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Comment by karles | Hacker News Reader

Producing it is not the hard part.

Researching it is... And you are not paid for your research "up front". It's added to the cost afterwards.

There is an awful lot of sympathy for the drug company in this thread. You are correct, research and approval is expensive. But at some point there is a limit.

Things like insulin are long paid off, and the pricing there has generated controversy. People have been charged $1000 a month for it [1].

What’s fair? They are screaming out to be regulated when they behave so badly, and that’s what’s happened with insulin.

[1] https://www.thelancet.com/journals/landia/article/PIIS2213-8...

Insulin isn't a single product.

If you're not distinguishing between insulin extracted from a horse circa 1922 and a modern synthetic analog, well that's just not being honest.

There's good arguments that the modern synthetic analogs are overpriced, but that's a more subtle argument.

The situation described in that Lancet article doesn’t seem very subtle.

And if the US is able to impose maximum pricing that is so much lower, it would seem likely that price gouging was occurring.

The lancet 'article' doesn't actually say anything. It's just a political hack job.

When people complain about being forced to pay thousands a month for insulin, they're talking about the newest synthetic insulins that were developed very recently at substantial costs.

They could take the older insulins for $50 a month, no one is stopping them. It's just that those older products are less convenient.

So why is older insulin more expensive in the US than elsewhere, by a large margin?

https://www.visualcapitalist.com/cost-of-insulin-by-country/

https://www.rand.org/pubs/research_reports/RRA788-2.html

https://worldpopulationreview.com/country-rankings/cost-of-i...

Only the last one makes the distinction between modern synthetics and basic insulin.

Frankly the US pays for the cost of the research while the rest of the world just pays for the cost of production.

If you want to fix the cost of insulin products (and many other drugs) in the US you need to figure out how to make everybody else pay for the true costs.

Edit: also your last source there doesn't even know what it's talking about Novolin is a generic brand name for 3 distinct products that have distinct pricing.

The argument that the US is paying for everyone else’s drugs is often made in defence of big pharma, but their profits make it hard to swallow. In recent times the US hasn’t really shown any other other signs of chasing socialist policy where it subsidises the rest of the world.

perhaps most of the research would not be incentivized in a socialist society? it's not like the talent doesn't exist elsewhere, but US embrace of capitalism is a factor in the research development research.

> Frankly the US pays for the cost of the research while the rest of the world just pays for the cost of production.

Oh come the fuck on, this has been the talking point since the early 2000's. Surely nobody still believes this horse shit. Phizer by itself raked in 50 billion last year alone.

It comes up here in NZ every few years, as there is frustration that we aren’t paying as much as the drug companies would like. The US leaned on us hard to scrap our single payer system.

This sympathy for these massive companies in this thread depressing. Big Agg and Big Tech don’t get this free pass.

It was depressing in 2008, now it's just pathetic. It's no wonder they feel so emboldened to continue fucking people raw for their medications, they have hordes of defenders in government and otherwise ready to offer page upon page of apologia for their rampant profiteering.

Pfizer's world wide net income was $2.12bn USD in 2023.

I guarantee you 100% of that came from the united states.

Okay? Then if the US starts changing its policy they won’t make stupid deals with the rest of the world then.

Pfizer net income for 2023 by quarter. After taking in 10s of billions in vaccine profits this certainly looks like some fun accounting.

2023-12-31 $-3,369 2023-09-30 $-2,382 2023-06-30 $2,327 2023-03-31 $5,543

https://www.macrotrends.net/stocks/charts/PFE/pfizer/net-inc...

The history of insulin shows a great deal of involvement and progress made by researchers in several countries, and the US would probably not even rank as first among them.

Eli Lilly was the first commercial producer of insulin at any significant scale.

Genentech developed biosynthetic human insulin using engineered ecoli.

Eli Lilly produced the first of the modern synthetic insulin analogs.

Literally every major breakthrough except the initial bovine extracts were done in the US.

Novo Nordisk is based in Denmark and they did a lot of research. Of course, cherry picking the stuff Eli Lilly brought first makes it seem they are the ones driving the thing forward but it only makes sense in the wider contact and when compared with what other have done first as well.

Novo piggybacked on a ton of research especially with metformin done in the US. Let's not be delusional that Denmark is a bastion of cutting edge biological research

> Novo piggybacked

Isn't this how research and science works?

> Let's not be delusional that Denmark is a bastion of cutting edge biological research

Except in this case, it is? All I read seems to point they did push the envelope a lot of times. Do you have some other reason to say this except "psht, get real, it's Denmark"

> Frankly the US pays for the cost of the research while the rest of the world just pays for the cost of production.

Top 10 pharma companies, 5/10 are US (2 UK, 2 Swiss, 1 French).

4 of the top 6 for profit margins (from 43%(!) to 19%) are US (Merck is the only outlier, 9th, at 10%).

4 of the top 5 for Sales and Marketing Spend (both on raw dollars and as a percentage of revenue) are US.

3 of the bottom 5 for R&D spend (as a percentage of revenue) are US.

Source: http://www.bbc.com/news/business-28212223

That's a 10 year old article. Although if we rank by market cap top 6 are from the US these days (by revenue 5 out 10 seem to be European) so not much has seemingly changed (besides Novo Nordisk becoming the second most valuable pharma company out of nowhere)

> That's a 10 year old article. Although [the] top 6 are from the US these days […] so not much has seemingly changed

Well, thanks for the update. Correcting a citation an out-of-date article that is - as you admit - apparently still relevant as cited was definitely worth everyone’s time.

The very specific figures from that comment are obviously not really correct. e.g. Pfizer's profit margin in 2023 was ~3.5% which isn't that great (and that's the largest pharma company by revenue).

Keep in mind that marketing is a bit complicated - very few countries allow direct to consumer marketing. I think kits just the US and New Zealand. Obviously there would still be marketing in other countries, but a heavy US presence likely skews things.

https://en.m.wikipedia.org/wiki/Direct-to-consumer_advertisi...

Fun fact: the main reason it was legalized in New Zealand was heavy US pressure and lobbying over trade agreements and there’s been substantial pressure to get rid of it since then.

Because almost nobody actually pays those prices

> One key limitation of this study is that most of our analyses used manufacturer gross prices, not manufacturer net prices after rebates and other discounts are applied.16 Given the generally competitive insulin market, rebates in the United States are substantial (Mulcahy, Schwam, et al., 2021; Dickson et al., 2023). After applying a 76 percent manufacturer gross-to-net reduction, U.S. prices were roughly twice as high as those in other countries (compared with nearly ten times as high without the discount). We caution that these results likely underestimate the magnitude of the price differential because we were unable to estimate similar gross-to-net discounts in other countries. If manufacturer net prices in at least some non-U.S. OECD countries are lower than their manufacturer gross prices, the ratio of U.S. to other-country prices would be higher. In addition, because of data limitations, we applied a single U.S. gross-to-net reduction across all insulins. Actual product-specific gross-to-net discounts likely vary along product characteristics (for example, prescription versus over the counter and timing category). As a result, our estimated ratios of U.S. to other countries’ prices for specific insulin categories likely reflect measurement error.

As far as I can tell they also aren't attempting an apples to apples comparison, they're lumping all "long lasting" insulin drugs together. There is no such drug as "insulin", or even "long-lasting insulin". There are dozens of insulin analogs being sold at an incredible range of prices, easily over 10x from the most expensive to the cheapest.

https://www.goodrx.com/healthcare-access/research/how-much-d...

My default take on this kind of analysis is that people in the US are wealthier and are therefore paying for the newer, more effective, more expensive insulin drugs than people in other countries. I'm happy to be proven wrong on this but I haven't ever seen that analysis, they always conspicuously avoid direct comparisons of the same drugs.

This falls into a greater pattern of behavior in the us that I have noticed where pricing for almost everything is completely opaque. The price on the menu for a burger is not what comes out on the bill (tax, gratuity).

The price for healthcare is beyond understanding for mortals. The price for drugs, again you and your neighbour could be paying something completely different for the same medication. The actual cost to your wallet for university? Who know, everyone seems to get different levels of subsidy and scholarship. Visa Cash App - you can make the same purchase on two different days and pay different prices, unique only to you.

I find it incredibly exhausting to visit the US and navigate all these pricing systems, I dont know how you have let this become a psychological status quo.

>> So why is older insulin more expensive in the US than elsewhere, by a large margin?

Here you go kid: https://en.wikipedia.org/wiki/Free-rider_problem

Read that, and then you can explain to me the answer to your question.

the fact that noodles cost 10x as it does in Canada? cost of labor and minimum wages

One bit of nuance here is that you cannot buy FDA approved non-human insulin in the U.S.

That’s not because of an action by the FDA, but just that the manufacturers stopped selling it between 1998 and 2006:

https://www.fda.gov/drugs/frequently-asked-questions-popular...

So your only option is to buy the modern day synthetic analogs - or illegally import the old stuff, which the FDA notes here it has the right to block, but may allow under exceptional circumstances.

That limit is the length of a patent (plus/minus some factors like extensions and time to market). That's been the deal ever since the FDA was a thing. It's nothing new.

My understanding is that the controversy is over a newer type of fast acting insulin that's not yet generic. In general insulin is really cheap, but the really nice new stuff makes life a lot easier for diabetics so everyone wants it.

Turns out many many of the drug companies have been abusing the systems. The feds created a process for handling drug patents, and companies keep filing extenuating patents on existing stuff, and they also have been submitting not just drugs but devices to the registry illegally too, to hold monopoly. No one has guarded the registry.

FTC is finally taking some charge, after all the other agencies (patent office, FDA) have failed to do any enforcement.

Really good recent write up by the usual king of company & capitalism watching, https://www.thebignewsletter.com/p/monopoly-round-up-how-ftc...

> There is an awful lot of sympathy for the drug company in this thread.

And for good reason.

> Things like insulin are long paid off, and the pricing there has generated controversy. People have been charged $1000 a month for it [1].

Humalog and NovoLog both have expired patents. There are newer, better insulins. But these drugs were state of the art just 25 years ago.

The older products are much more expensive in the US too. It’s price gouging, and that’s when regulation has been imposed.

The newer products are cheaper elsewhere in the world. The US is getting ripped off by big pharma.

First of, I think that health-care prices in the US are horrible and have terrible consequences for patients

However, the blame doesn't lie with pharmaceutical companies. They're not selling their products cheaper elsewhere because they hate the US and love other countries

They're doing it because the US has created a system that benefits corporations more than its citizens. If blame needs to be distributed it lies with the people in power who built these systems and those who gave them that power

Healthcare in Europe is cheaper because the population fought for it, sometimes literally

And they’re actively lobbying to keep it that way.

Which they can do because the US has created a system that incentivizes companies to lobby for their own interests over that of the US population

I can think of two reasons on how we got here:

1. Expensive drugs are expensive to compete again. Any new entrant will have an uphill climb. They will need a new way to solve the problem, so it doesn’t infringe on the incumbents patents.

2. Drug manufacturing is still a niche business. In many other advanced industries, the tooling has become commoditized leading to a lower bar for entry and increase in competition. Repairing phone displays and soldering memory modules is now possible at home. Pharma is still waiting for that 3D printer/indie moment.

I don’t know if it’s even possible - we’re talking about chemicals and amino acids here. Every drug will need a different set of ingredients (not that different from cooking food).

You can have selective outrage. Insulin is clearly overpriced. Semaglutide, maybe not as much.

> But at some point there is a limit.

But we are nowhere close to that point. Ozempic is going off patent in 2031. It is a new drug, and it happens to be a miracle drug. Why should the company that brought the drug to market not monetize on it?

so should they charge $1b for the first pill and then $5 thereon? what is the argument you're making?

Wonder how many of these folks are on big pharma’s payroll and feel a need to defend those profiting in the billions from patented blockbuster drugs. Thankfully Biosimilars are eating away at patented drug molecules/biologics to reduce prices.

Not only are there different types of insulin, but there are different types of delivery mechanisms. "Convenience" is continually being "innovated."

Approval of biosimilars, state laws capping price, and manufacturer out of pocket max are driving down the price over the last 4 years.

https://www.goodrx.com/healthcare-access/research/how-much-d...

I'm not Pharma industry expert but ... I'm pretty sure it's much the same as venture capital.

That is to say that's it's not that expensive to R&D it, certainly compared to the eventual sale price, but it's carrying the cost of the hundred potential drugs that never made it to market that's the killer.

It takes $300m to $2B to get a drug approved.

And the approval rate is less than 12%.

The crazy pricing is to compensate for the failed projects.

Also, it's not like you can bootstrap yourself or grow organically like Startups.

You have to wait for like 10 - 15 years. To actually start selling it.

[1]: https://www.google.com/amp/s/www.policymed.com/amp/2014/12/a...

> Also, it's not like you can bootstrap yourself or grow organically like Startups.

So if they have a effectively built monopoly, chopping down the maximum they can charge via regulation would seem sensible wouldn’t it?

there is also a lot of problems with pharma not wanting to invest in cures for smaller diseases because the payback seems unlikely to happen or not be great enough to warrant the risk, so this seems like a pretty good vote getting maneuver that might have unintended consequences.

I think that's difficult to implement. There's a risk that companies might end up not launching new products on the US market

There's several factors that impact US drug prices. For instance FDA approvals are significantly more costly than EMA ones and the bargaining power of healthcare providers is worse compared to a single payer system

I have no knowledge of US laws, but I wouldn't be surprised if there's some kind of law preventing government interference with "the free market"

No such law here in the states, just a political atmosphere where some people adore the idea of socialism and others see it as the coming of the end of times. Combine that with a highly complex industry structure that’s been entrenched for decades, and you end up in a situation where it’s near impossible to pass laws that actually structurally change our system.

(It’s almost the opposite, in fact, where our courts have expanded the Commerce Clause over time to allow the federal government the ability to regulate close to any economic activity.)

Thanks for the clarification! :)

Regulation has hit insulin pricing. https://www.whitehouse.gov/briefing-room/statements-releases...

No it’s also ludicrously expensive to R&D a drug, even if you just count the costs of the successful program. You’d be looking at easily $50-$150MM just in clinical trial costs, not to mention the years or decades of preclinical work.

Factor in the failed programs and you’re looking at about $2B of spend in order to bring a drug to market.

If I remember correctly that cost is also only the price of developing a successful drug

Several drug developments are halted before they reach market. Novo for instance lost a lot of money on their bet to develop inhalable insulin 15 years ago

That cost also has to be recouped when finally hitting the jackpot

Of the top 10 pharma companies, 5 are American, and three of them rank 8th, 9th and 10th for R&D investment.

So the whole "American big pharma needs to make a billion dollars a week in profit to recoup their R&D" is nothing but marketing fluff.

Does it matter that only some of them are headquartered in the US? Presumably those other companies also sell drugs in the US?

I would think any company - regardless of where it’s headquartered - would seek to recoup R&D costs in a huge market like the US where prices aren’t capped by the government.

I… am not following this. Novo Nordisk for example is a Danish company.

I haven’t seen anyone say American pharma companies in particular need to make a ton of money.

The American-specific topic is that American consumers pay a ton more for drugs. That can be chalked up to lack of single-payer making American consumers incredibly easy to bully/negotiate against + all the rent-seekers who sit at various points along the care delivery system.

It’s even riskier than VC, because the capital requirements in pharma per venture are _significantly_ higher.

There was a recent story right here on HN that contradicts that narrative.

"Big Pharma spends billions more on executives and stockholders than on R&D" https://news.ycombinator.com/item?id=39405547

According to Acquired.fm, they are required to sell their products at cost in Denmark, and allowed to make up for that around the world. I am curious for feedback here on the accuracy of this information.

I can't believe that I'm sharing YouTube shorts on HN, but this is the best way to share this info at the moment:

https://www.youtube.com/shorts/IVut-PE6LCA

https://www.youtube.com/watch?v=lsCvQSNsaVk

There's not a single drug company on the market that stops charging a high price for a drug as soon its covered its research expenditure.

you also need to cover the cost of the 100 drugs that failed at various stages of the pipeline.

Not saying that it's not a screwed up industry, but stories like these distort the problem as well

Are the people running drug companies barely scraping by?

Not nearly as much as they claim they are. The system is basically rigged in their favor. Just compare the financial statements of companies like Ford and Boeing to Eli Lilly and Novo Nordisk. Pharma does very good business.

Obviously not, but my general experience with conversations like these is that people never do the math.

If we split the profits across all of the people that "deserve reimbursement" you usually end up with a few dollars per person. Definitely, not enough to make a meaningful impact.

Additionally, the American consumer subsidizes R&D and costs for the rest of the world. America routinely pays 5x-20x more for drugs than other countries and American grants account for >50% of worldwide medical research funding (caveat: the last time I checked). Yup, even Europe is a fraction of what America pays.

I would encourage you to actually do the math and decide for yourself rather than taking (or anyone else's) word for it.

Should they not profit on that capital invested for that research? Do landlords drop rents when the loan is paid off? Of course not, they’re going to price rents what the market supports. Competition is what makes markets work. Invent a drug? And someone else invents a similar drug? Prices will go down.

There's no free market for lifesaving drugs. Just extortion.

Is it ethical for a doctor to accept payment for life-saving services, then?

A much more interesting discussion could be had around who pays for it (and how, and how the prices come to be as high etc.) – because somebody ultimately does.

Nope it's not. They can get paid a wage from gov and charge nothing. Private Healthcare in its entirety is unethical. Shouldnt exist. Full stop.

That's exactly the more interesting discussion I meant. Who pays the doctor, nurse, pharmaceutical companies, how are wages and prices negotiated etc.

But I hope you agree that in all of these models, the doctor does in the end get paid, i.e. accepts payment? I never said that the patient should be the one paying them directly. But if nobody does, there will be no doctor.

Have the entire healthcare system gov run. Need funds for it? Write em up out of thin air. Keep wages pegged above avg labor market because having a healthy society is more productive than an unhealthy one. To the extent where all other industries come 2nd as they are basically useless without healthcare keeping their workforce alive. Can't run a company if all your workers can't get well once they get sick. Literal unnecessary waste of human resources all because we want to prop up a few folks profits? The jobs and demand for the work will still be there if it's gov run, you just don't have a swathe of investors profiting off it. Zero loss. Go invest elsewhere.

One of the arguments against this is inflation from creating money out of thin air to fund it. Its a lie. The service is required and you don't get inflation from paying folks a wage to do a job. You do get it by propping up profits of private companies which essentually through the fattening of their bank accounts devalues money. Remember if you have a large number of folks competing for a good or service and they are all on similar playing fields (e.g wages near market avg), competition is high, the value of each dollar earned remains high.

If you have a handful of companies with buying power that far outweighs that of others allowing them to capture more than their share of a service or good because they can literally just throw more money at it than the majority of us can. This drives Inflation. It devalues money creating a new norm of your dollars being worth less.

Tldr: The benefit from entirely gov funded healthcare far outweighs that of a privatized system.

That sounds noble but... What do you propose? Free drugs for everyone? If nobody is allowed to profit on researching drugs, nobody has a reason to sponsor drug development - which is very expensive.

Of course I agree this market should be regulated - like we regulate it in Europe - but at the end some company is investing into drug research in order to make a profit.

Rental markets rooted where I am. Fails to provide for society the purpose it exists for. So yeah if your saying big pharma is the same sure I'm on board.

Profit enough to survive. But don't take more than your worth. Tbh profiting off medicine is about as low as profiting off weapons manufacturing. You literally make money out of the misery of others.

Thank f#@k I live in a country that has free healthcare. The concept of privatizing the health of your citizens and letting a select few profit from that is absolutely batshit insane.

Free healthcare is not really free. And it is good until you hit the point where the next available appointment date is 12+ months ahead.

Or when your country decides the benefit of treating you with the new treatment doesn't justify the cost. I understand this is quite common in Europe with some cancer treatments.

Society contributed to that research in the form of education, academia, infrastructure, ...

And Novo Nordisk contributed back to society. By a lot. Large part of earnings goes to Novo Foundation, which is used to help people in Denmark and make it to a nicer country for people (even though its already amazing country).

And for that investment society now has a new drug anyone can make at cost from t+20 year till forever. I'm not seeing how society is getting screwed here in the big picture.

I agree, someone has to pay for the research.

Stories like this seem to pretty clearly represent the hazards of private funding for drug research. Publicly funded research and possibly publicly funded drug production could eliminate this issue.

Marketing spend dwarfs (dwarves?) R&D costs by multiple factors.

I believe that claim ignores the R&D that is occurring in small companies. The large companies are good at marketing, so they buy small companies that have a hit, and then market it. The large purchase price they pay for the small companies reflects all that R&D that was done by the small companies (including the ones that didn't get a hit and weren't purchased.)

On top of research, FDA approval doesn’t come for free either.

Are the downvotes expression of disapproval with the FDA process or disagreement with the assertion that it's become slow and expensive enough to pose an ethical problem (e.g. for people with diseases for which a cure exists but is still waiting for approval)?

Or does anybody actually believe FDA approval is very easy and cheap to come by these days?

Pharma stocks actually underperform compare to other companies. So, it's not like pharma companies are making insane profits. Research, regulation, approvals and failures are expensive

> So, it's not like pharma companies are making insane profits.

Huh.

> Gilead Sciences gross profit for the twelve months ending December 31, 2023 was $20.618B

Not insane profits, indeed.

That's GROSS profit. That's basically saying that the same as the article, they have insane margins, selling 5$ pills for 1000$. They have to pay for the other stuff. Net income was 5.6B. Still, a lot but yeah it's a big company.

GILD is down 10%+ YoY. SP500 is up 28% YoY. Or Cigna (health insurance, also 100B market cap) 43% up

#DingDingDing

In general, mono-dimensional arguments merit an extra dose of skepticism from the audience.

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