit like saying it should be able to solve the problem of providing flagship-quality phones for everyone. But in fact, given the "law" of supply & demand, a product like healthcare which is in demand by literally every single person, yet constrained by supply, the solution the market converges on is going to extract the most amount of money it can from however many customers can be served by the available supply.
Supply constraints are also one of the problems I would, given complete faith in market forces, expect the market to solve but it has not done that either. Market forces did not prevent or resolve the dumping of cancer-causing chemicals, or known cancer-causing product like cigarettes to be removed, or any number of other undesirable things whose costs end up being paid by society as a whole rather than a given individual(s) responsible for the problem. When the market fails to solve a problem, some other force needs to intervene.
Maybe a free market purist would say we didn't give it long enough to solve these problems. I don't believe that, but let's say it's true: Saying the market will eventually solve a problem, when human lives or suffering are at risk, is a bit like saying evolution will eventually solve a problem. It may be true, but the timescales involved are sufficiently long to render their eventual solution irrelevant to the people who die or suffer before it materializes.
I don't claim to know the best way to do this, and perhaps my analysis above is incomplete or over-simplified, but the point stands that the market has not solved this problem, and does not show signs of doing so.