US Healthcare Is So Screwed I Fly to Britain for My Medication | Hacker News Reader

US Healthcare Is So Screwed I Fly to Britain for My Medication

wired.com

I think a better title might be: I Missed the Obamacare Open-Enrollment Deadline, So I Fly to Britain for My Medication.

There are exceptions to the open-enrollment deadline. The author is not completely clear on his situation, but two exceptions may apply: gaining "status" (i.e. permission to work, or permanent residency) or moving to a new area. Either will allow you 30 days to apply through the insurance marketplace. It would be interesting to know if neither of these applied, or if even Obamacare-subsidized insurance wouldn't cover the drug he needs.

The fact that prescription drugs are more expensive in the US than anywhere else is not news to me, at least...

You could write the same article in reverse if you had atypical haemolytic uraemic syndrome (aHUS). Soliris, the only drug available to treat aHUS, was launched in the US back in 2011 (and all payers cover it), but only just this year did the NHS decide to fully fund it in the UK.[1]

[1]http://www.pharmaphorum.com/articles/nice-backs-full-nhs-fun...

> but only just this year did the NHS decide to fully fund it in the UK

So that means it is covered by the NHS now?

Yup, but for 3+ years it wasn't where it was available in the US.

It was available on the NHS. It was available under the "named patient" scheme which is a bit more complex than just a doctor prescribing it but suggesting people couldn't get it on the NHS is false.

The cost to the patient would have been exactly the same - about £8 per item per month with a range of discounts and exemptions.

Named patient scheme is different. That allows access to a drug before it receives market authorization, not before the NHS funds it. Patients in the UK that could have benefited from Soliris were not able to receive it (without paying full price).

"Up to 70 patients are in the same position as Dianne Illingworth, 41, who have been forced to put their lives on hold, and risk their condition deteriorating, while ministers and officials argue over whether the NHS can afford the drug, Eculizumab, which costs more than £300,000 per patient per year."[1]

[1]http://www.independent.co.uk/life-style/health-and-families/...

"Named patient" does not mean they have to pay full cost for their meds and I'm not sure where you get that from. It's not in the link you supply. That link talks about the cost to the NHS, not to the patient.

> In the meantime, NHS England has established an interim scheme under which new patients – around 20 a year – will get the drug and existing patients already on it will continue to receive it. But patients not currently receiving Eculizumab, such as Dianne, will have to wait for Nice's decision.

The newspaper distorts what actually happened. New patients got it, and existing patients with critical need got it.

Nothing in the link you supplied suggests that patients had to pay more for the med - the link does say that some people were denied the medication. The reason for that denial was a lack of communication from the manufacturer.

http://www.nice.org.uk/news/press-and-media/high-cost-of-tre...

"“Eculizumab is an effective treatment for aHUS. The NHS has already recognised this by making it available on an interim basis, pending the outcome of NICE's appraisal. However, before we can make a confident recommendation for routine use, which we estimate would cost the NHS about £58 million in the first year, rising to over £80 million in 5-years, we need more information."

"Alexion insisted that its information about the overall cost of eculizumab be kept confidential and so NICE is unable to share these details of the Alexion submission with stakeholders. We're disappointed about this decision, for which we have not had an adequate explanation."

But note that people who were critically ill did get the med, for the £8 NHS prescription charge. From your link

> A spokesperson for NHS England, said: "Patients who are critically ill and who need Eculizumab urgently will receive it."

So: people who needed it were getting it. At first they were getting it under the named patient scheme and they only had to pay the normal NHS prescription fee; now it's available under an interim commissioning policy from NHS England - so, again, patients only pay normal NHS prescription fees. For a short time some people who were ill but not dying did not get it, but that gap in provision was caused by the manufacturer not communicating with the regulators.

Since you mention the US: how many people were denied this expensive med by their insurance companies?

My point about paying more is that is the NHS doesn't cover it, it's still available at full cost.

We'll have to agree to disagree about patients getting it. aHUS is a terrible disease. To say everyone who needs it got it is untrue. The "critically ill" got it, but what about people who weren't critically ill, but were sick?

I studied in the US for a bit, inspite of the university having a decentish setup for medication. I preferred getting treated by local doctors in my home country. Studying about the healthcare system in the US makes me sad. It shouldn't be so painful and expensive

It isn't that bad in the vast majority of cases, and in many ways it's better. 5 year cancer survivability rates for instance are top notch, ability to see specialists with little to no wait, etc.

Example: My friend's son was diagnosed with leukemia on Monday. They went to their primary care doctor Monday morning for some gum bleeding that wouldn't stop, were referred to a specialist Monday afternoon, and is already in a children's cancer hospital receiving treatment where he will be for the majority of the next 8-9 months.

I'm happy for your friend, but this is anecdotal evidence.

Statistics don't agree with your story:

http://en.wikipedia.org/wiki/List_of_countries_by_life_expec...

While I agree that there are great flaws in the US medical system, I don't think that life expectancy statistics is a good proof of them.

It gives you an idea where the health care system stands because life expectancy is low in places where there is no health care system. But life expectancy is greatly increased just by public sanitation - generally, education - and vaccinations, but could be lowered by factors that have little to do with health care.

American life expectancy is surely lowered by how Americans eat (no, I don't blame McDonalds who often gets the blame as an iconic brand). The kind of health insurance or lack of it, or how doctors work, cannot really decide how people eat. They try to impact but they cannot decide. Also, the US has a homicide rate that is substantially higher than in other developed countries. I won't bother myself by calculating how much that alone decreases life expectancy, but it's just an example of these other factors.

Your link doesn't disprove what I stated in any way.

I said "5 year cancer survivability" which relates directly to quality and availability of medical care. Poor care and difficult to access care will directly affect that.

> U.S., Japan, and France recorded the highest survival rates among 31 nations for four types of cancer http://www.webmd.com/cancer/news/20080716/cancer-survival-ra...

America's life expectancy issues (in which we are 1-3% behind the rest of the modern world, oh noes!) has to do with us being overweight. So, no, the stats you provided are completely unrelated.

And if your friend doesn't have good insurance it would mean total financial ruin

Which is a different issue than the quality of care. Again, we have some of highest (if not the highest) cancer survival rates in the world, and you're apparently more worried about if he will have to declare bankruptcy.

His son living is just slightly more important and with the ACA the chance of him having to declare bankruptcy is significantly decreased.

The US government spends more on healthcare per capita than countries with "socialised medicine". That funding is skewed to the over-65s on the Medicare system - the group where you see most cancer. That large spend on over 65s is what gives the US good cancer survival rates.

> The US government spends more on healthcare per capita than countries with "socialised medicine".

That's true of US public expenditures in total, but that's not just "the US government", it includes healthcare spending by non-federal government entities, as well.

Or go on Medicaid? Or receive an ACA benefit that pays for insurance?

I don't know exactly what's going on, but I'm on a mediocre Obamacare plan that costs less than the author's plan. Even though it's in the most expensive drug tier, as far as I can tell Abilify would cost me $70 a month.

> I arrived in America just as Obamacare was rolling out. Since I couldn’t meet the deadline for insurance

Well it's been rolled out for a while now. Can't he switch now?

Apparently it varies based on the plan:

http://www.phrma.org/sites/default/files/pdf/exchanges-menta...

(In some bronze plans, up to $4300 of deductible applies to medications)

The article is not very careful. It goes from saying the drug is cheaper over in Queens to the "$720 a month my medication costs in America".

> Well it's been rolled out for a while now. Can't he switch now?

Not sure if the annual open enrollment periods are nationally synchronized or differ per state, but Covered California (California ACA Exchange) currently has an open enrollment period (ending 2/15.)

I would like to share my very positive experience with private Mexican health care.

A family member got in a kayaking accident. They were in severe pain (mostly from their chest area).

We had a concierge doctor drive out to our remote hotel. He did a basic checkup, gave us some pain meds, and called ahead to the nearest private hospital. $100

We drove about an hour and a half to the hospital. A doctor was waiting at the door for us. She was with us for the whole two hours we were there. We got 2 x-rays and an ultrasound. We also got more pain meds at the pharmacy. $150

It was the best medical service I've ever experienced in my life. I would be very happy if U.S. medical care was the same as Mexican medical care.

I realize I never checked up on this: how is the Mexican private medical system regulated? I remember we did very little paperwork, and it seemed like there was much less red tape than at US hospitals.

"It was the best medical service I've ever experienced in my life. I would be very happy if U.S. medical care was the same as Mexican medical care."

What you are actually saying is you would be very happy if U.S. medical care was the same as Mexican medical care for tourists carrying US dollars.

The real question is, what is the standard of care for a 50th percentile Mexican national after their own kayaking accident? What percent of their annual discretionary spending does this incident cost them? And is the existing system improving, stable, or on the verge of collapse?

Well, yeah. I said "private", didn't I? And it's not like the good hospitals in Mexico rely on the bad hospitals to exist.

One would expect the average standard of care to be lower because Mexico is much poorer than the U.S.. If you took whatever the good Mexican hospitals are doing and brought it to the U.S., it would presumably be roughly as high-quality and inexpensive.

Is the author actually right to live and work in the US, and only fly back to Britain for getting medication subsidised by British taxpayers? And is the fact that he can do this just an indication of US healthcare being screwed?

The post doesn't tell too much about facts and I don't know the British rules for eligibility to NHS, but I think it's possible he could be committing fraud. If he were doing the same with my country's national system, it certainly would be fraud (though it would probably not be possible in the first place, because we have a Big Brother that knows more than the British one).

The rules aren't written in a particularly clear way, but in general the idea is that NHS eligibility is residence-based, and people who aren't ordinarily resident are entitled to urgent treatment only. Flying back just to pick up prescriptions is definitely against the spirit of the rules.

Enforcement -- or even understanding -- of the rules on a local level seems spotty. I've helped overseas visitors find their way through the NHS. Some GPs and out of hours services have treated them like a local patient and when asked about payment had no idea, whilst one GP pulled their wallet out in the consulting room and demanded cash there and then. Hospitals are supposed to be more consistent, but I haven't any experience there.

Well the fact that drugs are twice as expensive (or more) in the US* and the fact that the US accounts for a huge chunk of government funding into the relevant sciences are part of the reason why drugs are so cheap overseas. British taxpayers buying drugs in Britain are effectively getting a subsidy from US taxpayers even though they don't pay into the pot, so this all seems like a stroke of cosmic justice where I'm standing. Of course, I doubt the British tax authorities care much about what I think.

* Why? Remember how bargaining works: the biggest customer gets the best deal. First imagine Kaiser, Wellpoint, and Aetna sitting down at the bargaining table. Now imagine Canada sitting down at the table. Now imagine the European Union sitting down at the table. But at least our insurance companies are more efficient due to competition, right? Spoiler: not even close, and that's before you take into account the costs they offload onto the rest of the system in the form of incompatible claims policies, paperwork, and exploitation of information asymmetry against consumers.

The European Union is not bargaining as a single buyer.

There are considerable differences between the health insurance systems of EU member countries, and each of them buys their medication differently. In fact, it looks to me that the US is closer to being a one buyer than the European Union, which would first need to do a lot of harmonizing and more or less set up a United States of Europe.

Kaiser, Wellpoint and Aetna each have as many health plan members as a medium-sized European country. That's not the problem.

As far as I understand, the problem is the unavailability of generic replacement medicines in the US, clearly for IPR reasons.

> Well the fact that drugs are twice as expensive (or more) in the US

You have to compare like for like though - looking at the cost to the end user is not relevant, you'd have to look at the cost to the NHS versus the cost to US health insurance companies.

For the NHS, this is publicly available data[1] and we can see that a course of once-daily apiprazole (the drug described in the article) costs the equivalent of $150-300 per patient per month, depending on formulation. Is such data (of actual cost) available for the US?

Also, regarding biomedical research - the British taxpayer funds this as well. Anyway, apiprazole was developed in Japan. It's not all US-centric.

[1] http://www.hscic.gov.uk/searchcatalogue?productid=14494

I don't know figures, but I imagine Kaiser represents more than 35 million people (the approx population of Canada). Shouldn't they be able to negotiate the same price?

Bingo! The largest US private insurer (United) cover 40M lives in the US. They pay higher prices than nearly all European countries (even the ones with smaller populations).

Drugs aren't cheaper in places like the UK because the gov't negotiates lower prices. Drugs are cheaper because the gov't mandates lower prices. People shouldn't confuse the two.

So is the UK not concerned about mandating lower prices and squeezing the R&D funnel for new drugs... because Americans are making up the difference?

Drug companies spend more on marketing drugs to doctors and consumers than they do on R&D.

In the UK, marketing drugs is illegal and therefore they don't need to go to that expense. All they have to do is convince an NHS board and then it's on the list of approved prescribed drugs.

Do you have a favorite citation for that factoid?

Some similar claims I have looked at have used the "Selling, General, Administrative" off of an income statement as the marketing expense, but that category includes salaries and buildings and lots of other things, not just marketing expenses.

Just a quick googling:

http://www.washingtonpost.com/blogs/wonkblog/wp/2015/02/11/b...

http://www.bbc.co.uk/news/business-28212223

Reading the BBC article reminded me of all the fines also. People are paying extra because drug companies push off-label uses on consumers and then get fined for it. It's not like the company really pays, they just up their prices a bit and push it onto the consumer. That sort of off-label usage doesn't happen in the UK so much, because doctors don't have any incentive to prescribe anything other than the NHS approved drug for a condition.

So here's the financial segment of Johnson and Johnson's 2013 annual report:

http://2013annualreport.jnj.com/sites/2013annualreport.jnj.c...

(linked from here: http://2013annualreport.jnj.com/financials )

In one place, it says this:

Advertising

Costs associated with advertising are expensed in the year incurred and are included in selling, marketing and administrative expenses. Advertising expenses worldwide, which comprised television, radio, print media and Internet advertising, were $2.5 billion, $2.3 billion and $2.6 billion in 2013, 2012 and 2011, respectively.

That advertising number most likely does not include money they spend directly marketing to doctors and so on. So the Global Data report referenced by the BBC implies they are spending $15 billion directly marketing to doctors and other medical people/organizations.

The next step would be to figure out what they are spending paying employees (with 120,000 of them, quite a lot), but I can't find good numbers on that.

"Marketing drugs to doctors" is not exactly the same as "total sales and marketing budget". I don't even know if "cost of sales" includes the cost of regulatory approvals in various countries.

Also note that there is not necessarily anything bad about off-label use of medicines.

Medicines could be off-label simply for the reason that the regulator - out of pressure from the public health insurer, or more bluntly just the Department of Treasury in the country - does not approve using a medicine for some purpose, even though it is known to be efficient and without bad side effects.

In fact, in some cases patients are complaining bitterly because they cannot get the medicine that their doctor knows would help them, because their regulators do not approve off-label use.

Off-label use is scary because there is often no evidence base. You have doctors prescribing meds because they "know it works".

When we look at popular off-label meds and the eventual evidence we often find that they're not very useful, or even actively harmful.

A medicine can also be off-label simply because of its price - there is evidence base, but the regulator says that the health care system shouldn't pay this much for ailing this medical condition.

Of course that keeps the prices lower. That's the purpose. It also keeps some medication unavailable for some patients. I don't think it's a huge problem, but it's there.

In the UK, marketing drugs is illegal

Whoa there. Says who? The largest part of marketing drugs is paying sales reps to visit doctors. Are you saying that's banned in the UK? From what I've seen that's not true.

If you're saying DTC (direct to consumer) marketing is banned, then I agree (for prescription drugs). DTC is not all there is to drug marketing.

Also, you're fooling yourself if you think doctors have the time to research new drugs. That's why there are reps. They provide educational information, data from new trials, etc, etc.

Individual doctors do not make purchasing decisions. They don't have pharma reps turn up at GP clinics handing out free lunches in exchange for prescriptions. The NHS decides what drugs are allowed to be prescribed and doctors are limited to that list. It puts a huge crimp in any marketing.

I'd have to disagree.

Individual doctors don't make purchasing decisions, but they do make prescribing decisions which drive sales. They are the key stakeholder when it comes to pharmaceutical marketing. They may not be buying lunches in the UK, but sale reps are getting time with doctors and talking up their products.

BTW, is there a law in UK (or US) about using generic products? Over here, a doctor prescribes something, but pharmacies have the responsibility to offer cheapest product, typically a generic replacement when available, unless the doctor justifies a specific brand with specific medical reasons (which are rather hard to come by).

From a moral standpoint, I'd say this person is in the right - they've paid in to the NHS at some point earlier, or their parents had - to cover this sort of thing. Legally, I don't know enough about the NHS to say for sure.

From a moral standpoint in the USA the international megacorp will say "Oh, your health is worth anything to you? Hmm. Howabout everything you got minus $1" Like a semi-kind mugger. Its not a free market. Pay up or die, sucka!

In the UK the .gov will fight for you instead of the corporation so you pay a fair price. The UK gov is under no life and death pressure to pay up or die, and they have regulators who are educated and understand the market. It is a much free-er market than the USA market.

Arguably what he's coughing up in hotel fees and surcharges and taxes and hotel prop tax is Exactly how a visitor should be paying for medical care, so on an individual level he's moral and ethical.

Not getting screwed over when someone else gets screwed over does not imply some kind of survivors guilt is ethical.

It is a much free-er market than the USA market

Umm...no. The UK is a single payer system, that is, the government holds a monopoly over healthcare purchasing (or nearly all healthcare delivered).

If a really skilled doctor wanted to charge a higher rate for their services, tough, he/she would get the same as every other doc.

It's not a "freer" system.

That's an interchangeable commodity service and the discussion was about commodity medication. A free market requires a meeting of equals and we have a journalism grad vs the combined minds of PHD chemists and MBAs... sounds fair and free. It also requires participants in the negotiations to not be under duress, like, say, death without medication. Obviously the UK market is free-er than the US market by a considerable amount.

This is false. The UK has a national health service and private provision running side by side. Any doctor is free to work outside the NHS to provide private practice.

Maybe you're thinking of Canada?

I'm talking about the UK, that's why I put "nearly all healthcare delivered".

My argument is that calling the UK system more "free" when a very large percentage of all healthcare delivered is purchased by a single payer is inaccurate.

>From a moral standpoint...

From a moral standpoint it is immoral to force person A to pay for person B's misfortune. You and I call that stealing.

>they have regulators who are educated and understand the market

It is impossible to "understand the market" without market prices.

>It is a much free-er market than the USA market

The USA is not a free market. Anyone who claims otherwise is lying.

>> "they've paid in to the NHS at some point earlier, or their parents had"

Yeh, to cover them for the time they were paying. If you're no longer paying your taxes or seeking employment or unable to work due disability the money you paid in the past should't cover you morally.

Edit: There's no doubt the price the writer has to pay in the US is a disgrace and if they couldn't afford it then I think using the NHS is a good temporary solution but the fact that he could afford it but uses that money for a holiday instead is very immoral imo.

I know, we should take this person their medicine away, so they can have a wretched and miserable life!

Healthcare should not be something you can or cannot afford, we should all be able to access healthcare. It is just common sense.

Huh? I didn't say that at all. This person CAN afford their medicine. Instead they spend that money on a trip to the UK to see family but also gets their medicine. Medicine they didn't contribute taxes to pay for.

> Yeh, to cover them for the time they were paying

So... what if someone is no longer paying anything in, living there, but is a huge net drain? Should people only be covered while they're able to pay premiums/taxes?

He doesn't really indicate that he can afford it. min $500/month for 6 months is $3k. Trip to UK, staying with family, is far less than $3k.

Not to mention that most young ex-pats do eventually come back to the country and contribute. I'd rather they came back alive and well, even if it is me footing the bill for them in the meantime.

That's one of the big missing parts of the US healthcare debate. It's not just about immediate cost, it's about potential future tax revenue and economic value that you're losing when you let people die before their time.

EDIT: strikeout [In my opinion it's fraud.] /strikeout

http://www.nhs.uk/chq/pages/1086.aspx?categoryid=68

http://www.nhs.uk/chq/pages/1087.aspx?categoryid=68&subcateg...

But the rules are a bit complicated so maybe it's fine.

It's weird that he gets a six month drop of medications each time -- that is very unusual behaviour from the prescribing doctor and the prescription-filling pharmacist.

It's not fraud. Such charges for overseas visitors only apply for hospital treatment - prescriptions are explicitly excluded, and are subject to the statutory price that everyone pays (unless they are exempt and get their medicine for free), see: https://www.gov.uk/government/uploads/system/uploads/attachm...

Thank you for finding that - a surprisingly readable source. Para 23+24 spell it out quite clearly, as does "Powers to charge those not ‘ordinarily resident’ were introduced through the NHS (Amendment) Act 1949, but were not enacted through regulations until 1982. These charges were and remain only applicable to hospital treatment."

Really doesn't seem that complicated at all.

This article doesn't really make a compelling case. Facts would have been nice.(I would spend x dollars for the drug I need in the US which is more than I would spend flying to the UK and getting 6 months worth at a time. Or something like the drug I need is in short supply in the US so I go to where it's plentiful in the UK) What is so screwed about it in the authors eyes?

Vox did something a while back that's more along those lines.[1]

The cost of care in the US is much higher than in other countries. There are a bunch of reasons for this, and everyone has their preferred scapegoats and solutions, but the end result is that healthcare prices in the US are astronomically higher than in other countries. So it's often cheaper to just go somewhere else and buy the care you need there at a fraction of the cost.

[1] http://www.vox.com/cards/health-prices/america-is-getting-go...

>> "What is so screwed about it in the authors eyes?"

Maybe I missed something but it seems blantantly obvious. In the US he has to pay for health insurance PLUS $720 a month for drugs he needs. In the UK this is provided at almost no cost to the patient through taxes. No health insurance and no huge drug cost.

So maybe a more fair comparison would be to compare total costs in the US (insurance premium and drug cost) to the total costs in the UK (higher taxes and small Rx cost)?

Of course the end result would all depend on your salary level.

So, if I understand well, people with mental disorders cannot access to medication if they cannot pay for it?

People with mental disorders use to have trouble to find a proper job if they cannot threat their issue with medication. So maybe they just end up in jail or living as homeless?

Is there a way to find out how much drugs cost in other countries? I take a biologic that runs me $300/mo after insurance.

For England: http://www.ppa.org.uk/ppa/edt_intro.htm

why not Mexico? it's a big destination for Health Care tourists, it's cheaper than Canada or Europe and you would only need to go to a doctor once to get a prescription and re-use that prescription. Also you would get to spend a few days in places like the mayan riviera.

He mentions both Canada and Mexico in the article.

> Otsuka’s patent on Abilify will expire in April, costing it an estimated $65 billion over the next four years.

That statement is false, and demonstrated clearly in the author's source:

> Drug makers face another patent cliff in which the industry will lose roughly $65 billion in revenue through the end of 2019, according to a research firm’s report.

...

> GlobalData estimates Otsuka will lose $6.2 billion in annual sales due to competition from generics by 2019.

Edit:

Continuing on this theme, according to Google finance Otsuka's net profit margin is 10%, which I think is on the higher end of reasonable. Now, I'm not saying the price they charge in the US is fair (for some definition of fair), but one does need to consider how much the ridiculous American drug prices are subsidizing the $24/year NHS prescriptions. A government can regulate the price of drugs, but can't force the companies to sell them in the first place. Not directly, anyway.

> Now, I'm not saying the price they charge in the US is fair (for some definition of fair), but one does need to consider how much the ridiculous American drug prices are subsidizing the $24/year NHS prescriptions. A government can regulate the price of drugs, but can't force the companies to sell them in the first place. Not directly, anyway.

Remember that the cost to the NHS is far more than $24 - which refers to the £8 prescription fee paid in the UK, twice per year. It's actually £220.41 per patient per month for the NHS - about $335. So whilst it's still somewhat more expensive in the US, it's not much more expensive - and well within the bounds of shrewd negotiating (which I'd imagine insurers would normally do).

[1] - http://www.awp.nhs.uk/handlers/downloads.ashx?id=9572

I figured it was costing the NHS much more than that, but I did not know they were covering so much. Thanks for the information.

The issue of what insurers actually pay versus what the uninsured are expected to pay is a tangential hot button issue for me, especially since I started treatment for my sleep disorders.

Any prescription you get on the NHS costs the same amount (and there are many exemptions, for example they're free if you're a child, unemployed, retired, a cancer patient etc). There's always some debate about certain very expensive drugs (generally for cancer) and whether the NHS should pay.

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