Hacker News Reader

Comment by CapmCrackaWaka | Hacker News Reader

My wife and I recently decided to do IVF. The doctor specifically told us that we needed to order the medicine (menopur, Gonal F, etc) from an American pharmacy. That alone made me suspicious, so I looked at foreign options. Altogether, the medication required would have cost us about $5000 from American pharmacies. We found out that we can just buy the exact same stuff from a German pharmacy for about $1000. So yes, Americans get wrecked by drug prices.

View on HN

When my wife needed a rabies post-exposure shot course, it would have been around $25000 range for the shots without coverage. Our (expensive high end) insurance brought it down to "only" $2500 out of pocket for us. The alternative is to take the gamble of a possible horrible death.

In the UK? Around £150-£300 total.

> In the UK? Around £150-£300 total.

For whom? I can't imagine this in particular would not be free at the point of use like almost everything else. That said, the UK has famously been free of (classical) rabies since the 1920s, so it's unclear if it would be easily available if there aren't other uses.

Was talking about from a private clinic [1]. Obviously it's free via NHS. It's a good example of a system in which the government in incentivized to not tolerate drug price gouging.

https://www.citydoc.org.uk/conditions/rabies

Not quite free for most people, we have to pay the prescription charge of about £12

Not in Northern Ireland weirdly, they have free prescriptions there

Most dispensed _items_ are free of charge (as in, the prescription charge is not paid - only around ~11% of items are paid). There isn't enough data to know how that breaks down to people though.

Is it a good example of drug price gouging? I would bet the major part of the price is that provider.

Yes, it's the drug.

So what's the breakdown of that $25k for the provider?

> doctor specifically told us that we needed to order the medicine (menopur, Gonal F, etc) from an American pharmacy

Why do they care? Referral bonus?

Did you report them?

what do you mean? you expect american doctors to prescribe you medicines from german pharmacies?

I actually do expect doctors to have even a tiny concern for not making their patients go bankrupt, yes.

Is that really such a high bar?

You need to understand that the system is deliberately so opaque that doctors don't even know what your costs would be. Sure there's a sticker price, but for most medications that's so high as to be absurd. From there, it's entirely dependent on your insurance, coinsurance, pharma benefits, etc, etc.

They try, but they're not in a position to do anything about it.

> They try, but they're not in a position to do anything about it.

Well, somebody's got to be, and the doctors seem like the ones with the most leverage to get those people to do something about it, right? Customer/patient pressure obviously isn't working.

> the system is deliberately so opaque that doctors don't even know what your costs would be.

You're telling me professionals who make $300k after 20 years of education have 0 clue about what their patients might pay, or have never had patients who expressed concern over costs? Or don't have friends or relatives who expressed dissatisfaction with a high-deductible plan? Or aren't complicit in getting kickbacks for prescribing opioids?

We gotta stop absolving people of accountability. And that includes EVERYONE in the chain who benefits. Yes, this includes doctors.

Btw, I have had doctors who do try, and many more now will accept reasonable cash prices for their services. That should be encouraged and commended.

They often don't. There are a lot of variables that affect the price. The doctor is not going to know all of them.

Indeed. At the end of the day, the entity underwriting the insurance plan decides the price. This is often the individual's employer. Your doctor does not know what your HR team decided to ask for when designing their health plan.

I'd assume it was their telling them specifically not to get it from a foreign country that was the odd part, as opposed to simply prescribing it from a US pharmacy since ofc that is what a US doctor will do. Maybe enough patients tried this, to save costs, that it resulted in some kind of issue for the doctor and that is why they brought it up.

Fear of counterfeit/low quality drugs?

It is often illegal to purchase drugs from other sources?

The named drugs are injectable and require cold storage so it is not trivial to safely source them from overseas.

Well, for one ... it's illegal to import drugs that aren't FDA approved. You can import a few months personal supply of a prescribed drug that is FDA-approved but doesn't just mean that the active-ingredient is FDA-approved. It has to be the same exact product, manufactured in the same FDA-approved facility with the same packaging/labeling/etc to be considered "FDA-approved". The most expensive FDA-approved drugs are sold at US prices globally, so there's no geographic arbitration. Then other non-FDA approved brands are sold at lower prices - importing these is a smuggling offense, though enforcement was pretty low (but now with CBP's upcoming budget increases, who knows if this will continue to be practical or ultra-risky).

More practically - HMG is a very difficult drug to assay for purity. It's too complex to interpret with qNMR, HPLC testing is also very hard to interpret. The testing that exists evidently either has a very high margin of error or involves lots of rats and dissections.

Even testing for hCG, while it can be done reliably with HPLC, results between different labs are not comparable because the primary assay is also to test bioactivity on rodents, so they're not normalized to the same standard.

The lack of any independent testing for HMG means that some of the more accessible international manufacturers don't actually test their own product. Combined with its high price, that all makes it a very common target for counterfeit.

Yes, the American pharmaceutical system absolutely has quality-control issues. 80% of our generic pharmaceuticals come from overseas production. The pentagon wanted to independently test the drugs it was purchasing for the VA, so it worked with a company named Valisure who determined that about 10% of the drugs had issues with contamination or a lack of the active ingredient[0]. The FDA responded by shutting down Valisure's third-party testing.

But even with the problems we have here in the USA, HMG is the one drug I would particularly not trust from gray-market supply chains. It's conjecture, but I wouldn't be surprised if the doctor said that because other patients had tried it and had poor results.

0: https://archive.ph/ubLmg

Not only the drug has to be approved but the production process and laboratory.

There is a lot of bureaucracy and audits. It is but as if a European laboratory is allowed to sell a generic drug without at huge costs for certifications ( and viceversa)

I am not saying that buying your medicines to questionable online web is a good idea. Just that other countries have their own controls depending on their policies

Yes. There are a lot of good non-FDA drugs that have been available for online purchase by US citizens. It's illegal to get them shipped to you, but enforcement has historically been nearly non-existent and given that 75 million Americans are under-insured ... it probably has been the rational option for many. India, China, and Turkey are perfectly capable of making high quality pharmaceuticals when the business owner actually cares about quality.

Also, compounding pharmacies in the USA sometimes get their raw active ingredients from even the shadiest suppliers in China and India. It's not always perfectly legal, things aren't always QA/QC'd at any point in the process the way they should be, but it happens. So again, "buying American" isn't exactly a golden ticket.

European HMG from reputable pharmacies is probably great quality - but it's still rather expensive compared to Chinese HMG and there's really no way to trust anyone selling it online, you'd basically have to fly to Europe yourself. And taking it back on the airplane would still be illegal, and you'd be rather more likely to be caught by customs than a mailed package.

The only reason Americans complain about drug prices is because that’s the one they usually pay directly.

The other parts of the healthcare system are hidden behind taxes and insurance.

Not to be unnecessarily sparky here, but are we limiting this discussion to legal drugs?

Drugs like Oxy are both "legal" yet also consumed illegally. Made by a perfectly legit pharma company.

And that's before we discuss the river of fentanyl apparently flowing across the Canadian border...

I think insurance prices are very much a part of the overall healthcare conversation too though.

YouTube Premium is also cheaper in Bangladesh.

Is it cheaper in the UK, Canada, Germany, etc?

Pricing in healthcare is very tightly regulated and there isn't a simple one line answer for why certain prices are they way they are. Its easy to scapegoat bigpharma for being greedy, but they're just as greedy as any other US corporation.

https://en.wikipedia.org/wiki/External_reference_pricing

I only brought up YouTube because when a company is free to set their price, you will still end up with a pricing model where the pricing is different based on region.

Reply on news.ycombinator.com