The $2.7 Trillion Medical Bill
nytimes.com
nytimes.com
In essence, Americans are subsidizing the socialized healthcare systems of other countries.
... no wait.
At most one of those can be true (and possibly neither). Which do you pick to be true?
No, I didn't mean anything like that. I have no idea how you got that out of what I said.
> By the way, aren't there many people here that say it's the legal duty of the directors of a company to do everything they can to maximize shareholders' value?
Yes, and it is.
> Wouldn't THAT (make less money than legally possible in the US) be a violation of that supposed duty?
Yes, but it's not happening, so I don't see your point.
You wrote: "This means that pharmaceutical companies have to recoup their fixed costs (R&D) and generate their real profits from the US market" (emphasis mine). What did you mean with that phrase, if not that if they could make their real profits outside the US pharmaceutical companies wouldn't have to recoup their costs in the US?
You're right that a drug company will always charge as much as it can, so the US price of a drug will not be affected by the price it can charge elsewhere. However, the chance a drug is developed in the first place is dependant on the total size of the market for that drug. If the potential profit for, say, a breast cancer cure is $300 billion rather than $100 billion then there is more chance that a cure will be found.
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174966/ [2] Ben Goldacre. Bad Pharma. 2012. Fourth Estate
And if you want to boost the sales of your second line drug convincing people it is the best you are actively hurting the patients.
Doctors find out through journal articles etc- there is no need to market to us
Public Citizen and many others have done research debunking such claims in detail. (http://www.nybooks.com/articles/archives/2004/jul/15/the-tru...)
Let me start by saying that half of my family works in the healthcare sector: my dad is trauma surgeon, my sister is a chemical engineer at a (very) large European pharma company, and my mum works extensively with pharma sales/marketing teams around Europe. I'm no expert, but I tangentially know the industry.
i. 6 out of the top 10 pharma companies by revenues are European (Novartis, Roche, GSK, Sanofi, Bayer, Astra Zeneca).
ii. Europe accounts for 1/3 of all pharma R&D in the world.
So with the above two points in context, let me pull apart your unsubstantiated comment:
First, lets talk about pharma and drugs for a second.
>make little to no margnial profit in non-US markets
European pharma co. Novartis made in 2012 revenues of $19.7bn in Europe vs $18.6bn in the US (and a total of $56.7bn). Novartis invested 21% of sales into R&D.
U.S. pharma company Pfeizer, total revenues of $59bn in 2012, U.S. was $27bn and international $36bn. Pfeizer invested $7.9bn in R&D (c. 13% of revenues).
Look at any other large US or European company and you will see that Europe is as profitable, if not more, than the U.S. Europe, by itself, on a total revenue minus total R&D expenditure, is (in the $ billions) profitable.
>pressures of a single-payer system driving down prices as low as they can possibly go.
No European country has a single-payer, that is false. Purchasing is not made by a country, and it is not even done at the regional level. Purchasing decisions are made at a hospital per hospital level. Each hospital manages its own budget and pretty much pay market rates (to check this simply go to the pharma companies annual reports and do the math).
>This means that pharmaceutical companies have to recoup their fixed costs (R&D) and generate their real profits from the US market.
So given the math above, and given that R&D is a fixed investment (even if the final compound is produced ad infinitum), the U.S. tends to contribute to 25% to 35% of any pharma companies' revenues, while the rest of the world makes up the rest. This simply means that the U.S. by itself would cover R&D, but in no way it could cover for R&D + operational costs.
>Without the US market, there would be no incentive to actually create the drugs.
European pharma, by itself, makes over 1/3 of all world R&D in pharma, while U.S. contributes 1/3 of all revenues. Without the rest of the world, U.S. companies would not invest at all.
Second, lets talk ER and other primary patient care with no drugs involved.
How is it that any transplant, operation, etc. in any part of the world is cheaper, face value wise, in RoW than in the US?
Well, let me say that while in Europe healthcare is considered important, it is not seen as a business, but a basic right. Not the right to FREE healthcare, but the right to healthcare. Healthcare in EU countries is seen as the recurring cost of keeping the citizens healthy, and hence healthcare is managed as a cost centre and not a profit centre. E.g. Doctors and nurses, across the same EU country get paid very consistent salaries, unlike the US, where a surgeon in Orlando makes a completely different salary than one in Idaho, or even in the same city! Salaries of public employees in the EU are transparent and consistent. The overall U.S. healthcare system lacks price transparency at every level. How can it be that the same surgical procedure in the same U.S. city varies in price by 2x or 3x? In the U.S., hospitals, large healthcare companies and other parties are there to make a profit, not to run a business at a loss. They have shareholders, it's understandable. In Europe, the shareholder is the citizen, and healthcare is not a for-profit business. Nevertheless, if you want more "customer service" in your European healthcare you can have it, pay for private insurance, but pay for it, it's not illegal.
My final comment would be this insightful chart: https://www.e-education.psu.edu/drupal6/files/geog438w/image...
ii. Do you understand that revenue and profits are different concepts?
ii. Lets for a second do a fermi equation on those us and European revenue figures.
We have roughly the same revenue figures We have roughly the same population (give or take 20-30 million) between Europe and the is
Now if there is no profit to be made in Europe either the Europeans consume vastly more pharmaceuticals (possible but unlikely) OR there is profit to be made in the European market
> U.S. pharma company Pfeizer, total revenues of $59bn in 2012, U.S. was $27bn and international $36bn. Pfeizer invested $7.9bn in R&D (c. 13% of revenues).
Do you know what fraction of those revenue figures are profit? It is entirely possible that the companies could have different profit margins in different areas.
Kind of like typical religious apologetics. "When people question your Bible beliefs here are points you use to refute their arguments..." stuff like that.
But don't worry, if the usual suspects are successful, we'll all be paying peanuts for drugs in due course. Pity there will be no effective antibiotics against many resistant drug bacteria strains....
(The thing that really gets me is how many of these advocates for an end of medical innovation as an inevitable outcome of their nostrums will find their own lives cut short in due course due to it. Ideology trumps self-preservation.)
At the very least, there needs to be better regulation of big pharma practices and prices in the US. Unfortunately, due to the lobbying power of the industry, I doubt we'd see any real solution anytime soon.
As for patent protection: something needs to change there as well, because too damn much of the research budget goes into drugs that are no improvement over existing ones, purely to take market share from a competitor or replace drugs whose patent protection is running out.
source (look at the 10th and 11th paragraph): http://www.nybooks.com/articles/archives/2004/jul/15/the-tru...
High cholesterol is associated with higher risk of heart attacks, but lowering cholesterol isn't associated with a lowering of heart attack risk. In addition, the side effects are vile and costs are high.
The most depressing thing about the modern pharmaceutical industry is that its two biggest cash cows, statins and the modern new-school psychotropics, have very little evidence that they actually help anyone, and involve lobbying budgets the size of small nation's GDPs to keep the gravy train going.
What "modern new-school psychotropics" are you referring to? That's a field I know a fair amount about, and I don't see the problem you're citing at all (which is not to say some aren't over-prescribed, but I believe that is a different problem). I would probably be very ill or dead without one (low dose, off label Seroquel to treat anxiety which I have a family disposition towards; it's the difference between 4 and 7 hours of sleep a night, bright light treatment gets me the final extra hour I need).
It and the other atypical anti-psychotics seem to be a lot better than the older "typical" ones, and those were miracle drugs, something witnessed by my mother when she was a nurse. Similarly, the current Prozac and beyond anti-depressants are maybe not quite as effective as the previous tricyclics but their side effect profiles are a whole lot better, e.g. making it more likely a patient will wait those out long enough for the therapeutic effect to begin, and I personally benefit from a laser specific SSRI (doesn't touch anything else), since "wrong" anti-depressants can make me manic.
I haven't followed the current info on atypical anti-psychotics possibly inducing metabolic syndrome or worse, but I do watch for signs of it. And that's not why my PCPs are pushing statins, it's because of my lipid levels. Which, strangely enough, are exactly where they were in 1999, they got a bit better for a while, and are now back to a level that wasn't considered worthy of dangerous medical intervention back then.
No doubt there are those who suspect previously not so bad lipid levels are actually bad; me, having watched the drama of lipids and health since around when it first became a big thing, and all the revisions in the conventional wisdom, I'm ... a bit more conservative with all that.
I have zero financial bias in making this statement.
If you have a particular concern about statins, you should state it precisely.
http://www.mayoclinic.com/health/statin-side-effects/MY00205
Clearly the medical community has decided that the benefits outweigh the risks for most people, i.e. lower cholesterol. However while statins are shown to lower blood cholesterol, benefits in terms of reduced heart disease are not necessarily clear, especially in people with no other history of heart disease. A recent study found that "Statin use is associated with an increased prevalence and extent of coronary plaques"
http://www.ncbi.nlm.nih.gov/pubmed/22981406
There is even disagreement that cholesterol levels alone are really predictive of heart disease:
http://www.minnpost.com/second-opinion/2012/05/latest-thinki...
No silver bullets....
That's simply not a balanced summary of the literature. On balance, statins reduce both secondary events (heart attacks after your first one) and primary events (first-ever heart attacks).
Even conservative groups such as Cochrane agree that, based on the scientific literature, statins are both efficacious and cost-effective for primary prevention [1].
Also, trying to throw away the cholesterol/heart-disease hypothesis is sort of like trying to throw away evolution. If you're right, that's Nobel worthy; but you're not right.
> A recent study found that "Statin use is associated with an increased prevalence and extent of coronary plaques"
That's not clear from the article you've cited, despite quoting a part of the abstract. You have left off an important qualifier that ends the sentence. Here is that full sentence, emphasis mine: "Statin use is associated with an increased prevalence and extent of coronary plaques possessing calcium."
The abstract does not state that statin use is associated with an increased prevalence and extent of coronary plaques overall. (I don't have access to the rest of that article from my hotel room, so if the article itself does state so, please feel free to quote it in reply.)
Also, this appears to be, effectively, a case/control study. The studies supporting statins are randomized, controlled trials -- the strongest form of evidence. Case/control studies suggest follow-ups, but are by no means equivalent to studies of highest-grade evidence.
1 = http://summaries.cochrane.org/CD004816/statins-for-the-prima...
- It has zero to negative efficacy, at least for the for the vast majority of people taking it, and virtually no efficacy for the rest.
- You can get generics that are equally 'effective' for virtually free.
- It's vastly less effective than even the most minimal of lifestyle interventions.
- If for some reason you really wanted to take those chemicals, you could just get them for free in your diet anyway. E.g. from red rice and I think certain other fungi.
Now granted none of us would be here if our ancestors weren't willing to eat random crap in the woods and risk dying, and there's certainly a need for us to do the same to benefit future generations, but if the work has already been done for you on a given substance then there's really no excuse not to do the research.
> - It has zero to negative efficacy, at least for the for the vast majority of people taking it, and virtually no efficacy for the rest.
Citations? This is a pretty big claim for a FDA-approved drug that was the most profitable drug on the market as of 2011[1].
> - You can get generics that are equally 'effective' for virtually free.
As of last year, yeah, this is a fairly recent development that if you don't follow pharma, you'd be unlikely to know.
> - It's vastly less effective than even the most minimal of lifestyle interventions.
Generally statins are prescribed in combination with recommendations of dietary restriction.
> - If for some reason you really wanted to take those chemicals, you could just get them for free in your diet anyway. E.g. from red rice and I think certain other fungi.
You're thinking of a different active ingredient, monacolin K, which is also sold in pill form (Lovastatin[2]) and found in red yeast rice and oyster mushrooms. A quick literature search found Lipitor to be more efficacious[3] (Double blinded, placebo controlled, n = 1049).
Keep in mind that, as with all drugs, both are dose-dependent and have unpleasant side-effects when taken in combination with certain drugs, foods, and certain patient populations, such as pregnant women and those with liver disease. Hence why it's recommended to check with a doctor who is well versed in this matter, rather than self-prescribing at unknown dosages.
[1] https://en.wikipedia.org/wiki/Pharmaceutical_drug#Leading_bl...
There are a bunch of books about this that you can get on Amazon. A good one I read is Overdosed America. But if you search on Amazon for 'statin' there are a lot more books that are specifically about this.
"A quick literature search found Lipitor to be more efficacious[3] (Double blinded, placebo controlled, n = 1049)."
The academic literature generally isn't a reliable source for information about pharmaceutical drugs, unless it's one of the NIH trials or another trial sponsored by an independent entity. The only way to get accurate information from trials sponsored by pharma companies is to FOIA the FDA, unless the raw data is on clinicaltrials.gov which it almost never is. There are again a number of books that explain why this is, I personally like both Overdosed America (again) and also Marcia Angell's book The Truth About Drug Companies. I'm sure Ben Goldacre's new book probably covers the same stuff though.
"eep in mind that, as with all drugs, both are dose-dependent and have unpleasant side-effects when taken in combination with certain drugs, foods, and certain patient populations, such as pregnant women and those with liver disease."
Plant-based medicines tend to be fairly forgiving about dosage. E.g. you're probably not going to get sick from eating any reasonably amount of oyster mushrooms, at least as long as they're fresh and you cook them properly.
Make an argument here and cite your sources here, I'm not going to read a book just so I can respond to your post in half a month...
> The academic literature generally isn't a reliable source for information about pharmaceutical drugs, unless it's one of the NIH trials or another trial sponsored by an independent entity
How's a paper in a top tier medical journal[1]? It's paywalled, but if you actually care enough to read the information on the other side, I can grab you a copy. It's even registered on clinicaltrials.gov[2].
> I'm sure Ben Goldacre's new book probably covers the same stuff though.
This is one that I am somewhat familiar with. He makes plenty of good points with regards to transparency of information and reducing reporting bias, but you can't leap from that to the biggest drug on the market right now having zero efficacy.
> Plant-based medicines tend to be fairly forgiving about dosage. E.g. you're probably not going to get sick from eating any reasonably amount of oyster mushrooms, at least as long as they're fresh and you cook them properly.
False[4]. The end effect of consuming the plant material is a chemical ended up in your circulation at a given concentration. If that concentration is too high, you'll see adverse effects. If it's too low, you won't see any effect. At least in pill form, you know your dose and have quality assurance about that fact.
And we're ignoring the potential case of the process of cooking the food destroying the active compound...
[1] https://www.ncbi.nlm.nih.gov/pubmed/18061058
[2] http://clinicaltrials.gov/ct2/show/NCT01687686
I'm not especially interested in discussing this at length, I listed the books I did for the benefit of you and anyone else who is interested. You could instead read Wikipedia and random papers you find on Google scholar, but I don't think you'll really learn much that way. And in Overdosed America it's really only one or two chapters that are relevant.
"How's a paper in a top tier medical journal[1]?"
Not really worth much unless it's a large NIH trial, a well-cited meta study, or an IOM report. Individual research papers are generally pretty worthless, at least for medical related stuff.
> Of 1000 people treated with a statin for five years, 18 would avoid a major CVD event which compares well with other treatments used for preventing cardiovascular disease. Taking statins did not increase the risk of serious adverse effects such as cancer. Statins are likely to be cost-effective in primary prevention.
Why People Believe Weird Things (http://www.amazon.co.uk/People-Believe-Weird-Things-ebook/dp...)
The Believing Brain (http://www.amazon.co.uk/The-Believing-Brain-ebook/dp/B005RZB...)
Irrationality (http://www.amazon.co.uk/Irrationality-ebook/dp/B0046ZRNLE/re...)
etc etc.
My mother lives in Indiana. She is disabled, but has not been approved for disability yet. And I don't mean NPR's version of disabled, I mean she is physically incapable of working due to medical issues. She is on Medicaid (Hoosiercare I believe its called). Even with Hoosiercare (state subsidized insurance), I pay for between $500-800 month for her medications. These are co-pays, not the full amount. I have even considered inventorying her medication and ordering it in bulk from Canada.
If I was not lucky enough to make the salary I make, be in good health, and have somewhat affordable health insurance, there is absolutely no way my mother would be able to afford her prescriptions. She requires these prescriptions to survive.
I hate living in the US, and I was born here.
Consider moving elsewhere. Canada is close by, culturally familiar and has your health deal comfortably beat.
Seriously, if you don't like it but you are paying through the nose for it (and thus helping perpetuate it), why not take your talents and labour elsewhere?
I immigrated to Canada 15 years ago; I’m pretty sure that I would not be eligible to immigrate today with how the Harper Government has gamed the immigration system. :|
With the skill sets of many people on this forum, they do.
Source: I'm a European that moved to California and then Canada, both for work, on accelerated work-permit programs.
This isn't capitalism, it's strangulation of an industry by middlemen and lobbyists.
I, for one, am hoping that Accountable Care Organizations will prove financially viable.
Obviously this is cheap because its just augmenting the public system, but I probably don't pay much more tax than you guys. The difference is just crazy to me.
I.e. it's not comparable at all without knowing how much the "public system" costs. A more comparable data point: my German "free" (public) health care costs almost €6000 per year, of which €3200 is paid by me and the rest by my employer. There are co-payments, but very low (a maximum of €10 for drugs and per day of hospital stays).
And yet, it's cheap compared to plans in the USA, given that there is no such thing as a "deductible". And the premium doesn't rise with age, or any existing conditions.
So, clearly either the private or public healthcare, possibly both, in the US is run very inefficiently.
United Kingdom: 2857.3 United States: 3966.7
Where did you get your numbers from? If they're more accurate, I'm happy to go with them.