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PaperclipPerfector  1mo ago (text post)   25859 thread views

Culture War Roundup for the week of March 25, 2024

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Conversation has been slow here. I feel like the standards have increased to the point where people are afraid to post (except of course for bad faith posters who don't care).

So, let me try a post that's more of a conversation starter and less of a PhD thesis.

According to Bernie Sanders, it costs about $5 to make a monthly dose of Ozempic, the blockbuster-weight loss drug. Americans pay about $1000/month. Canadians pay $155. Germans pay $59.

The stock of the company which makes the drug, Novo Nordisk, has doubled since the beginning of 2023. (I considered buying in 2022 but didn't because I thought I was already too late 💀) It now has a market cap of nearly $600 billion, making it the most valuable company in Europe.

I assume that if companies were forced to charge the same price in U.S. as they do in Europe, the global pharma industry would become insolvent.

So why is the United States paying for > 100% of global pharma research? And how can we fix the glitch?

Conversation has been slow here. I feel like the standards have increased to the point where people are afraid to post (except of course for bad faith posters who don't care).

Well 1) I'd rather have a slower forum with higher quality posts than a faster forum with lower quality posts, and 2) I don't think the standards are actually that high. I've never seen a top level post get modded for effort as long as it had ~2 paragraphs of original text that wasn't copy-pasted from the linked article. Maybe even one paragraph would be fine.

I think discussion has been slow simply because the news itself has been slow. The American culture war has entered its trench warfare phase, and it's not nearly as fresh and exciting as it was in the 2015-2019 period - the lines have been drawn, wokeism isn't going anywhere, much like the Ukrainian situation the territory that has been won is very unlikely to be ceded. It's hard to come up with a hot new take at this point. Instead we'll simply witness the long slow grind of things continuing on as they have for the past decade.

There was a lot of AI discussion around the time of the site transition, but AI news has also been rather slow for the past year, compared to the frenzy of activity that happened in late 2022 and early 2023.

I'm always happy to read high quality evergreen philosophical/theoretical essays, but these sorts of posts have understandably always been less popular and fewer in number than current events-y type stuff.

I think some people here are so stuck in a doomer mindset that their minds refuse to accept wins for their own side. It's like they are committed to a world-view in which they are eternally oppressed. Much like the wokes are.

From where I sit, wokism looks much less dominant than it did 4 or so years ago.

For example, Musk buying Twitter has been a huge win for anti-wokes. With that act, he pulled a bunch of previously taboo and semi-taboo discussions right into the mainstream. If he had instead tried to start a Twitter competitor, network effects would probably have meant that it would never take off. But because he bought Twitter, network effects are instead working in his favor, making it so that even many of the people who dislike the changes he has made still stay on the site.

Another interesting recent event is the civil war inside the Democratic coalition over the issue of Israel. That divide has been there for a long time, of course, but I do not recall it ever having been as intense as it is now.

Yet another interesting event is the increasing European shift against immigration from MENA countries. Reddit's /r/europe is practically indistinguishable from here now when it comes to stances on MENA immigration, with the one exception that they do not usually discuss genetics quite as much.

I think it's not so much that there aren't interesting things happening, it might be more that this is a pretty small community with not a lot of fresh blood and a lot of fixation on a small set of topics (HBD, trans, Jews, etc...), and so if you've been here for a while, you've already seen the same 20 or so people rehash the same 5 or so topics over and over again in pretty much the same ways. People's takes are often good, but it gets repetitive.

I mean the rebuttal I expect to see is to ask if those represent progress or a rebound to further-left than it was before.

Is being allowed to discuss freer-but-not-freely on some subreddits and X/twitter a win? Certainly it isn't the wild west I remember.

Your other examples are a change in vibes in some places, which I think is important but is far from an actual realization of a win.

I am not quite blackpilled, but I've not seen many wins for the Rand Paul clan of the red tribe and I don't see a path to get there.

I think discussion has been slow simply because the news itself has been slow. The American culture war has entered its trench warfare phase,

This has been my feeling as well.

We're literally facing down a repeat of the 2020 election, and so the battle lines are already very well defined, with maybe some defections one could note here and there.

Trump is a 'known' quantity. Virtually nothing he can say should shock anyone. The left still sees him as the fascist boogeyman. Anyone who could be convinced of that is already convinced.

There's an active tug-of-war over the trans issue, especially as it pertains to kids. Issues like same-sex marriage, gun control, and abortion have taken a backseat to this almost across the board.

Honestly it seems like most people who are active culture war participants know exactly what their goals are, have a decent idea of who their allies are, and are now just probing around for effective ways to advance their cause and break the 'stalemate' that has somewhat emerged.

Israel-Palestine is still a hot fight where it's not clear where things will fall, but against the backdrop of world events right now, seems like small potatoes?

All that said, expect another flurry of activity in the immediate leadup and aftermath of the election because no matter who wins the other side is being heavily primed to simply not accept it as legitimate.

To fix the overall problem requires burning the whole system to the ground. But to fix this particular issue -- European governments putting price controls on drugs -- it "only" requires a trade war. Allowing re-importation is a start, but those countries would ban re-export. So by law, refuse to allow US drug companies to sell in foreign countries (or at least some selected set of wealthy foreign countries) for less than they sell here. Refuse to allow non-US drug companies to sell here for more than they sell in other countries. And if the Europeans respond by abrogating patent rights, go nuclear (figuratively) on them -- remove them from normal trade relations, start abrogating THEIR patent rights, etc.

Agree it's what it would require.

It'd be interesting because I think the result would actually be to bring America to EU style price controls. I imagine the intelligensia is more in favour of the socialist price controlled system than the US one. The big loser would be pharma RnD (and stock prices). It is crazy the extent to which the US subsidises pharma RnD for the rest of the world. I saw a graph showing pharma investment returns slowly projecting down over time, reaching 0% around 2020 then going negative. I think this is based off a low-hanging-fruit theory and the data supports it.

On Ozempic I am rather bearish. There are very few buttons in the body which can be pushed for gain without many side effects. It sort of violates a no-free-lunch theorem (which I do believe in) regarding pharmacology. I think over time many people will decide the side effects aren't worth the benefits for them and the positive effects are actually quite modest when viewed in their totality.

I have actually seen some things which violate this no-free-lunch recently. Follistatin gene therapies appear to boost muscle mass, QoL and maybe longevity (30% boost in mice). This counts for me; even though it's not a drug it's a single protein and it's impressive you can get so many positives boosting one thing. There will likely be others along this line, but I don't imagine too many being available.

On Ozempic I am rather bearish. There are very few buttons in the body which can be pushed for gain without many side effects. It sort of violates a no-free-lunch theorem (which I do believe in) regarding pharmacology.

That seems too strong. A no-free-lunch theorem for pharmacology might make sense for things that we expect to have been already optimized by evolution. Maintaining a good weight in an environment of caloric abundance and whatever else is causing the obesity crisis (corn syrup? microplastics? the chemicals they put in the water to turn the frogs gay?) is probably not one of those things.

It's more that there aren't buttons you can push in without affecting everything else. The signalling systems aren't anything like a computer where there is one variable for each discrete thing. If a molecule has one major effect you can ride off and only a few other minor effects you are very lucky. Often molecules have different major effects in different parts of the body because their release is isolated. But they usually also just regulate multiple important things simultaneously, so with GLP-1's you see a lot of GI side effects. You're not pushing a button that decreases appetite, you're pushing a button that greatly upsets the entire downstream digestive process.

And if the Europeans respond by abrogating patent rights, go nuclear (figuratively) on them -- remove them from normal trade relations, start abrogating THEIR patent rights, etc.

It would be interesting to see what the effects of this kind of patent war would be. Europe has a trade surplus with the US (iirc), but the outcome in this case would depend a great deal on whether the US’ IP is more valuable to the American economy than the EU’s IP is to its. Certain kinds of niche skilled manufacturing is harder to replicate domestically even if you don’t have to worry about IP than, say, copy-pasting Disney movies is.

How would allowing re-importation help? Edit: who is downvoting me just for asking a question? Can we not turn this into Reddit?

It's hard to do price discrimination among countries when there's re-importation.

My complaint is the other way round: it's impossible to get Ozempic over here, because the demand in America for people who want to drop a few pounds without effort is so high, and from what you're saying American prices are so profitable, all the output is going to the US. Sucks if you're a European diabetic, but at least some neurotic woman who does gig-economy clickbait pieces can write about how she dropped two dress sizes and now looks like she spent a month in Bergen-Belsen after trying the hit new drug (I remember the same craze for Prozac in the late 80s/early 90s as a wonder drug that would solve all mental health problems, and the same kind of pieces by lassies hopping on the "it's the latest fad" bandwagon to write it up and sell it as a freelancer).

I have a family member with diabetes who recently switched insurance, and the new insurance had her doctor jump through a lot of hoops to demonstrate the drug was actually being used as medically indicated. It took a while for the back and forth to finish so she could get the drug. So it's not just across the pond that it's causing issues.

I'd like to take the low effort opportunity of warning anyone reading this NOT to take Ozempic or any other GLP-1 agonists for shits and giggles. (That is, take it to loose weight).

Curious about your objections. I used a low dosage to drop my BMI from 23 to 21, with minimal side effects. (Using sketchy shit imported from some UGL in China.)

I've been considering it. It seems like it's been in the field for a while with what I view as reasonable and expected side effects. Any more detail on your position?

Taking the artificial hormone will downregulate your own production. When you stop the drug you get whacked.

Why not? Assuming you mean Wegovy instead of Ozempic as that's the Semaglutide product specifically designed for this.

The entire US medical system is fucked. Higher drug costs are a substantial input cost, but another huge one is the AMA.

The steps for fixing US healthcare are actually pretty simple:

  1. Smash the AMA cartel by allowing unlimited immigration of doctors trained in Canada, UK, Australia, NZ and Ireland without any licensing requirements, re-doing residency etc. Allow doctors from other Northern European (not southern) countries if they pass a tough English written and oral exam that requires fluency. This will lower US doctors’ salaries (currently 300% or more of what they are in Europe) by half, to a more reasonable rate where surgeons are respectable PMC but not making a million dollars a year solely because the AMA lobbies to restrict residency places. Doctors should be paid $120-300k a year at the cap, with the high figure for the most elite surgeons in tough specialties. Why is the American middle class paying for anesthesiologists to make $700k a year when their equivalents in European countries that are almost as rich are paid like $150k? There are almost a million doctors in America, this overpaying adds up.

  2. Handle drug pricing centrally. Insurers pay a price negotiated by a trade association chartered for that purpose and which represents all US insurers (including the state for the VA etc), exempt from the usual rules around cartels. The trade association negotiates as a bloc and can therefore refuse to accept pricing that is any more than a basket of comparable countries (eg rest of Anglosphere) + 20% (at most). Pharma companies will essentially be forced to comply, since there is no other major wealthy market that would possibly pay more than the US. The reason manufacturers can charge so much is that (much as with doctor pay) so much of the cost is offloaded onto third parties (eg employers for most health insurance) in a way that causes huge economic drag but which is often not immediately visible.

Why is the American middle class paying for anesthesiologists to make $700k a year when their equivalents in European countries that are almost as rich are paid like $150k?

Because they graduate with $300k+ in school debt? Doctor salaries are a part of artificially constrained supply, yes, but becoming a doctor in the US requires you take on enormous financial risk.

A decade on from completing undergrad, folks in medical-adjacent fields are still underwater on pretty high interest student loans. Long term they're massively overpaid, but the people who somehow don't pass exams or don't get into medical school are fucked.

  1. $300k in debt isn't that huge when the median physician pay is $350k - at 6% interest and 40% taxes it drops your take-home from $210k to $192k.

  2. The much larger cost for doctors is the opportunity cost of going to medical school and one or more residencies. The median doctor graduates from medical school at age 30 and then still has years of residency(ies) to go. Making peanuts for a decade+ after college for the types of driven/conscientious/smart people who go to medical school is an enormous opportunity cost, dwarfing the literal debt (e.g. discount rate of 5%, forgone earnings of $100k per year, for 10 years = $1.26m at the end.

  3. It's not really an "enormous financial risk". The 6-year graduation rate from medical school is 96%, and virtually all of them find a residency. That is, an admission offer from a medical school is as close to a "golden ticket" as you can get in life. The only risk is whatever time you invest in getting in to medical school beyond undergrad - a risk that, for most people, is 0-4 years.

  4. Finally, re people being underwater. This can happen, but it usually stems from specific decisions - i.e. spending many years trying to get into medical school, switching specialties late in the game, refusing to give up on a very selective specialty, choosing to do academic medicine in a high cost-of-living area, etc.

Surely a $300k debt isn't very high for a doctor who can easily bring in that much annually?

There are many, many fucked up things about the American medical system, as has been pointed out by others in this thread, but the silver (well, maybe aluminum) lining here is that the massive debt incurred by a medical education does incentivize graduates to monetize their skills, instead of just treating the MD as a vanity/MRS degree.

Unfortunately, as someone pointed out downthread, "monetizing their skills" these days increasingly means going into tech or pharma, rather than actually, y'know, treating patients.

Unfortunately, as someone pointed out downthread, "monetizing their skills" these days increasingly means going into tech or pharma, rather than actually, y'know, treating patients.

This is a really important point in my mind, you can argue that doctors aren't the smartest people in the world but by the time you get into late training you've demonstrated that you are among the hardest working (24-36 hour shifts, 80+ hour weeks for some specialties) and best at stupid box checking.

Pretty much everything you've said about the doctor side of things is wrong and much of it borders on malpractice. Frustratingly, I've corrected you on some of the clear matters of fact in the past and you've refused to update, so I guess this is more for the benefit of others who may be looking.

-Physician salaries are not responsible for high healthcare costs. They are a low percentage of healthcare costs. 8.6%. Half physician salaries (which nobody is suggesting and would collapse the system anyway) and you would barely make a dent in cost. Data: Stanford (SIEPR).

-Anesthesiologists do not make 700K a year. The average salary of a gas attending in the northeast is 380k. Data: MGMA survey (granted the one I have is a few years out of date).

--Can a gas attending make that much? Probably not in a desirable geographic area but if they want to work 2x full time or take a lot of weekend/holiday call they can get close. Maybe in L.A. if they do celebrity work, pain management or something like that? The ones I know who crack that level make the money off of owning something, patents, or something else of that nature, not working.

--On a more editorial note, why does gas make $$$? Gas is like being a pilot, most of the time it doesn't look like you are doing something outside of take off or landing but you get paid for the hopefully rare emergencies. Additionally procedural work reimburses well in the U.S. for historical reasons. Fix that problem if you want.

-The average physician salary is 350,000 in 2023. Not far off from Cim's range. Data: 2023 Mescape reports.

-Over half of doctors are in the "low paying" specialties where it's not uncommon for your salary to be under 200k (IM, FM, Peds, Psych). Depending on where you work and what you do you may be able to go over 500k but that's pretty much 95% percentile and involves shady cash only practice or working exclusively night shifts in Arkansas.

-No specialty makes over 800k without it being "fair." What do I mean by that? To make that much you are doing something like cash practice plastic surgery for wealthy people in LA, own and run a business (unrelated or related), have patents/high level consulting work, work 350 days a year (yeah people do do this), or are a neurosurgeon (egregiously long training, work hours, stress, and competency requirements).

-Doctors. Do. Not. Make. Millions. A. Year.

-The federal government is in charge of residency spots. However, state governments and private companies can and do make their own residency spots. We've had a bunch of recent scandals about this as the residents have been critically undereducated and frequently unhireable outside the system that trained them (specifically: HCA in Florida). Turns out medical education is complicated and you cannot just increase spots this is most true in surgical specialities which have small number of highly trained doctors, but also represent most of the specialties making the most money.

-The AMA is not a cartel. Most physicians hate the AMA and have for decades, as they've been lobbying for depressed physician salaries in the form of increased midlevel involvement (which is to the benefit of end career physicians at the expense of everyone else).

Their's a lot more to say here on things like "docs in Europe get paid less because their training is shorter and they don't have hundreds of thousands of dollars in debt" or "training quality if much higher outside the U.S., even in wealthy western countries" but this has gone on long enough.

Cim you have to reevaluate your level of knowledge on this topic because (among other things) you said "doctors should be paid $120-300k a year at the cap, with the high figure for the most elite surgeons in tough specialties" is very close to the system we already got.

Additionally doctor's wages in real terms have been decreasing for over 30 years while costs (including med school tuition) have been skyrocketing. It's driving a lot of people you want in medicine out of medicine. Just 68% of medical school graduates at Stanford went on to residency (with the majority of the rest going into tech or business instead). And that stat was in 2011, can't imagine how much worse it is now.

docs in Europe get paid less because their training is shorter

This is not true. Doctors in the UK have comparable training length to doctors in the US.

they don't have hundreds of thousands of dollars in debt

The amount of debt US doctors are saddled with has nothing to do with how much they should be paid in a free market. Expensive medical school is a whole another problem entirely and the way to fix it is not by increasing doctor wages, it's by controlling costs, including subsidising doctor training (as the UK does).

Most European countries have 6 years of combined med school and undergrad (see: Germany) vs. 4 years of undergrad + 4 years of med school in the U.S. these days 1-2 gap years is also common, with 3-5 being uncommon but not rare (for things like PHD, MPH, MBA).

The amount of debt is important because it is relevant to the level of pushback you get for changes, and the fact that if you cut salaries by half and allow limitless importing of doctors then you will have pretty much zero people applying to med school in the U.S. overnight (and that would be the rational response). People still interested will do PA/NP school instead.

Do also keep in mind the quality difference which is real but is frequently not acknowledged.

vs. 4 years of undergrad + 4 years of med school in the U.S.

The 4 years of undergrad could be in a variety of subjects and aren’t really comparable to the first few years of training in countries where med school begins at 18.

We have 6 years of combined med school and undergrad here in the UK (3 years undergrad + 3 years clinical training), but that doesn't mean that when you're done with those 6 years you can start working as a doctor. After those 6 years you have to do another 2 years "foundation training" which brings it up to 8 years. Even than that's not enough, becuase after those 8 years you have to do mandatory "specialist training" which is 3 years for GPs and 5-8 years if you want to do a speciality (and are good enough to get in).

At a minimum to become a fully qualified and independent doctor it takes 11 years and at the most it takes 16 years. That's not dissimilar to the US.

Do keep in mind that the UK does its own thing and doesn't map well to the process in the U.S. (or other western countries).

At an extreme example if you want to be an electrophysiologist in the U.S. you'll be doing a minimum of 16-18 years of training after high school, with many looking at 22 years. During 8 of those years you will be working 60-80 hours a week with some programs closer to 100 hours a week. Even if the years are the same you are doing twice* as much work during each year (is that sane? No. But it is).

All the while you are dealing with an average student loan debt of around 250k, with that number not counting interest or all the rich kids (who are admittedly a fair chunk) with zero debt.

If you want anybody in the U.S. at all to do that you need to offer them a pretty big carrot. And you do want them to do that - we've seen the outcome disparity between U.S. MDs and other populations (most notably of late, midlevels).

AND.

Lower quality doctors (or doctor replacement) increase overall healthcare cost due to increased unnecessary testing. Very well documented at this point.

You need to change the regulatory and malpractice environment first if you want any of this to work, which nobody seems to be interested in doing, and if you did things would cost less without coming for MD salaries at all.

*these days 1.5 times the work is much more common and realistic but that's still a fuck huge disparity.

I think you’re discussing a few separate issues:

  1. “Debt loads are too high to pay less.” Agree in part, the solution is to subsidize medical school costs such that medical students pay no more than the average STEM degree haver who goes on to a well-but-not-exceptionally-highly paid job.

  2. “No talent will go into the profession”. Plenty of smart people are going to continue to want to be doctors for a salary of $120-300k a year. Are you going to get the 99.9th percentile people who want a guaranteed path to being moderately rich? No, but the question here is ‘do we need them?’. Is it really so bad if doctors are 95th percentile people instead of 99th percentile? I don’t think so, I think there are plenty of moderately smart people happy to do this job for $200k a year if trained. And healing people is high status vs. sales or finance or other professions people consider a little dirty. That boosts demand to be a doctor too, in the same way that many smart people want to be journalists or diplomats even though they get paid badly.

  3. “Residency sucks”. Again, completely agreed. Doctors shouldn’t have to work 100 hour weeks during training. That’s an issue for hospitals and people who manage residency programs to solve, ideally with the help of residents. On the other hand, a lot of doctors have a ladder-pulling mentality and think that because they went through it, the kids of today have to do so too.

  4. “Midlevels are taking our jerbs”. Again, I agree that this is a problem and I sympathize with doctors who see poorly-trained midlevels hurt patients and waste time and money. But they don’t seem to understand that mid levels are a consequence of desperation on the part of other elements of the healthcare system (ie the hospital managers who have to try and balance budgets) because doctors are paid so much money. In other systems, doctors might be paid 60-80% more than nurses. In the US (excluding rare examples of temp/travel nurses etc), specialist doctors and surgeons often make 300% more than baseline unspecialized nurses; this naturally leads to the creation and proliferation of midlevel roles. If doctor pay was halved and there were many more doctors in the US, hospitals would obviously hire them instead of CRNAs and specialized NPs etc.

Actually, if the AMA really cared about solving the midlevel problem, they’d provide a simplified pathway for CRNAs and NPs to become physicians, with guaranteed residency at their current hospital (if they pass whatever assessment required) and negotiate some kind of federal support for any dependants during the study process.

Right now it takes like 10-12 years for a competent CRNA to become an anesthesiologist, even if they can already do much of the job. Surely you can see how ridiculous it is - do you REALLY think it takes 10+ years to teach a good CRNA to do an anesthesiologist’s job?

On 1), don’t multiple other countries subsidize medical school, and all of those countries have in common medical school working very differently from the US? Specifically, things like a shorter overall path, strictly meritocratic admissions with no fudge factors at all, etc, etc.

Obviously if the US declared medschool free for anyone who could get in, there’d be all sorts of problems. For one, medical schools would admit thousands of people who spend immense amounts of money to never graduate(or graduate into incompetence). No doubt right wing Twitter would find someone literally named Shaniqua who’s getting paid to take organic chemistry again after failing it three times, but the problem is actually deeper than that- students who never graduate are now a money printer for medical schools. Currently there’s some incentive but actually doing this pretty much requires the federal government to pay for every medical student’s books and classes and also give them all living stipends. That changes things.

That's all stuff which is much amenable to discussion and debate (even if we disagree) but these are unrelated to my problem with your post which was the gross factual inaccuracies.

It's several orders of magnitude more common for a doctor to start making 250K a year at age 32 with a half million dollars in debt than it is for a doctor to be making over 750k a year, which nearly zero are doing through clinical duties alone.

Your comment, much as I loathe to use this term, is misinformation.

"What is the right amount of money for a doctor to make" is a reasonable question but it's functionally entirely unrelated to healthcare costs in America.

The amount of debt US doctors are saddled with has nothing to do with how much they should be paid in a free market.

I don't think that's true. You can't decouple a party's costs (in this case, school) from the prices they charge (i.e. wages) because the costs are a significant part of the price one is willing to accept in the marketplace. If you lower the cost to be a doctor, people will more readily accept lower wages because they're still doing OK for themselves. And if you lower wages without lowering costs, one would expect to see fewer doctors out there as young people decide to go down different (more lucrative) career paths.

Why should doctors need to be able to prove they can speak English to be allowed to work in the US? The point of medical licensing is to make sure that doctors know what they're doing, something that is not easily verified by patients. But patients can tell immediately if a doctor speaks English. If he can't, no one is actually going to be harmed by it and he may still be able to help patients who speak some other language.

If insurers in the US negotiated a lower price for drugs, that would kill the incentive to develop new drugs.

Smash the AMA cartel by allowing unlimited immigration of doctors trained in Canada, UK, Australia, NZ and Ireland without any licensing requirements, re-doing residency etc.

This would be so nice. I have lots of medic friends who studied alongside me at an elite university and now are doing shitty training years in the NHS only to be rewarded with a crap £60k job at the end of it all. These are highly competent people I would not hesitate to say are better than the 90th percentile doctor in the US. But for whatever reason they can't go over to work in the US and now are striking to get paid more than a derisory amount for a role which requires almost a decade of post school graduation training. Having a minimal friction market for doctors with the US will not only fix their problems but also force the rest of the developed world to pay doctors a wage commensurate with the effort it takes to become one.

  1. Make market more free
  2. Make market less free, but more free, but less ?

Just make it more free in the most straightforward of terms and everything will fix itself.

No the answer is to stop gate keeping drugs by requiring a doctor to write a prescription for all of them.

This is the most obvious and correct thing to do. My health insurer would save 500-1000 dollars a year if this were permitted

Tylenol would not be approved as an over the counter drug if discovered today because of how easy it is to kill yourself accidentally (or intentionally) with it.

The average person has no idea how badly many drugs can interact with each other, recreational substances, and with medical comorbidities.

And that's ignoring other problems like the people who would give themselves antibiotics for viral infections etc.

Yes, but anyone who, say, completes and undergrad economics major should be capable of using a computer to check for negative drug interactions. Let them prescribe drugs after passing some test.

People fuck this up constantly. Educated people. Smart people. People believe in antibiotic stewardship until they have a cold and demand antibiotics "just in case." People take medications and are told "no really tell me if you start supplements or something really bad could happen" and then something really bad happens. People are told "don't eat before your expensive, time sensitive, maybe life saving surgery" and then they eat. Sometimes they die because they eat and we can't do surgery.

See front page of meddit today for a discussion on colonoscopies.

People can't be trusted to do a good job of this, and that includes health care professionals (including doctors). Thus the waves of verification.

The problem is that just letting people get drugs as they like means that if they're the one in ten thousand who gets the rare but really severe reaction, who ends up getting the blame?

It's risky enough with prescriptions and people taking medication they're not sure of, or there are interactions with drugs they already are prescribed, or the doctor was careless about checking are they safe to take this drug. I've been prescribed things that gave me (fortunately) low side-effects and now have it on record that I can't take X or Y medication. Without some system of doctors and prescriptions, how are you going to manage this?

who ends up getting the blame

Simple, the person who took the drug without a prescription. This is no different to how if you park in an open parking lot you have to bear the risk of someone breaking in and stealing your shit.

You really think that's going to happen? "Oh my bad, my mom or brother or kid took that drug and suffered a severe side-effect, their fault for being too dumb to read the label"?

No, it will be Something Must Be Done and they'll sue the government and the drug manufacturer and the hospital and anywhere else they can think of: yes this is legal but someone else is to blame!

Yeah, it doesn't matter how blindingly obvious you make the risks. A lot of people will say they're OK with the risk right up until they lose a roll, at which point they are mad and want something to be done.

Yes, and it is the responsibility of the systems established by society to make sure nothing is done in response to such tantrums. It's fine if they sue, as long as they lose and have to pay the court costs.

That attitude leads to things like the opioid crisis where the rest of society is left cleaning up the mess left behind by people making questionable decisions.

A huge chunk of healthcare costs these days are associated with lifestyle related problems. That's going to get worse if you have 100k people fuck up their kidneys and need dialysis.

Negative externalities are a thing.

So why is the United States paying for > 100% of global pharma research? And how can we fix the glitch?

Read bad medicine and bad pharma - R&D costs of pharma are minor percentage of their total expenses. They spend more on marketing than R&D

AbbVie spent $11 billion on sales and marketing in 2020, compared to $8 billion on R&D. Pfizer spent $12 billion on sales and marketing, compared to $9 billion on R&D. Novartis spent $14 billion on sales and marketing, compared to $9 billion on R&D. GlaxoSmithKline spent $15 billion on sales and marketing, compared to $7 billion on R&D. Sanofi spent $11 billion on sales and marketing, compared to $6 billion on R&D. Bayer spent $18 billion on sales and marketing, compared to $8 billion on R&D. Johnson & Johnson spent $22 billion on sales and marketing, compared to $12 billion on R&D.

1st - remove patents. The whole point of a patent is to share the secret sauce so it is not lost, but lately patents don't share the secret sauce (most glaringly in software patents). They can't hide the molecule - and their competitors can figure out synthesis of their own. Since they will have an edge with internal knowledge they will have competitive advantage initially and if they keep their margins sane - there probably won't be incentive for the others to invest the capital to figure out how to produce the thing and set up a supply chain.

2nd - extend patents and order maximum margin over the production cost. If they have 5times longer period to recoup the investment their books may be balanced.

3rd - change the procurement procedure. For society wide needed drugs - Uncle Sam (with pitches from EU) grants the players some money to do R&D, offers generous prepurchase and prize grants for the winner, and ends owning the patent - afterwards the pharma companies can manufacture wherever they like and compete with generics. Something similar was done with covid and no matter what your opinion on vaccination was - it worked in delivering multiple safe-ish working products in record time

Yup, I have sympathy w/ pharma companies over R&D costs. I don't have sympathy for all the TV, magazine, and online commercials they run. The only downside is we might have a flood of unemployed attractive, moderately intelligent women from various sororities around the country if pharma has less marketing dollars.

Trump had a policy where he wanted rich European countries to pay the same amount that gets charged to medicaid/medicare for these medicines however he wasn't able to get it implemented before he was booted out and the Biden admin scrapped it.

Americans pay about $1000/month.

How much of that cost is borne by consumers, and how much by insurance? How much of that is actually paid, and how much is negotiated away when the drug manufacturers and hospitals and insurance companies square up? In this system, Novo Nordisk would be stupid to charge less, and it's not especially their fault that drug costs are so high.

A lot of problems with the American healthcare system seem to be caused by the fact that so much of it is paid for with insurance. Insurance is for catastrophes that are unlikely to happen. Most people should never file an insurance claim in their lives. The fact that it's used for things like having a baby is absurd.

This is much worse. If obese people pay $1000/month to lose weight they are freely making that choice.

Why should I pay $100/month in taxes and insurance for this drug which I don't even take? And why aren't German taxpayers paying for it - just me?

I feel like the standards have increased to the point where people are afraid to post

looks at three previous top level posts Two deserved to get pruned, and two top level posts in an hour is a bit dodgy.

I do kind of miss the bare links thread, since I mostly get my news from here, though I realize that's my own fault.

So why is the United States paying for > 100% of global pharma research? And how can we fix the glitch?

I would potentially be open to a regulation that companies can't sell drugs to Americans at a higher cost than they sell them to Germans, though there's probably some reason why that wouldn't work. Even in America, it'll be worth having in the long run, so I wouldn't want to discourage the process entirely.

Seems like the simplest solution would just be to stop making it illegal to buy drugs from abroad. Then if drug companies tried to jack up prices in the US we'd just buy them from the Germans for a much smaller markup. I didn't have insurance coverage in college and ordered a drug I needed from a sketchy online pharmacy in Canada for around 1/4 the price that I would pay in the US. The disadvantage was the risk that it would get stopped at customs and confiscated, but that's an entirely self inflicted problem.

Is there actually punishment for buying non controlled drugs from abroad? A quick google search makes this seem like it would be trivial to do.

I wonder if countries like Canada or Germany would even allow that on their end, since it would probably mess up their own deals with the drug companies to be selling openly to Americans?

They absolutely don’t want it because yes, it will leave the pharma companies (many of which have large operations in Europe) with no choice but to substantially raise costs for their healthcare systems.

looks at three previous top level posts Two deserved to get pruned, and two top level posts in an hour is a bit dodgy.

So sorry for posting. What was I even thinking?

I would potentially be open to a regulation that companies can't sell drugs to Americans at a higher cost than they sell them to Germans,

I was thinking something similar. Here's what I'd propose. Drug companies can't sell drugs to Americans at a price more than 5x what they sell to Germans. For the same reason, I'd like to propose a 10 strikes and you're out law for career criminals. Pruning the most egregious misconduct can create a lot of value at relatively little cost.

I like your posts buddy. Please keep posting new top-levels.

No, better yet make it a command economy. They can't set the prices over 3x what it costs to manufacture the drugs.

So sorry for posting. What was I even thinking?

I'll respond down there.

I was thinking something similar. Here's what I'd propose. Drug companies can't sell drugs to Americans at a price more than 5x what they sell to Germans. For the same reason, I'd like to propose a 10 strikes and you're out law for career criminals. Pruning the most egregious misconduct can create a lot of value at relatively little cost.

That sounds plausible enough, I'd probably vote for either if they were options.

How is it a glitch having access to new medicines? Expensive drugs but more drugs is better than options only being limited to Tylenol or Asprin, which is what you'd get if there was no profit incentive. No one pays out of pocket for life saving drugs anyway. I am perfectly fine with the makers of Ozempic and Mounjaro making billions if it means reducing obesity and making people's lives better. Americans have high expectations for healthcare; they want some cutting-edge drug that costs tens of thousands of dollars a month to add maybe a few months of life for terminal cancer. Much of healthcare is for end of life spending.

This doesn't address my concerns. On a global level, yes, spending on drugs must pay for research and development. But why must the United States specifically pay for more than 100% of the cost of research?

A: You can't just look at the marginal cost, you have to consider the fixed costs that go into making the first dose. Drug development has a lot of candidate drugs that don't pan out and so they need big hits to pay for failed drugs.

B: For the past two years there have been and continue to be pretty severe GLP-1 supply shortages in the US, availability for those prescriptions in centralized health care systems ration access to GLP-1 meds much more strictly on top of similar supply shortages. Good luck getting Ozempic in Canada/Germany without a T2D diagnosis, and most US insurance does cover Ozempic at reasonable rates if you have a T2D diagnosis and can jump through some hoops with a prior authorization. If you just want a weight loss drug, then you're looking at $900+ every four weeks here.

C: To a large extent, the 'system' is working. US citizens are getting earlier access to these drugs. Companies are churning out new and better versions, Mounjaro/Zepbound is a big step up from semaglutide and there are even more and better drugs in development. High prices mean should help supply issues get sorted out sooner and more weight drugs means that US insurers should be able to force drug companies to compete and lower prices over time.

You can't just look at the marginal cost, you have to consider the fixed costs that go into making the first dose. Drug development has a lot of candidate drugs that don't pan out and so they need big hits to pay for failed drugs.

Yes. Bernie Sanders is quite dumb and honeymooned in the USSR. His understanding of economics is at the /r/antiwork tier.

For the past two years there have been and continue to be pretty severe GLP-1 supply shortages in the US,

Cool. Why don't they just cut off all supplies to Europe and sell exclusively to the US at 20x the price.

C: To a large extent, the 'system' is working. US citizens are getting earlier access to these drugs

Where can I sign up to wait in line 12 months like a German and get drugs for 95% off?

$12,000/year is immense. Americans are being uniquely screwed here.

Edit: Apologies for unnecessary antagonism. No hard feelings I really just want more posts on this frickin' forum already!

Cool. Why don't they just cut off all supplies to Europe and sell exclusively to the US at 20x the price.

Because they’re a European company. And I think you’re ignoring a major risk, which is that if the US tries to push for the same price, and the Danes say no, and the US says “fuck it, we’ll make generics”, the EU actually has a lot of leverage. A huge amount of US exports are intellectual property sold at zero marginal cost. The EU can make it legal to ignore those rights.

An argument that only works if Europe isn't fearful of Russia.

Where can I sign up to wait in line 12 months like a German and get drugs for 95% off?

$12,000/year is immense. Americans are being uniquely screwed here.

If you have a T2D diagnosis, you can get the drug for 95% off tomorrow after going through a prior authorization on most insurance (mine quotes me $30).

If you don't have T2D, the more accurate comparison is more like 340$ in germany for Wegovy (so ~400 after you adjust for purchasing power parity) and you can get a Zepbound prescription with coupon for $550, which is a much better drug: fewer side effects, higher average weight loss. That's an extra $2k a year (13 four week boxes*150) but it's hardly $12k.

Cool. Why don't they just cut off all supplies to Europe and sell exclusively to the US at 20x the price.

I'd guess politics, these companies do have to play the long game and I'm certain that the supply is much more limited in other countries.

Yes. Bernie Sanders is quite dumb and honeymooned in the USSR. His understanding of economics is at the /r/antiwork tier.

You'll get a better quality discussion if you present the stronger version of an argument. If that's such a dumb argument and missing context, why didn't you add that in your top level post? ಠ_ಠ

You'll get a better quality discussion if you present the stronger version of an argument. If that's such a dumb argument and missing context, why didn't you add that in your top level post? ಠ_ಠ

Good point. Set aside Bernie's worthless statement about Wegovy costing only $5 to make, which ignores the immense cost of research and regulatory compliance.

Let's say that Americans paid the same price for medication as Germans do. The pharma industry would no longer be profitable and drug development would slow to a crawl. Why must the entire global pharma industry be dependent on a single country with less than 5% of the world's population? How do we make Germans pay their fair share?

Because America by being willing to pay 1000 more is showing they value it at that price. And they can value it at that price because they are richer.

In theory the best pricing practice for companies is to sell their product at 100 bucks to people who will pay that, then 60 to whover will pay that and then 40 and so on, down to where the price still creates profit per unit. In practice that is tricky because fluctuating prices is something direct consumers don't like. But when selling to different countries you can set your prices depending on what the local market will bear in each one.

So the US pays more because it is richer and therefore is willing to pay more. That is the market signal the companies are following. And arguably the US is richer because it interferes in market signals less than other countries.

In that case asking about paying their fair share is looking at the question the wrong way round. How do you get Germany to be richer so that they too value the product equally is the more accurate question. And the answer would seem to be, promote more free market principles.

Of course if Germany gets richer that may have other knock on effects on the US economy. No free lunches here unfortunately.

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