Medicare should spend 1% of its budget each year to buy pharma stocks. Slowly it will become neutral to drug prices since what it pays for expensive drugs will be returned in the stock value.
Why would it collapse? Can limit govt holdings to say 25% of each company to maintain profit motive. I think this would attract other investment - front running the govt money - and greatly increase the ability to research new drugs. Can also direct some research money into drugs with significant benefit but little profit. Over time increased investment would allow lower prices. Over time compounding would help fund medicare.
Monopolies for drugs that received even a penny of government subsidies should not exist. We should simply pay for research and open the patents on the results, or outlaw drug patents outright. Let the drug companies compete on manufacturing.
Like quantitative easing raises the whole market? Govt would dollar cost average at least and can spread out buys to avoid front running. Larger market cap with investors holding for the long term helps increase the R&D spend and timeframes.
If you’re someone who is interested in these drugs, just know that you can get them from China for 1/10th the cost of what telehealth providers want. I’ve since supplied a few of my friends who have been interested in various peptides and it has been great overall. Some thought it would be a scam or bunk but they’re losing the weight with no side effects. It’s been great.
You can order GLP-1 peptides from China for cheap. Once you have the peptide, all you have to do is put it in the right amount of bacteriostatic water. In theory this is no harder than any other mix-powder-with-water task. But this time if you do anything wrong, or are insufficiently clean, you can give yourself a horrible infection, or inactivate the drug, or accidentally take 100x too much of the drug and end up with negative weight and float up into the sky and be lost forever. ACX cannot in good conscience recommend this cheap, common, and awesome solution.
Wait, people are buying stuff of unknown quality off the internet, mixing it with water in their kitchens, _and injecting it?_
That's wild. Even the article author seems to have a tongue in their cheek when issuing this "warning" that is definitely not a hint. Is it safer than it sounds?
It can be relatively safe with proper handling. There are independent laboratories you can send this "product" to for analysis. Often people organize group buys with some random samples tested.
It’s just cutting out the middleman of the compounding pharmacy and/or medspa provider. If you think they take much more due care than a careful educated Chinese buyer you’re suffering from delusion and/or trusting authority too much.
You can do group buys with your friends to get a single batch made, then send in a few random samples to a lab for HLPC and sterility testing. This adds a few bucks per month to the total cost depending on the size of your buys. The ancillaries are all US medical grade from various sources and not material to the discussion.
There are no other sources for the raw compounds so it’s all coming from the same place and handful of Chinese finishers if it’s not not direct from Novo or LLY.
If you give yourself an infection with a subq shot you almost have to be trying. The rest is basic math.
There are certainly additional risks involved - but they are not the obvious ones you think of in the first 10 seconds.
Can someone please explain the economics of GLP-1s? How can people pay $1000/month for the rest of their life, just to keep weight off? Rent and mortgages are already insane as is, and then there’s insurance, kids, etc.
> How can people pay $1000/month for the rest of their life
No one actually pays that price. The $1000 misrepresented in the article as the "usual insurance price" is actually the list price, from which insurers negotiate discounts (that is, the full price -- not just the out of pocket price charged to the insured -- for insured patients is significantly less than that $1000 price), while most people who get the drug outside of insurance get it through some program (if it is the actual, brand-name drug, run by the manufacturer) that also charges much less than the list price.
> No one actually pays that price. The $1000 misrepresented in the article…
With respect, that is absolutely incorrect. People absolutely pay over $1000 and do so monthly. For example, Kaiser of Northern California makes it very difficult for their doctors to prescribe these, and nearly impossible to get a prescription for Monjaro (which is particularly effective). Therefore, Kaiser patients/insured for whom these drugs are of immense benefit but who must have their prescriptions from out of network physicians receive ZERO insurance coverage. This means they get neither the negotiated insurance price discount nor any co-pay on the full cost. I am directly aware of this. And it is a travesty. Yet the benefits of these drugs is so significant and uniquely available through these drugs that in a sense, if it is possible to pay, then pay one must. Because in effect they are invaluable.
They would buy direct from LLY for $550/mo or pay the $650/mo via manufacturer coupon for Zepbound. If their primary care provider refuses to prescribe telehealth will trivially do it in 10 minutes for about $150 every 6mo.
The only folks not covered by the latter mostly either have no insurance or Medicare.
That said, many folks take a few months to figure out these programs exist, and some consumers simply never do the research.
The US government requires that they receive the lowest public price for any medical care they pay for. Unfortunately, the US government is a very expensive customer to work with for many reasons. By sandbagging costs with very high public prices, it gives healthcare providers the latitude to, after various hidden discounts, charge the government more than private sector customers that actually cost them less to serve.
It is a perverse incentive created by the government insisting on the lowest price but having a very high overhead cost to deal with relative to everyone else that has to be paid for. Far from ideal but that is where we are. Quite a few fake prices in regulated markets can be explained by the government requiring that they receive the lowest price while incurring an unusually high cost overhead to the vendor.
Properly its neither a "principle agent problem" nor a "principal agent problem" but a "principal-agent problem" (that is, the problem is a conflict between the principal and the agent [both nouns] nominally acting on behalf of that principal, not a problem with the principal [adjective] agent [noun].)
That's still two words and only one was wrong. Hyphenation is not mandatory, there is no formal description of a "problem with the principal [adjective] agent [noun]" to be disambiguated from.
It's confusing, but each payer (insurance companies) negotiates a series of prices for things. Each one is a unique, bespoke, business deal -- and this is why prices are never clear: the cost of something is unique to the deal hammered out by an individual insurance company and individual health care provider networks.
Different payers will come up with their own unique take on health care coverage prices, favoring some things (lower costs) over others. Some may favor prenatal care and maternity, some may favor meat-and-potatoes basic health needs over specific categories of care. Larger payers may get a percentage point or two average-over-everything lower, smaller ones may favor a particular subcategory to create what they feel is a "good enough but still competitive in some key marketable categories" package. Each one is bespoke and quite varied.
From the outside, it can look insane: you walk into a hospital and ask how much a procedure costs, and the person at the desk is honestly confused and honestly has no answer. The reason? The cost is entirely relative to the cost structure package hammered out by a specific insurance company - there isn't really a fixed "cost" per se.
I take a fancy medication every week with an MSRP adding up to over $7,000 a month. Even with the cheapest insurance on my state's marketplace, I pay $0 for the drug because of a manufacturer copay savings program. This arrangement also happens to delete my yearly deductible and out-of-pocket max astonishingly quickly, making most of the rest of my healthcare free.
I have literally no skin in the game. Speaking as one of the winners in this charade, this whole thing is so stupid. It makes you wonder why they don't set drug MSRPs even higher.
The US healthcare system is a patchwork of policy, local incentives, and unchecked capitalism that barely works, some of the time. You can read intent into it, but it's really just a big mass of inscrutable complexity.
That said, a lot of the time, inentionally or not, the answer is "it facilitates the transfer of money to the shareholders of the big private health insurance companies"
Of all the industries in the US Health Care is the MOST regulated. How on earth is that "unchecked"? The problem is the checks are (and always will be) written by the companies.
you're right, I really should have said "poorly regulated capitalism." My comment on "unchecked capitalism" was more of a commentary on the lack of trustbusting for vertically integrated behemoths like UHG/OptumHealth/Optum PBM/OptumRX and for regional near-monopolies like UPMC.
Healthcare has a lot of regulations, for sure, but it adds a lot of complexity doesn't result in a good system for users -- so, bad regulation. OTOH, I think FSI regulations like Glass-Steagall and Dodd-Frank, as well as regulatory agencies like the SEC and CFPB (gasp!), have been huge successes for retail users of banks and financial markets -- so, better regulation.
I'm not an expert, but I've worked at a bank and had to go through all the regulatory trainings. I didn't hear about any good regulation other than things that should be covered by regular law. Like apparently there's special regulation about basically not commiting fraud?!
Everything else is some weird sneaky BS.
Again not an expert. Just a guy who had to listen to some awfull training courses.
What does this mean? You don't get to write off the difference between your "target price" and actual sale price.
And a reminder that companies always do better if they make more money, not point in purposeful losses (unless you are getting a side benefit like goodwill from charity).
I think, but am not sure, the point they're trying to make is that hospitals and insurance companies can "charge" really high prices and then they can forgve those high prices in exchange for a tax break?
That's not at all how it works so they don't have any idea what they're talking about. This is like when people say businesses can "write it off on their taxes". Only people who don't know what that really means say it.
Few people actually pay 1000/month. Most get it through insurance (I pay 25/month), and most of the remaining get it through compounding pharmacies like HenryMeds which comes out to 300-400 per month.
In fact, I know a few people who get brand pills (Rybelsus) mailed from India, where it's much cheaper. This insane pricing is a US only thing.
Further, as noted in TFA, it’s possible to get higher doses at the same or almost the same price, though a compounding pharmacy, because pricing is basically the same no matter the dose (the materials are dirt cheap, the drug is very cheap to make, so they sell “the drug’s effect at however much you need” not “this amount of the drug”, basically) and then stretch it by taking smaller amounts than prescribed, or split a prescription with someone else.
1) Any number of ways, they don’t pay that much. Or,
2) They’re rich. Not even that rich. I mean hell we paid $1,500/month for two kids to go to preschool, for years, and that sucked but we could still save. And we had a household income of like $130k or so at the time. Doing fine, not saying we didn’t have alright income, but not that uncommon. Now imagine a two-FAANG income like many folks on here. $1,000/month, even times two, is entirely within reach for them. Also,
3) You can go off it for periods and just go back on if the weight starts to creep up. Anyone who’s successfully maintained weight for periods in the past may be able to manage long stretches without it and not gain much. And further,
4) It’s not going to cost that much for long, in the scheme of things. The price will likely settle in the tens of dollars per month when the patents expire.
JFC HN, I hedge and demure about as much as I reasonably can without distractingly and pointlessly (anyone can Google) turning the post into a dissertation on median household income percentiles and still someone complains. This is poor reading, and poor posting.
The first year of that, about 20% of households were around our level of income or higher. We could have covered $1,500 in daycare without much trouble at a somewhat lower level of income, so say 25% could cover $1,000/m without driving themselves into a really, really bad place financially, provided they’ve not already committed that to other things (expensive car payments, they have very young kids in daycare, whatever)
Neither 20% nor 25% are uncommon.
If you’re thinking “well that’s just coastal cities dragging the stats up” then check stats on 3rd-tier but not-notoriously-poor cities and see what they look like. In the flyover state city fitting that description we lived in at the time, the local household income percentile distribution roughly matched the national one.
That’s a TAM of people who can afford $1,000/month for something they really want of, what, 50 million or more adults in the US? And that’s at full sticker price, which few are paying.
How much more than one-in-five before a category of person is not uncommon?
That you perceive it as a complaint is hilariously ironic. I'm just telling you that your notions of "common" are wrong. You are attempting to use your economic situation to justify the outcomes for others. That, my friend, is poor posting.
> about 20% of households
This is super easy. 1 out of 5 is "not common." You can be as parsimonious as you like it doesn't change the ground reality that there are fewer people like you than there are people like you.
> How much more than one-in-five before a category of person is not uncommon?
Weird hill to die on. There's nothing wrong with or your economic situation except your expectation that other people share it. Which they generally don't.
1 in 5 is certainly not uncommon by any reasonable interpretation of the term. 20% of the US is an absolutely massive market many could only dream to begin to address as a customer base.
That said, even that is not really all that useful. Anyone who is motivated can get these drugs for around $500-600/mo via programs that exist for the vast majority of the population. That roughly halves the cost comparisons here. Very few folks who want these drugs have zero options other than to pay full retail.
He didn't say 1 in 5 is common. He said 1 in 5 is not that uncommon. He's right. If 1 in 5 people in 1991 have a computer in the house, having a computer is not that uncommon.
This is a circular argument. In order for it not to be, you need to show how “having a computer in the house in 1991” is already a not uncommon thing for that to then apply to 1 in 5 not being uncommon.
Americans are wealthy and don’t even realize it. The median household has >$1000 left over each month after all ordinary expenses against income, per the US government’s own data and statistics. Not everyone can afford it but a large percentage can. They may value this more than many other things they can waste that excess income on.
The drugs are only going to get cheaper with time.
It's easy for Americans to think they're poor when half the country buys into a false version of reality where crime is rampant, the economy is constantly failing and welfare queens are eating your dogs.
I can afford 1k/month and will if that's what's required. My life is well over 1k/month better with a healthier weight. I preform better at work, I'm happier, and I should live longer. That's worth the money.
Or you eat less and/or healthier food to achieve the same result without the side effects. Spend part of that $1000 (but not too much) on better food which you (or someone in your family) prepares at home, keep the rest for other purposes.
For some reason this suggestion, i.e. the suggestion to solve a problem by eliminating the root causes, does not seem to be popular on this forum. I'd very much like to know why this is given that this place is supposedly frequented by rational people. If eating too much unhealthy food is making you fat you don't solve that by putting a chemical stopper in your veins, you solve it by eating less of the bad stuff.
I don’t think anyone here disagrees with the premise that fat people can lose weight by eating fewer calories than they expend. What you are missing is that — for many people — your solution is akin to telling an alcoholic to just drink less. Yes, it would solve their problem, but for a variety of reasons it’s probably not gonna happen.
Most fat people who want to lose weight have already tried eating less food. Just like many alcoholics have tried to cut down or stop drinking. Some of those people succeed, but many others don’t. The reasons why are far more complex than commitment and willpower.
This might not be a popular opinion: but I think that for roughly 99% of people losing weight and keeping it off long term is impossible once they’ve become overweight. They are just destined to be fat at that point no matter what they do. Weight may come off for a bit, but it returns… their body is irreparably compromised.
This reminds me of Sheldon Cooper's suggestion to Penny on The Big Bang Theory when she was having financial problems: "You know, it occurs to me that you could solve all your problems by obtaining more money".
Weight depends on a complex interaction between many systems of the body. Losing significant weight and keeping it off in healthy way without side effects can be difficult.
There was a good look at much of this in the Nova episode "The Truth About Fat" in 2020. Old Nova episodes are usually behind a paywall if you aren't a member of your local PBS station but occasionally old episodes become free for a while. It might be worth checking occasionally to try to catch it during one of those free periods.
Deliberately disingenuous? Pretending it's a diet problem, and not a psychological one.
Try this experiment: put a gun to your head and pull the trigger. You may find it hard. Your hand may shake; you will start sweating; rising panic will cloud your thinking.
But it's so easy! Just a couple pounds of pressure on the trigger. Anybody can do it.
That's me substituting a physiological problem for a psychological one.
Theoretically, a lot (most?) of healthcare costs are downstream of being overweight. Going to the doctor for diabetes, hypertension, knee problems, and the long term effects of those might be less costly than a constant subscription to purchase GLP-1s.
Bonus is you no longer crave expensive sugary or alcoholic drinks and food.
Most people I know using it were using insurance, so paying much less than that, however for many of them the insurance companies are dropping coverage for it. That had pushed some to the compounding, and thus ozempocalypse as that avenue is removed as well.
They don’t. If you live outside of the USA it is cheaper (e.g. 400 cad a month in Canada)
The article also mentions the grey market, where you can buy a year’s worth of power from China for a couple hundred bucks. You do need to be able mix it up properly though.
Knowing a couple people who've done it, they do it for a few months to lose weight, then stop taking it and try not to gain the weight back. I don't know anyone who's chosen to go on it permanently.
The drugs have been cheaply and widely available for a little over 17 months, and by some measures, about 1/3rd of patients prescribed semaglutide or tirzepatide are forecasted to be using either permanently.
Well, it’s a medication designed for diabetes (the weight loss variant has a higher dosage and different brand name, Wegowy or so), and for diabetes the usage is, by default, permanent. Unless it is replaced by other medication or if the lifestyle changes make the insulin resistance not be an issue any more.
Say it costs you $300/mo for the GLP-1, but it saves you $300+/mo in groceries/snacks from the gas station/eating out at restaurants/alcoholic drinks at a bar, it's pretty easy to explain the economics.
This is actively improving health outcomes for millions of people so of course insurance won't cover it and it is being taken away from consumers. If the shortage is over, why does it cost $1k or even $500? Sounds like there is still a shortage to me. I guess vaccines are out but price gouging is still in in the US healthcare system.
Pharmacies have to have crazy high prices though because PBMs reimburse at such shit rates, based on some percentage of the price given to them. Because if they buy the bottle at $30 and list the price at $60, the PBM contract will only reimburse at the adjusted wholesale price (another made up number), eg: 17% plus a $1.99 dispensing fee. This disgusting math results in getting a loss on the drug.
Even all this leaves out some of the most absurd abuses of PBMs. They set minimum drug copays, have the pharmacy collect a $15 copay for a $5 drug, and have the pharmacy pay the PMB the $10 difference. They make it a breach of contract for the pharmacy to inform the patient this is happening or to charge the $5 and bypass the insurance. The total lack of anything even approaching ethnics is absurd...
This is an extremely politicized question in the US, where a public health insurance option (a solution that's popular in much of the rest of the OECD) is fiercely opposed by a large swath of the population.
At the very least though, in an ideal world, payers, providers, pharmacies, and PBMs should not be allowed to be part of the same company.
Just force price transparency. Force drug makers to advertise the selling prices of their drugs, and enforce price discrimination laws. Force insurance and PBM companies to advertise the drug prices if purchased through insurance or PBM. Everybody should be paying the same price. And if not, everyone should be allowed to find out if they can pay a lower price.
And yes, get rid of PBMs. They are toxic middlemen who want their 'cut' for doing nothing at all.
Compounding pharmacies existed before Ozempic and their entire business model is producing custom drugs at reasonable prices. For Ozempic, they order the GLP-1 peptides from a large Pharma company and then mix it to order with bacteriostatic water and any other additives. Mine includes a B-12 compound that is attempting to help with the weight loss. They are highly regulated and require trained and licensed employees. The compounding pharmacies I don't trust are the ones that only started to do Ozempic and nothing else. But I do trust my local one. They've made me medication for my animals for decades now.
> They are highly regulated and require trained and licensed employees. The compounding pharmacies I don't trust are the ones that only started to do Ozempic and nothing else.
We already know that the compounding pharmacies violate patent law. Why should I believe they follow any other regulation?
And this type of drug lends itself to some of the least expensive trials you can hope for. The dosage level, expected dosing period, and measurement of outcomes are all uniquely well suited to inexpensive study. The trials were also exceedingly fast and quickly broke off into testing for all kinds of conditions such as Parkinsons but for the core case of weight loss it was as easy as it gets.
The status quo was pretty good for the FDA. Lily and Novo Nordisk still saw major stock price rises. Patients had super cheap drug options for something that would free up lots of money for non-medical spending in the economy. Why does an administration ruling via EO not keep the compounding loophole? It aligns with their goals. IMO, the compounders need to turn this into a media sound bite sized win for politicians. Because it certainly doesn’t make any scientific or objective medical sense to cease the compounding.
Medicare should spend 1% of its budget each year to buy pharma stocks. Slowly it will become neutral to drug prices since what it pays for expensive drugs will be returned in the stock value.
No, slowly it will pay out on one side and get back a bit on the other until it becomes a major stock holder and the whole house of cards collapses.
Why would it collapse? Can limit govt holdings to say 25% of each company to maintain profit motive. I think this would attract other investment - front running the govt money - and greatly increase the ability to research new drugs. Can also direct some research money into drugs with significant benefit but little profit. Over time increased investment would allow lower prices. Over time compounding would help fund medicare.
It collapses because by the time it is the majority owner the state will pay for it's own "profits".
Monopolies for drugs that received even a penny of government subsidies should not exist. We should simply pay for research and open the patents on the results, or outlaw drug patents outright. Let the drug companies compete on manufacturing.
> Medicare should spend 1% of its budget each year to buy pharma stocks
People would just raise the price for pharma stocks then.
Maybe that is a good thing since it would make it harder to buy pharma stocks for others, but the government will still pay too mcuh.
Like quantitative easing raises the whole market? Govt would dollar cost average at least and can spread out buys to avoid front running. Larger market cap with investors holding for the long term helps increase the R&D spend and timeframes.
Our health care system is a profit making enterprise with medical care as a side effect
If you’re someone who is interested in these drugs, just know that you can get them from China for 1/10th the cost of what telehealth providers want. I’ve since supplied a few of my friends who have been interested in various peptides and it has been great overall. Some thought it would be a scam or bunk but they’re losing the weight with no side effects. It’s been great.
From the article:
You can order GLP-1 peptides from China for cheap. Once you have the peptide, all you have to do is put it in the right amount of bacteriostatic water. In theory this is no harder than any other mix-powder-with-water task. But this time if you do anything wrong, or are insufficiently clean, you can give yourself a horrible infection, or inactivate the drug, or accidentally take 100x too much of the drug and end up with negative weight and float up into the sky and be lost forever. ACX cannot in good conscience recommend this cheap, common, and awesome solution.
Wait, people are buying stuff of unknown quality off the internet, mixing it with water in their kitchens, _and injecting it?_
That's wild. Even the article author seems to have a tongue in their cheek when issuing this "warning" that is definitely not a hint. Is it safer than it sounds?
It can be relatively safe with proper handling. There are independent laboratories you can send this "product" to for analysis. Often people organize group buys with some random samples tested.
It is safe. People do this already on their own with some medications.
If you’re very paranoid, you can get it third party tested again and it will still be way cheaper than buying from a compounding pharmacy.
It’s just cutting out the middleman of the compounding pharmacy and/or medspa provider. If you think they take much more due care than a careful educated Chinese buyer you’re suffering from delusion and/or trusting authority too much.
You can do group buys with your friends to get a single batch made, then send in a few random samples to a lab for HLPC and sterility testing. This adds a few bucks per month to the total cost depending on the size of your buys. The ancillaries are all US medical grade from various sources and not material to the discussion.
There are no other sources for the raw compounds so it’s all coming from the same place and handful of Chinese finishers if it’s not not direct from Novo or LLY.
If you give yourself an infection with a subq shot you almost have to be trying. The rest is basic math.
There are certainly additional risks involved - but they are not the obvious ones you think of in the first 10 seconds.
Yeah, I just want to be clear that it’s also way cheaper. This is where the compounding pharmacies are often buying from too btw.
The price for tirzepatide is under $0.50/mg at this point.
How can one mix these peptides with bacteriostatic water in one's garage? Any special instruments, instructions?
Can someone please explain the economics of GLP-1s? How can people pay $1000/month for the rest of their life, just to keep weight off? Rent and mortgages are already insane as is, and then there’s insurance, kids, etc.
> How can people pay $1000/month for the rest of their life
No one actually pays that price. The $1000 misrepresented in the article as the "usual insurance price" is actually the list price, from which insurers negotiate discounts (that is, the full price -- not just the out of pocket price charged to the insured -- for insured patients is significantly less than that $1000 price), while most people who get the drug outside of insurance get it through some program (if it is the actual, brand-name drug, run by the manufacturer) that also charges much less than the list price.
> No one actually pays that price. The $1000 misrepresented in the article…
With respect, that is absolutely incorrect. People absolutely pay over $1000 and do so monthly. For example, Kaiser of Northern California makes it very difficult for their doctors to prescribe these, and nearly impossible to get a prescription for Monjaro (which is particularly effective). Therefore, Kaiser patients/insured for whom these drugs are of immense benefit but who must have their prescriptions from out of network physicians receive ZERO insurance coverage. This means they get neither the negotiated insurance price discount nor any co-pay on the full cost. I am directly aware of this. And it is a travesty. Yet the benefits of these drugs is so significant and uniquely available through these drugs that in a sense, if it is possible to pay, then pay one must. Because in effect they are invaluable.
They would buy direct from LLY for $550/mo or pay the $650/mo via manufacturer coupon for Zepbound. If their primary care provider refuses to prescribe telehealth will trivially do it in 10 minutes for about $150 every 6mo.
The only folks not covered by the latter mostly either have no insurance or Medicare.
That said, many folks take a few months to figure out these programs exist, and some consumers simply never do the research.
It seems like the entire US medical system runs on prices that no one actually pays.
I don't really understand what all that extra complexity achieves?
The US government requires that they receive the lowest public price for any medical care they pay for. Unfortunately, the US government is a very expensive customer to work with for many reasons. By sandbagging costs with very high public prices, it gives healthcare providers the latitude to, after various hidden discounts, charge the government more than private sector customers that actually cost them less to serve.
It is a perverse incentive created by the government insisting on the lowest price but having a very high overhead cost to deal with relative to everyone else that has to be paid for. Far from ideal but that is where we are. Quite a few fake prices in regulated markets can be explained by the government requiring that they receive the lowest price while incurring an unusually high cost overhead to the vendor.
It hinders individuals from making purchasing decisions that affect price. Less clarity on the actual price means that it's harder to shop around.
I’m convinced nearly every problem in the modern US economy boils down to a principle agent problem in the end.
I think you mean principal
Properly its neither a "principle agent problem" nor a "principal agent problem" but a "principal-agent problem" (that is, the problem is a conflict between the principal and the agent [both nouns] nominally acting on behalf of that principal, not a problem with the principal [adjective] agent [noun].)
That's still two words and only one was wrong. Hyphenation is not mandatory, there is no formal description of a "problem with the principal [adjective] agent [noun]" to be disambiguated from.
It's confusing, but each payer (insurance companies) negotiates a series of prices for things. Each one is a unique, bespoke, business deal -- and this is why prices are never clear: the cost of something is unique to the deal hammered out by an individual insurance company and individual health care provider networks.
Different payers will come up with their own unique take on health care coverage prices, favoring some things (lower costs) over others. Some may favor prenatal care and maternity, some may favor meat-and-potatoes basic health needs over specific categories of care. Larger payers may get a percentage point or two average-over-everything lower, smaller ones may favor a particular subcategory to create what they feel is a "good enough but still competitive in some key marketable categories" package. Each one is bespoke and quite varied.
From the outside, it can look insane: you walk into a hospital and ask how much a procedure costs, and the person at the desk is honestly confused and honestly has no answer. The reason? The cost is entirely relative to the cost structure package hammered out by a specific insurance company - there isn't really a fixed "cost" per se.
I take a fancy medication every week with an MSRP adding up to over $7,000 a month. Even with the cheapest insurance on my state's marketplace, I pay $0 for the drug because of a manufacturer copay savings program. This arrangement also happens to delete my yearly deductible and out-of-pocket max astonishingly quickly, making most of the rest of my healthcare free.
I have literally no skin in the game. Speaking as one of the winners in this charade, this whole thing is so stupid. It makes you wonder why they don't set drug MSRPs even higher.
PBRs have contracts with medical insurance. They get paid based on how much money they "save" the insurance company.
"Save" is defined as list price minus contracted price that the insurance pays for the drug.
PBRs manipulate the list price to be higher so that they "save" the insurance company more money.
They also manipulate the co-pays so that patients will choose drugs that "save" the most, as opposed to the lowest price drug.
If you use an abbreviation like PBR, it helps to either explain what it means or use the correct one. Do you mean PBM = pharmacy benefit manager?
The US healthcare system is a patchwork of policy, local incentives, and unchecked capitalism that barely works, some of the time. You can read intent into it, but it's really just a big mass of inscrutable complexity.
That said, a lot of the time, inentionally or not, the answer is "it facilitates the transfer of money to the shareholders of the big private health insurance companies"
> unchecked capitalism
Of all the industries in the US Health Care is the MOST regulated. How on earth is that "unchecked"? The problem is the checks are (and always will be) written by the companies.
you're right, I really should have said "poorly regulated capitalism." My comment on "unchecked capitalism" was more of a commentary on the lack of trustbusting for vertically integrated behemoths like UHG/OptumHealth/Optum PBM/OptumRX and for regional near-monopolies like UPMC.
Healthcare has a lot of regulations, for sure, but it adds a lot of complexity doesn't result in a good system for users -- so, bad regulation. OTOH, I think FSI regulations like Glass-Steagall and Dodd-Frank, as well as regulatory agencies like the SEC and CFPB (gasp!), have been huge successes for retail users of banks and financial markets -- so, better regulation.
I'm not an expert, but I've worked at a bank and had to go through all the regulatory trainings. I didn't hear about any good regulation other than things that should be covered by regular law. Like apparently there's special regulation about basically not commiting fraud?!
Everything else is some weird sneaky BS.
Again not an expert. Just a guy who had to listen to some awfull training courses.
The sellers can write it off as a loss. It’s a way to avoid paying taxes
What does this mean? You don't get to write off the difference between your "target price" and actual sale price.
And a reminder that companies always do better if they make more money, not point in purposeful losses (unless you are getting a side benefit like goodwill from charity).
I think, but am not sure, the point they're trying to make is that hospitals and insurance companies can "charge" really high prices and then they can forgve those high prices in exchange for a tax break?
That's not at all how it works so they don't have any idea what they're talking about. This is like when people say businesses can "write it off on their taxes". Only people who don't know what that really means say it.
This is you: https://www.youtube.com/watch?v=XEL65gywwHQ
Few people actually pay 1000/month. Most get it through insurance (I pay 25/month), and most of the remaining get it through compounding pharmacies like HenryMeds which comes out to 300-400 per month.
In fact, I know a few people who get brand pills (Rybelsus) mailed from India, where it's much cheaper. This insane pricing is a US only thing.
Further, as noted in TFA, it’s possible to get higher doses at the same or almost the same price, though a compounding pharmacy, because pricing is basically the same no matter the dose (the materials are dirt cheap, the drug is very cheap to make, so they sell “the drug’s effect at however much you need” not “this amount of the drug”, basically) and then stretch it by taking smaller amounts than prescribed, or split a prescription with someone else.
Rybelsus doesn’t work.
Of course it does, it is just much less effective than the injectable versions.
1) Any number of ways, they don’t pay that much. Or,
2) They’re rich. Not even that rich. I mean hell we paid $1,500/month for two kids to go to preschool, for years, and that sucked but we could still save. And we had a household income of like $130k or so at the time. Doing fine, not saying we didn’t have alright income, but not that uncommon. Now imagine a two-FAANG income like many folks on here. $1,000/month, even times two, is entirely within reach for them. Also,
3) You can go off it for periods and just go back on if the weight starts to creep up. Anyone who’s successfully maintained weight for periods in the past may be able to manage long stretches without it and not gain much. And further,
4) It’s not going to cost that much for long, in the scheme of things. The price will likely settle in the tens of dollars per month when the patents expire.
> And we had a household income of like $130k or so at the time. Doing fine, not saying we didn’t have alright income, but not that uncommon.
Americans with six-figure incomes seriously don't understand the rest of the country lives.
he said household, that could easily be two incomes, both way below six figures
Median household income is ~$80,000.
> but not that uncommon
Taking in nearly double over the average household income is, by definition, uncommon.
JFC HN, I hedge and demure about as much as I reasonably can without distractingly and pointlessly (anyone can Google) turning the post into a dissertation on median household income percentiles and still someone complains. This is poor reading, and poor posting.
The first year of that, about 20% of households were around our level of income or higher. We could have covered $1,500 in daycare without much trouble at a somewhat lower level of income, so say 25% could cover $1,000/m without driving themselves into a really, really bad place financially, provided they’ve not already committed that to other things (expensive car payments, they have very young kids in daycare, whatever)
Neither 20% nor 25% are uncommon.
If you’re thinking “well that’s just coastal cities dragging the stats up” then check stats on 3rd-tier but not-notoriously-poor cities and see what they look like. In the flyover state city fitting that description we lived in at the time, the local household income percentile distribution roughly matched the national one.
That’s a TAM of people who can afford $1,000/month for something they really want of, what, 50 million or more adults in the US? And that’s at full sticker price, which few are paying.
How much more than one-in-five before a category of person is not uncommon?
> and still someone complains.
That you perceive it as a complaint is hilariously ironic. I'm just telling you that your notions of "common" are wrong. You are attempting to use your economic situation to justify the outcomes for others. That, my friend, is poor posting.
> about 20% of households
This is super easy. 1 out of 5 is "not common." You can be as parsimonious as you like it doesn't change the ground reality that there are fewer people like you than there are people like you.
> How much more than one-in-five before a category of person is not uncommon?
Weird hill to die on. There's nothing wrong with or your economic situation except your expectation that other people share it. Which they generally don't.
1 in 5 is certainly not uncommon by any reasonable interpretation of the term. 20% of the US is an absolutely massive market many could only dream to begin to address as a customer base.
That said, even that is not really all that useful. Anyone who is motivated can get these drugs for around $500-600/mo via programs that exist for the vast majority of the population. That roughly halves the cost comparisons here. Very few folks who want these drugs have zero options other than to pay full retail.
He didn't say 1 in 5 is common. He said 1 in 5 is not that uncommon. He's right. If 1 in 5 people in 1991 have a computer in the house, having a computer is not that uncommon.
This is a circular argument. In order for it not to be, you need to show how “having a computer in the house in 1991” is already a not uncommon thing for that to then apply to 1 in 5 not being uncommon.
I think that’s a pretty average income for a couple with two children
Median household income is like $80k
In San Francisco, maybe.
Yeah but the OP lives there, and many people around them make similar or more, so it seems normal.
This is incredibly common in many parts of life, humans gonna human I guess.
Americans are wealthy and don’t even realize it. The median household has >$1000 left over each month after all ordinary expenses against income, per the US government’s own data and statistics. Not everyone can afford it but a large percentage can. They may value this more than many other things they can waste that excess income on.
The drugs are only going to get cheaper with time.
It's easy for Americans to think they're poor when half the country buys into a false version of reality where crime is rampant, the economy is constantly failing and welfare queens are eating your dogs.
I can afford 1k/month and will if that's what's required. My life is well over 1k/month better with a healthier weight. I preform better at work, I'm happier, and I should live longer. That's worth the money.
Or you eat less and/or healthier food to achieve the same result without the side effects. Spend part of that $1000 (but not too much) on better food which you (or someone in your family) prepares at home, keep the rest for other purposes.
For some reason this suggestion, i.e. the suggestion to solve a problem by eliminating the root causes, does not seem to be popular on this forum. I'd very much like to know why this is given that this place is supposedly frequented by rational people. If eating too much unhealthy food is making you fat you don't solve that by putting a chemical stopper in your veins, you solve it by eating less of the bad stuff.
I don’t think anyone here disagrees with the premise that fat people can lose weight by eating fewer calories than they expend. What you are missing is that — for many people — your solution is akin to telling an alcoholic to just drink less. Yes, it would solve their problem, but for a variety of reasons it’s probably not gonna happen.
Most fat people who want to lose weight have already tried eating less food. Just like many alcoholics have tried to cut down or stop drinking. Some of those people succeed, but many others don’t. The reasons why are far more complex than commitment and willpower.
This might not be a popular opinion: but I think that for roughly 99% of people losing weight and keeping it off long term is impossible once they’ve become overweight. They are just destined to be fat at that point no matter what they do. Weight may come off for a bit, but it returns… their body is irreparably compromised.
This reminds me of Sheldon Cooper's suggestion to Penny on The Big Bang Theory when she was having financial problems: "You know, it occurs to me that you could solve all your problems by obtaining more money".
Weight depends on a complex interaction between many systems of the body. Losing significant weight and keeping it off in healthy way without side effects can be difficult.
There was a good look at much of this in the Nova episode "The Truth About Fat" in 2020. Old Nova episodes are usually behind a paywall if you aren't a member of your local PBS station but occasionally old episodes become free for a while. It might be worth checking occasionally to try to catch it during one of those free periods.
Deliberately disingenuous? Pretending it's a diet problem, and not a psychological one.
Try this experiment: put a gun to your head and pull the trigger. You may find it hard. Your hand may shake; you will start sweating; rising panic will cloud your thinking.
But it's so easy! Just a couple pounds of pressure on the trigger. Anybody can do it.
That's me substituting a physiological problem for a psychological one.
People who need statins are on them for the rest of their life. People who need blood pressure regulators are on them for the rest of their life.
Why should GLP-1s be any different?
There are a lot of very inexpensive statins and blood pressure drugs (not all of them, of course).
$1000/month seems like a lot. Although if you end up eating significantly less, there's some savings there.
Theoretically, a lot (most?) of healthcare costs are downstream of being overweight. Going to the doctor for diabetes, hypertension, knee problems, and the long term effects of those might be less costly than a constant subscription to purchase GLP-1s.
Bonus is you no longer crave expensive sugary or alcoholic drinks and food.
Most people I know using it were using insurance, so paying much less than that, however for many of them the insurance companies are dropping coverage for it. That had pushed some to the compounding, and thus ozempocalypse as that avenue is removed as well.
They don’t. If you live outside of the USA it is cheaper (e.g. 400 cad a month in Canada)
The article also mentions the grey market, where you can buy a year’s worth of power from China for a couple hundred bucks. You do need to be able mix it up properly though.
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Knowing a couple people who've done it, they do it for a few months to lose weight, then stop taking it and try not to gain the weight back. I don't know anyone who's chosen to go on it permanently.
I'm doing essentially right now. Not big by any means, but loosing 20 to 30 pounds would be amazing for my joints.
For me, I've been at a stable weight for over a decade. I figure if I can drop down over a few months, I can stay at my target weight.
The drugs have been cheaply and widely available for a little over 17 months, and by some measures, about 1/3rd of patients prescribed semaglutide or tirzepatide are forecasted to be using either permanently.
Well, it’s a medication designed for diabetes (the weight loss variant has a higher dosage and different brand name, Wegowy or so), and for diabetes the usage is, by default, permanent. Unless it is replaced by other medication or if the lifestyle changes make the insulin resistance not be an issue any more.
Say it costs you $300/mo for the GLP-1, but it saves you $300+/mo in groceries/snacks from the gas station/eating out at restaurants/alcoholic drinks at a bar, it's pretty easy to explain the economics.
This is actively improving health outcomes for millions of people so of course insurance won't cover it and it is being taken away from consumers. If the shortage is over, why does it cost $1k or even $500? Sounds like there is still a shortage to me. I guess vaccines are out but price gouging is still in in the US healthcare system.
Profits over patients.
Pharmacies have to have crazy high prices though because PBMs reimburse at such shit rates, based on some percentage of the price given to them. Because if they buy the bottle at $30 and list the price at $60, the PBM contract will only reimburse at the adjusted wholesale price (another made up number), eg: 17% plus a $1.99 dispensing fee. This disgusting math results in getting a loss on the drug.
Even all this leaves out some of the most absurd abuses of PBMs. They set minimum drug copays, have the pharmacy collect a $15 copay for a $5 drug, and have the pharmacy pay the PMB the $10 difference. They make it a breach of contract for the pharmacy to inform the patient this is happening or to charge the $5 and bypass the insurance. The total lack of anything even approaching ethnics is absurd...
How should this system work, in an ideal world?
Short answer: Systems 1, 3, 12, or 23 in Figure 3 in this paper are pretty good options: https://eclass.ekdd.gr/esdda/modules/document/file.php/KST_B...
This is an extremely politicized question in the US, where a public health insurance option (a solution that's popular in much of the rest of the OECD) is fiercely opposed by a large swath of the population.
At the very least though, in an ideal world, payers, providers, pharmacies, and PBMs should not be allowed to be part of the same company.
Just force price transparency. Force drug makers to advertise the selling prices of their drugs, and enforce price discrimination laws. Force insurance and PBM companies to advertise the drug prices if purchased through insurance or PBM. Everybody should be paying the same price. And if not, everyone should be allowed to find out if they can pay a lower price.
And yes, get rid of PBMs. They are toxic middlemen who want their 'cut' for doing nothing at all.
See Gale (2023): https://pmc.ncbi.nlm.nih.gov/articles/PMC10441264/
My insurance covers it, but it depends on why it’s prescribed.
I'm far from convinced that some random "compounding pharmacy" produces effectively the same thing as Ozempic.
Compounding pharmacies existed before Ozempic and their entire business model is producing custom drugs at reasonable prices. For Ozempic, they order the GLP-1 peptides from a large Pharma company and then mix it to order with bacteriostatic water and any other additives. Mine includes a B-12 compound that is attempting to help with the weight loss. They are highly regulated and require trained and licensed employees. The compounding pharmacies I don't trust are the ones that only started to do Ozempic and nothing else. But I do trust my local one. They've made me medication for my animals for decades now.
Is there a compounding pharmacy aggregator online youve found trustworthy?
https://www.glpwinner.com/ is a good resource for comparing compound glp-1 providers
> They are highly regulated and require trained and licensed employees. The compounding pharmacies I don't trust are the ones that only started to do Ozempic and nothing else.
We already know that the compounding pharmacies violate patent law. Why should I believe they follow any other regulation?
The thing is, GLP-1 isn't that hard to make, and these compounding pharmacies make effectively the real thing.
Even further, most drugs aren't _that hard_ to manufacturer.
The hard part is discovering them and proving they're safe and effective.
What would convince you?
Some of those pharmacies were using crushed Rybelsus as their source for semaglutude.
What do you believe is different between their process and the patent holders?
They don't need to recoup their investments in discovery and regulatory approval.
What do we believe the discovery pathway was? Billions of dollars spent by heady businessmen with a keen eye for the molecules of interest? Hardly:
https://www.pnas.org/doi/10.1073/pnas.2415550121
And this type of drug lends itself to some of the least expensive trials you can hope for. The dosage level, expected dosing period, and measurement of outcomes are all uniquely well suited to inexpensive study. The trials were also exceedingly fast and quickly broke off into testing for all kinds of conditions such as Parkinsons but for the core case of weight loss it was as easy as it gets.
The status quo was pretty good for the FDA. Lily and Novo Nordisk still saw major stock price rises. Patients had super cheap drug options for something that would free up lots of money for non-medical spending in the economy. Why does an administration ruling via EO not keep the compounding loophole? It aligns with their goals. IMO, the compounders need to turn this into a media sound bite sized win for politicians. Because it certainly doesn’t make any scientific or objective medical sense to cease the compounding.