Break Up the Insulin Racket(nytimes.com)
nytimes.com
Break Up the Insulin Racket
http://www.nytimes.com/2016/02/21/opinion/sunday/break-up-the-insulin-racket.html
197 comments
Type 1 for about 15 years now. A1C has always been fine (typically 6.2 - 6.4).
Recently I decided to get "back in shape". I'm 5-foot-8, and this meant going from ~170lbs to ~140lbs. I actually dropped it rather easily (just walking and calorie counting), and I've maintained that weight since (6 months so far).
The kicker? I cut my insulin usage by 40%. However that wasn't just because I was no longer eating excess calories, but tracked my macros to see what I was eating. General guidelines are 50/30/20 for calories from carbs/fat/protein. Before I tracked it, I was apparently 60/25/15 which was VERY surprising to me, as I didn't think I was eating that many carbs. Now I'm 45/30/25, and slowly edging towards 43/30/27.
Granted, high protein diets aren't cheap, so the costs largely balance out. However tracking what you eat may reveal that you're getting far more of your calories from carbohydrates than you think.
Recently I decided to get "back in shape". I'm 5-foot-8, and this meant going from ~170lbs to ~140lbs. I actually dropped it rather easily (just walking and calorie counting), and I've maintained that weight since (6 months so far).
The kicker? I cut my insulin usage by 40%. However that wasn't just because I was no longer eating excess calories, but tracked my macros to see what I was eating. General guidelines are 50/30/20 for calories from carbs/fat/protein. Before I tracked it, I was apparently 60/25/15 which was VERY surprising to me, as I didn't think I was eating that many carbs. Now I'm 45/30/25, and slowly edging towards 43/30/27.
Granted, high protein diets aren't cheap, so the costs largely balance out. However tracking what you eat may reveal that you're getting far more of your calories from carbohydrates than you think.
I eat semi-low carb. I've done better than I am right now, but during the spring/summer I was playing basketball/volleyball about 3-4 times a week. Some nights for 2+ hours straight with minimal breaks. Eating low carb and trying to maintain a good blood sugar was pretty tricky for me. You have to eat quickly eat/drink something when you check the blood sugar between games and it goes low, and then you end up having to correct that later with more insulin. I've found low-carb to be fine and maintainable when I'm just working and sitting at my desk all day, but have struggled when trying to combine it with any type of higher intensity activity.
It seriously baffles me why anyone would get 50% of the calories from carbohydrates, let alone someone with diabetes. You don't need to eat high protein do you? Just eat fat...
If you have a Walmart nearby they carry Novolin R for ~$24/10ml. It's still expensive, but better than the $120 or more for Humulin I was spending at Costco (and still better that the $300 charged at some places).
I hadn't realized there was such a difference between cash price and prescription price.
Through work currently we can use a web site to help find your cheapest place for prescriptions. One bottle of Novolin R like you said about is about $25 from Walmart for cash price. One bottle of the same prescription with a discount coupon is $138 dollars.
That's still cheaper than Novolog/Humalog, but how in the world is it more expensive to buy insulin with a prescription and insurance than without? When I pay a 20% co-pay am I essentially paying my insurance company the extra money?
Through work currently we can use a web site to help find your cheapest place for prescriptions. One bottle of Novolin R like you said about is about $25 from Walmart for cash price. One bottle of the same prescription with a discount coupon is $138 dollars.
That's still cheaper than Novolog/Humalog, but how in the world is it more expensive to buy insulin with a prescription and insurance than without? When I pay a 20% co-pay am I essentially paying my insurance company the extra money?
I think it's because of the pharmacy benefit managers mentioned in the article. You use your card, you pay the negotiated rate that they have with the insurance company. You pay cash, you pay the rate Walmart is willing to sell it at.
Of course it makes no sense that the fiddly details of how you buy medicine matter to the tune of 5x. I guess part of the problem is that an awful lot of people are insulated from the costs of their medical care.
Of course it makes no sense that the fiddly details of how you buy medicine matter to the tune of 5x. I guess part of the problem is that an awful lot of people are insulated from the costs of their medical care.
As I understand it, there's no way around type 1 diabetes, you just can't produce insulin, or at least can't produce enough, and therefore need to supplement it.
But if you eat no carbohydrates, would you really need much insulin?
I don't understand what the fuss is about type 2. The resistance is developed because there is too much insulin in the blood all the time, and the solution is to take even more insulin?! It seems a no brainer that the solution should be to cut sugar out of the blood stream at all costs and reverse the insulin resistance...
But if you eat no carbohydrates, would you really need much insulin?
I don't understand what the fuss is about type 2. The resistance is developed because there is too much insulin in the blood all the time, and the solution is to take even more insulin?! It seems a no brainer that the solution should be to cut sugar out of the blood stream at all costs and reverse the insulin resistance...
That's not how type 2 works. The resistance is developed for unknown reasons and it continues to build over time. For a while, your body can compensate by producing more insulin to overcome the insulin resistance of your cells. You don't become symptomatic until your cells are almost completely insulin resistant. Your pancreas will continue to make insulin at crazy high rates, but eventually the cells that make insulin will die off (presumably from hyperactivity). This is the point at which type 2 diabetics need insulin.
As far as cutting sugar out of your blood - you can't. Your body tries to maintain 80-110 mg/dL of sugar in your blood. You NEED sugar. It's energy. In fact, sugar is the ONLY energy source your brain can use. The problem is when you're a diabetic, your body's cells can't take that sugar out of the blood to use it for energy. That's when you try to minimize your sugar intake, because if you don't, you can do irreversible damage to your nerves and vasculature.
As far as cutting sugar out of your blood - you can't. Your body tries to maintain 80-110 mg/dL of sugar in your blood. You NEED sugar. It's energy. In fact, sugar is the ONLY energy source your brain can use. The problem is when you're a diabetic, your body's cells can't take that sugar out of the blood to use it for energy. That's when you try to minimize your sugar intake, because if you don't, you can do irreversible damage to your nerves and vasculature.
Not so, you certainly don't need to eat sugar, too much sugar is poisonous and if usage is prolonged, causes insulin resistance and Type 2 diabeties. Starches are not much better, since they are so easily converted to sugars.
Most high energy usage organs inc the brain are quite happy burning ketone bodies - made from fat, in fact the heart prefers them. A few brain and organ functions do require some glucose, but these can be made from protein, better though to eat some healthy carbs such as spinach, for this. Most Type 2 diabetes sufferers can be cured by a strict low carb high fat diet. Healthiest fats are saturated grass fed cow's butter and lard, coconut oil or mono saturated olive oil - contrary to most people's belief. Unsaturated vegetable oils are very dangerous they are unstable and easily become poisonous, margarine is evil.
Most high energy usage organs inc the brain are quite happy burning ketone bodies - made from fat, in fact the heart prefers them. A few brain and organ functions do require some glucose, but these can be made from protein, better though to eat some healthy carbs such as spinach, for this. Most Type 2 diabetes sufferers can be cured by a strict low carb high fat diet. Healthiest fats are saturated grass fed cow's butter and lard, coconut oil or mono saturated olive oil - contrary to most people's belief. Unsaturated vegetable oils are very dangerous they are unstable and easily become poisonous, margarine is evil.
I have a relative that is type 1. A couple of years ago he went on a no carb diet and at xmas he was telling me that he now uses a lot less insulin and generally feels a lot better. He also lost some weight (he wasn't obese, either, but he now looks very trim).
Have you tried something like that?
Have you tried something like that?
I know you mean well, but managing this sort of thing is something that's extremely different from person to person, very hard to get right, and often a source of great personal pain for people trying and failing. Please refrain or be extremely cautious about enthusiastically telling everyone what worked for your relative.
While I agree it's worth being cautious about how you phrase any "advice", I think the parent post was perfectly reasonable. There was something that worked well for someone he knew, and he mentioned it in case it might help.
For context, I've been a Type 1 diabetic since around '85 and, as I get older, I'm becoming more insulin resistant (Type 2) also. While I've been able to keep my blood sugar mostly under control, I test my blood 4-10 times a day and sometimes need to take insulin 5+ times in a single day (sometimes it just doesn't "work" and I need to take more in smaller amounts to bring my blood sugar down. I can't just retake the original amount in case the first shot suddenly "kicks in").
For context, I've been a Type 1 diabetic since around '85 and, as I get older, I'm becoming more insulin resistant (Type 2) also. While I've been able to keep my blood sugar mostly under control, I test my blood 4-10 times a day and sometimes need to take insulin 5+ times in a single day (sometimes it just doesn't "work" and I need to take more in smaller amounts to bring my blood sugar down. I can't just retake the original amount in case the first shot suddenly "kicks in").
Type I diabetes is a complex condition where restricting carbohydrates may not necessarily reduce hyperglycemia (high blood glucose) events. There is a dangerous downside counterbalancing the negligible benefits. The dieter significantly increases their risk of hypoglycemia (low blood glucose). Serious symptoms of hypoglycemia include heart palpitations, dizziness and coma.
I'm guessing a no carb diet could also imply high protein, to replace the carbohydrate calories. Too much protein (>20% of calories) is bad for Type I diabetics leading to a state known as microalbuminuria. In layman's terms: increased stress on your kidneys. More on this at: http://journal.diabetes.org/diabetesspectrum/00v13n3/pg132.h...
In summary, almost every (if not every) diabetes publication & specialist advises heavily against low/no carb diets, instead recommending a balanced diet.
I'm guessing a no carb diet could also imply high protein, to replace the carbohydrate calories. Too much protein (>20% of calories) is bad for Type I diabetics leading to a state known as microalbuminuria. In layman's terms: increased stress on your kidneys. More on this at: http://journal.diabetes.org/diabetesspectrum/00v13n3/pg132.h...
In summary, almost every (if not every) diabetes publication & specialist advises heavily against low/no carb diets, instead recommending a balanced diet.
I have T1 diabetes. Your post would create the impression that it's possible to do without insulin just by changing diet. The reality is that going without insulin is lethal in just a few days, and dietary changes can only reduce usage by a little.
I didn't mean to imply my relative went insulin free. He definitely did not. Based on the replies, I realize I probably shouldn't have posted what I did. I was trying to be helpful, but I'm no expert in this, so I should have stayed out of it.
Insulin goes bad about 30 days after first use. Pretty much all diabetics need to buy a vial or two every month, no matter if you've used it all or not.
Think of it like keeping milk stocked in your fridge. Even if you spread it out to last more than a month, the remaining half will go bad before you got to it.
So although changing diet and increasing physical activity may reduce insulin requirements in both type 2 and type 1 (as several people have anecdotally shared here), you can see how it doesn't avoid buying insulin every month.
Think of it like keeping milk stocked in your fridge. Even if you spread it out to last more than a month, the remaining half will go bad before you got to it.
So although changing diet and increasing physical activity may reduce insulin requirements in both type 2 and type 1 (as several people have anecdotally shared here), you can see how it doesn't avoid buying insulin every month.
I think the hardest thing for the American political system to grasp about our medical system is that spending more money is not the answer. We already spend 16% of GDP, about double what almost all other countries spend on health care and have worse outcomes.
I'm glad that there's some new thinking going on here that may lead to some movement. Unfortunately, all the incentives are aligned such that everyone who is making a ton of money off the system lobbies to make even more.
I'm glad that there's some new thinking going on here that may lead to some movement. Unfortunately, all the incentives are aligned such that everyone who is making a ton of money off the system lobbies to make even more.
At the same time doctor's income is actually decreasing. So America has a lot of parasitic Capitalists adding little value but sucking billions of dollars out of the system. This sort of Capitalism does no one any good. A lot of that money is being sucked out by regulatory capture.
Spending more money will lead to yet more money being lost to the same parasites which will simply find ways of increasing their ability to leech money from the system.
Spending more money will lead to yet more money being lost to the same parasites which will simply find ways of increasing their ability to leech money from the system.
It's likely that doctors earning less is an important component of reducing heath care costs in the US. Of course we should try to make that happen by increasing the supply of doctors rather than mismanagement.
Doctors make up less than 9% of total health care spending. The idea that you're going to make a dent in spending by cutting doctor salaries further is insane.
They are the only fully knowledgable people in hospital, and because they are so overloaded they are making thousands of key decisions everyday in a rush. It's already conventional wisdom that you can't make nearly as much money as a doctor as you use to, and so the best and brightest students are skipping it for more lucrative fields. This damage will take decades to be undone, even if we were to raise salaries immediately, because of the long training.
They are the only fully knowledgable people in hospital, and because they are so overloaded they are making thousands of key decisions everyday in a rush. It's already conventional wisdom that you can't make nearly as much money as a doctor as you use to, and so the best and brightest students are skipping it for more lucrative fields. This damage will take decades to be undone, even if we were to raise salaries immediately, because of the long training.
Yeah, I said we should work to increase the supply of doctors, not that we should fix their compensation.
Reducing the undergraduate requirement and subsidizing medical school would both be reasonable ways to do that.
Reducing the undergraduate requirement and subsidizing medical school would both be reasonable ways to do that.
Reducing the undergraduate requirements does not seem like a very good way to reduce spending without decreasing quality.
Med school admissions require a small number of classes and then consider GPA and MCAT scores. I don't expect 2 years of GPA to be much less informative than 4 or 5 years of GPA.
The insurance system is itself a racket. Putting even more people into the insurance system only makes insurance companies richer, doesn't do much for the average American.
True, that.
If pressed to name the single stupidest concept I've ever encountered in over forty years of life, I'd have to say it's the notion of selling "insurance" in a market where you know perfectly well that 99.9% of participants will eventually have to file expensive claims.
Communism is way up there, along with smoking, and religion, and then there's the time that Circuit City tried to sell their own proprietary brand of self-destructing DVDs. But none of them can compare, in terms of sheer forehead-slapping stupidity, to the idea of "health insurance."
If pressed to name the single stupidest concept I've ever encountered in over forty years of life, I'd have to say it's the notion of selling "insurance" in a market where you know perfectly well that 99.9% of participants will eventually have to file expensive claims.
Communism is way up there, along with smoking, and religion, and then there's the time that Circuit City tried to sell their own proprietary brand of self-destructing DVDs. But none of them can compare, in terms of sheer forehead-slapping stupidity, to the idea of "health insurance."
Briefly, since I'm on mobile, I'll explain why I think you're completely wrong.
Insurance doesn't seek to prevent the inevitable. That's not why we buy insurance. We buy insurance to insure against catastrophic risk. Would you rather flip a coin and lose your house, or flip 10,000 coins where each toss risks $100?
Humans are risk averse, and there is plenty to say about the value of risk reduction. We buy insurance as a trade off: we know we're getting skimmed by the salesman, but our preference for reduced volatility means we gladly take a small certain loss instead of a possible huge one.
On the other end, insurance sales men don't just sit on their obligations. They swap risk and find complementary risks: it's highly unlikely a hurricane in Florida will happen at the same time as an ice storm in the north east. Tally up all the insurance salesmen and you'll find they all aim to hold a bit of each other's risk. They, just like us, prefer to take a small certain loss than a possible disaster.
This is the purpose of insurance: to dilute the 'pain' of singularly disasterous events across a large enough population so we collectively do better off.
Health insurance is supposed to be the same way: you shouldn't need insurance for buying aspirin at Walgreens. $5 ain't gonna kill you. What will seriously damage you is an unforeseen large medical expense. As it stands, most people don't really need much in the way of serious medical care- it's true to say that a small population of people incur far higher medical expenses than the rest of society. This is exactly the purpose insurance was designed to deal with.
I leave my discussion here. I recognize that there is something deeply unfair about leaving a population out in the cold. I agree, we ought to do something for them, but this is not a critique of our social policies at large. I mean to simply remark that insurance is exactly the financial vehicle that best serves to smooth out the consequences of unlikely yet expensive occurrences.
Insurance doesn't seek to prevent the inevitable. That's not why we buy insurance. We buy insurance to insure against catastrophic risk. Would you rather flip a coin and lose your house, or flip 10,000 coins where each toss risks $100?
Humans are risk averse, and there is plenty to say about the value of risk reduction. We buy insurance as a trade off: we know we're getting skimmed by the salesman, but our preference for reduced volatility means we gladly take a small certain loss instead of a possible huge one.
On the other end, insurance sales men don't just sit on their obligations. They swap risk and find complementary risks: it's highly unlikely a hurricane in Florida will happen at the same time as an ice storm in the north east. Tally up all the insurance salesmen and you'll find they all aim to hold a bit of each other's risk. They, just like us, prefer to take a small certain loss than a possible disaster.
This is the purpose of insurance: to dilute the 'pain' of singularly disasterous events across a large enough population so we collectively do better off.
Health insurance is supposed to be the same way: you shouldn't need insurance for buying aspirin at Walgreens. $5 ain't gonna kill you. What will seriously damage you is an unforeseen large medical expense. As it stands, most people don't really need much in the way of serious medical care- it's true to say that a small population of people incur far higher medical expenses than the rest of society. This is exactly the purpose insurance was designed to deal with.
I leave my discussion here. I recognize that there is something deeply unfair about leaving a population out in the cold. I agree, we ought to do something for them, but this is not a critique of our social policies at large. I mean to simply remark that insurance is exactly the financial vehicle that best serves to smooth out the consequences of unlikely yet expensive occurrences.
> Insurance doesn't seek to prevent the inevitable. That's not why we buy insurance. We buy insurance to insure against catastrophic risk.
Ideally, that would be the purpose of health insurance, but in the USA its used to pay for essential health care such as regular visits to your dentist or general practitioner, or to get the negotiated rate on prescription drugs.
When people talk about the inevitability of healthcare use, they don't refer to heart attacks, an onset of cancer, or broken legs. They refer to chronic conditions like arthritis, or high blood pressure that will plague the vast majority of people simply because of their increasing age. These chronic conditions are seemingly inevitable, and are factored into the cost of health insurance.
Ideally, that would be the purpose of health insurance, but in the USA its used to pay for essential health care such as regular visits to your dentist or general practitioner, or to get the negotiated rate on prescription drugs.
When people talk about the inevitability of healthcare use, they don't refer to heart attacks, an onset of cancer, or broken legs. They refer to chronic conditions like arthritis, or high blood pressure that will plague the vast majority of people simply because of their increasing age. These chronic conditions are seemingly inevitable, and are factored into the cost of health insurance.
I leave my discussion here. I recognize that there is something deeply unfair about leaving a population out in the cold. I agree, we ought to do something for them, but this is not a critique of our social policies at large. I mean to simply remark that insurance is exactly the financial vehicle that best serves to smooth out the consequences of unlikely yet expensive occurrences.
The problem as I see it is that insurers swap and reinsure risk based on classifying the customers into various tranches. If I have a lot of accidents and tickets, I'll pay more for car insurance. I can expect the same fate if I buy a Corvette rather than a Civic. If my house has a thatched roof, I might have to pay more for fire insurance. If I live in Florida, I might pay more for flood insurance but less for earthquake insurance. If I smoke, I'll need to pay more for term life coverage. But my health expenses are correlated to nothing so much as my age. There's not that much I can do to change that. I can buy a different car, or a different house, or move to a different state, but no matter how healthy I strive to be, my last year of life is virtually certain to be more expensive than any other. Very possibly more expensive than all of the other years combined.
My mother had great insurance, thanks to her civil-service career back in the 1950s and 1960s... and in the three weeks leading up to her death (of old age, more or less) in the 1990s, the medical bills probably consumed half the economic value she contributed during her lifetime. That was not a "risk"... it was practically a certainty. In the absence of a sudden cause of death. I'll probably experience the same thing, and you probably will too.
So if "insurance" is just code for time-shifting the payments that the healthcare industry will eventually demand from almost all of us -- which it is -- how can that be the right economic model? It doesn't work anything like any other form of insurance. It might not be a racket, but it's also not a free market.
The problem as I see it is that insurers swap and reinsure risk based on classifying the customers into various tranches. If I have a lot of accidents and tickets, I'll pay more for car insurance. I can expect the same fate if I buy a Corvette rather than a Civic. If my house has a thatched roof, I might have to pay more for fire insurance. If I live in Florida, I might pay more for flood insurance but less for earthquake insurance. If I smoke, I'll need to pay more for term life coverage. But my health expenses are correlated to nothing so much as my age. There's not that much I can do to change that. I can buy a different car, or a different house, or move to a different state, but no matter how healthy I strive to be, my last year of life is virtually certain to be more expensive than any other. Very possibly more expensive than all of the other years combined.
My mother had great insurance, thanks to her civil-service career back in the 1950s and 1960s... and in the three weeks leading up to her death (of old age, more or less) in the 1990s, the medical bills probably consumed half the economic value she contributed during her lifetime. That was not a "risk"... it was practically a certainty. In the absence of a sudden cause of death. I'll probably experience the same thing, and you probably will too.
So if "insurance" is just code for time-shifting the payments that the healthcare industry will eventually demand from almost all of us -- which it is -- how can that be the right economic model? It doesn't work anything like any other form of insurance. It might not be a racket, but it's also not a free market.
He's got a point. Insurances are small payments to get a cushion in case of rare events.
Going to hospital at some point in life is not a rare thing. It's common and payments are not small.
Calling it insurance is stretching the term. Social security is way better name for it. But then why let the companies profit from providing it.
Going to hospital at some point in life is not a rare thing. It's common and payments are not small.
Calling it insurance is stretching the term. Social security is way better name for it. But then why let the companies profit from providing it.
I don't even understand how a progressive country like Canada can basically force people to take insurance because drugs (which if you have any health issue, you'll have to pay for) aren't covered by our universal healthcare system. It's ridiculous.
frandroid(2)
They should have never let mutuals demutualize. That's when the criminal level exploitation kicked into high gear. Rather, there should be incentives for for-profit insurance to transform into a mutual.
>We already spend 16% of GDP, about double what almost all other countries spend on health care and have worse outcomes.
The medical system is not the primary influence on a population's health. It's probably about third behind public health systems (sewage, water, and food inspection) and the health habits of the population. You're never going to have a health system that can compensate for four hundred pound diabetics who didn't realize they were pregnant for six months.
The medical system is not the primary influence on a population's health. It's probably about third behind public health systems (sewage, water, and food inspection) and the health habits of the population. You're never going to have a health system that can compensate for four hundred pound diabetics who didn't realize they were pregnant for six months.
I have been a Type 1 diabetic since I was eight years old. I am now 31 and am not and have never been obese.
In Type 1 diabetes, the immune system attacks the beta cells in the pancreas which would normally produce insulin.
It is a lifelong autoimmune disorder, not a lifestyle choice.
It also happens to be the population of diabetics most likely to be impacted by the cost of insulin, as our bodies do not produce any.
I understand that the last sentence was meant as a quip/jab at the clear obesity problem which the United States in particular is dealing with, along with the epidemic of type 2 diabetes that is resulting. It is real and needs to be fought on many fronts.
Your argument, however, implies that ALL diabetics are overweight, irresponsible people, which is simply not the case for type 1's at all and for many (if not most) type 2's.
In Type 1 diabetes, the immune system attacks the beta cells in the pancreas which would normally produce insulin.
It is a lifelong autoimmune disorder, not a lifestyle choice.
It also happens to be the population of diabetics most likely to be impacted by the cost of insulin, as our bodies do not produce any.
I understand that the last sentence was meant as a quip/jab at the clear obesity problem which the United States in particular is dealing with, along with the epidemic of type 2 diabetes that is resulting. It is real and needs to be fought on many fronts.
Your argument, however, implies that ALL diabetics are overweight, irresponsible people, which is simply not the case for type 1's at all and for many (if not most) type 2's.
I'm type 1 and I don't mind jabs about weight. Diabetes isn't a completely random autoimmune disease; some of us have it because of our mothers' diets, bad periods of sickness during childhood and so on. Late adult type 1 diabetics can often point to overwork, bad diet and some type 1s likely have issues with fatty pancreas disease (those with very low, but existent, c peptide, for example.) I believe we would have fewer type 1 diabetics in a healthier country. I also think that, though type 1s aren't as obese as type 2s on average, we can always do better at reducing our need for insulin and keeping ourselves fit and mostly well-functioning. I don't believe we have much to gain from telling people not to lump us in with pure type 2s as if we are a protected class.
Type 1 diabetic here. I remember having the flu before I got the diabetes, and later on there's been some research that if you have the genes and get the flu when you're a child, there's a big chance of losing your insulin production. Would love to have some sources for this though, because it's been a long time since I heard about this.
I was lucky though, born in Finland with the best type 1 diabetes study and completely free insulins and medical care.
I was lucky though, born in Finland with the best type 1 diabetes study and completely free insulins and medical care.
I have no idea what your comment has to do with mine. If you read it again you'll see I imply nothing beyond the fact that Americans, as a group, suffer from poor health choices.
Are you saying that the US population has health habits poor enough to account for the 1/3 more we spend on health care than anywhere else in the developed world?
No, I'm saying our health system is as good as, if not better, than anywhere else. The problem is there are a lot of Americans who have such a high opinion of the medical system they think they can adopt whatever habits they want to adopt without repercussion. Because the doctors can fix whatever problems result. This is a fantasy.
I'm pretty sure there are some additional costs that result from lifestyle choices, but I don't know how much they impact the bottom line.
And I don't think you can compare spending across countries like that. Americans have different expectations from the medical system - they don't accept money as a reason heroic measures shouldn't be taken, particularly at end-of-life.
There are a lot of countries where it's reasonable to say to the family "Look, your father is very old. We could operate and maybe put his cancer into remission, but he's likely to die in a month or two anyway and we only have so much money." The US isn't one of them, and my suspicion is when we get a single payer system the costs won't actually come down much if at all.
I'm pretty sure there are some additional costs that result from lifestyle choices, but I don't know how much they impact the bottom line.
And I don't think you can compare spending across countries like that. Americans have different expectations from the medical system - they don't accept money as a reason heroic measures shouldn't be taken, particularly at end-of-life.
There are a lot of countries where it's reasonable to say to the family "Look, your father is very old. We could operate and maybe put his cancer into remission, but he's likely to die in a month or two anyway and we only have so much money." The US isn't one of them, and my suspicion is when we get a single payer system the costs won't actually come down much if at all.
We don't have worse outcomes for the largest most serious illnesses, cancer and heart disease. The US medical system is top tier in those for one of the largest, most obese, generally unhealthy and diverse populations in the world. It's actually a miracle to have these kinds of outcomes.
Never thought about that, however the costs are still far to high and the amount of paperwork and administration that patients are subjected to is just a nightmare.
How timely: this just dropped in the NYTimes today as well, "A Do-It-Yourself Revolution in Diabetes Care".
http://www.nytimes.com/2016/02/23/health/a-do-it-yourself-re...
Featuring the Open Insulin project. Many of the supporters of that project came from HN.
http://www.nytimes.com/2016/02/23/health/a-do-it-yourself-re...
Featuring the Open Insulin project. Many of the supporters of that project came from HN.
One of my siblings is a major contributor to Nightscout, it's a great piece of open source software. The makers of the Dexcom software have been stonewalling their efforts, but at least that isn't killing the project. Hopefully something similar can be done for insulin, though that seems a lot more difficult.
I'm a biologist who works in the pharmaceutical industry. I like the idea of open source insulin as much as the next guy. But. I just took a look at their website and it's a complete joke, frankly. It's basically a high-school science experiment. The sort of thing that a single undergrad could do in a few days. Compared to the thousands of man-years required to produce and test a new pharmaceutical product.
I wish them luck, but c'mon. Biopharma is not IT where a smart kid can compete from his garage. It just isn't.
The NYTimes article says "the hackers hope to be able to demonstrate the technological feasibility" rather than manufacture a drug. But everyone knows that it's technically feasible -- the challenge (and cost) is in the doing.
I wish them luck, but c'mon. Biopharma is not IT where a smart kid can compete from his garage. It just isn't.
The NYTimes article says "the hackers hope to be able to demonstrate the technological feasibility" rather than manufacture a drug. But everyone knows that it's technically feasible -- the challenge (and cost) is in the doing.
"Biopharma is not IT where a smart kid can compete from his garage."
Well, I am currently producing one early-stage (xenograft) drug candidate literally in my garage, and have made two new molecules based on the structure, also in my garage, about to be submitted to structural characterization (and eventually, in vitro studies and maybe even xenograft)... But yeah, I do have a PhD in chemistry, and spend 10-20h/wk on the project.
(also with the caveat that all my studies hit a "brick wall" of can't do in the garage when I have to start worrying about GMP).
Well, I am currently producing one early-stage (xenograft) drug candidate literally in my garage, and have made two new molecules based on the structure, also in my garage, about to be submitted to structural characterization (and eventually, in vitro studies and maybe even xenograft)... But yeah, I do have a PhD in chemistry, and spend 10-20h/wk on the project.
(also with the caveat that all my studies hit a "brick wall" of can't do in the garage when I have to start worrying about GMP).
Don't get me wrong: synthesizing compounds and expressing proteins is not that hard. Those things can be done in a garage. Extensive pharmacological testing in cultured cells and animals is much, much harder. I respect what you're doing, but you obviously know what GMP is and have some idea of what drug research entails, so to claim that a garage hackers could produce a drug candidate is disingenuous. At our company, a drug candidate is something that has shown efficacy in animal pharmacology models and has gone through 13-week tolerability studies in animals appears safe. And that's all before GMP.
I don't think there are specific guidelines as to when you start calling something a candidate or not, although I personally wouldn't call a "hit" from a screen a "candidate". Everything I am working with is a natural product derivate, In fact, engineered to reduce tox of a compound that started off in late-stage preclinicals, so the odds of success are (qualitatively) higher to begin with.
>Extensive pharmacological testing in cultured cells and animals is much, much harder.
And that's why I'm contracting CROs for those parts. I guess technically that's "taking out of the garage", but I never said the whole thing is being done in the garage!
>Extensive pharmacological testing in cultured cells and animals is much, much harder.
And that's why I'm contracting CROs for those parts. I guess technically that's "taking out of the garage", but I never said the whole thing is being done in the garage!
>I don't think there are specific guidelines as to when you start calling something a candidate
True, that's why I said "at our company". It differs everywhere, as you mention. My only point was that we screen thousands of compounds, and it's only after a compound has shown desirable activity, safety, ADME, PKPD, etc, that it becomes a real "candidate". Not everyone realizes this, and thinks you can synthesize a compound and the next step is to file an IND.
Your point about CROs is a good one, and I thought of it after my post. We use lots of CROs, too. And there are obviously lots of successful virtual companies that don't do any wet-work at all. But CROs cost lots of money. Not really cheaper than doing it yourself, just more convenient sometimes. Virtual companies can work because they have millions in VC.
Anyway good luck with your endeavor. I don't mean to sound cynical or negative, but not everyone in IT realizes that the two fields are qualitatively different in many ways and I think the differences are worth pointing out since they're often overlooked around here...
True, that's why I said "at our company". It differs everywhere, as you mention. My only point was that we screen thousands of compounds, and it's only after a compound has shown desirable activity, safety, ADME, PKPD, etc, that it becomes a real "candidate". Not everyone realizes this, and thinks you can synthesize a compound and the next step is to file an IND.
Your point about CROs is a good one, and I thought of it after my post. We use lots of CROs, too. And there are obviously lots of successful virtual companies that don't do any wet-work at all. But CROs cost lots of money. Not really cheaper than doing it yourself, just more convenient sometimes. Virtual companies can work because they have millions in VC.
Anyway good luck with your endeavor. I don't mean to sound cynical or negative, but not everyone in IT realizes that the two fields are qualitatively different in many ways and I think the differences are worth pointing out since they're often overlooked around here...
CROs are really expensive, but it's surprising what is and what isn't. An NMR goes for ~$160 (but usually because you have unremovable features like GLP, which you may or may not care about depending on the step). So for some of these things I'm just "calling over a friend who is a professor at X university" and getting a bit of spectrometer time and a grad student.
OTOH, I'm getting xenograft for just about $30k, which I think is about right.
> not everyone in IT realizes that the two fields are qualitatively different in many ways and I think the differences are worth pointing out since they're often overlooked around here...
Totally agree.
OTOH, I'm getting xenograft for just about $30k, which I think is about right.
> not everyone in IT realizes that the two fields are qualitatively different in many ways and I think the differences are worth pointing out since they're often overlooked around here...
Totally agree.
> Biopharma is not IT where a smart kid can compete from his garage. It just isn't.
It isn't today, but it may be at some point. We tend to underestimate the effects of monumental shifts like we've had in IT. This project represents the first steps in that direction.
> The sort of thing that a single undergrad could do in a few days.
Even if this were true, the OpenInsulin project doesn't have a large institution's lab facility. Nor does the project have a government grant as benefactor. They are operating only off crowdfunding. It's obviously not enough to get through the FDA approval process, but IS enough to construct a roadmap to that end and make headway on a functional insulin producing organism. The project already has E. coli making proinsulin. The experimental focus has now moved to methods of purification. They are also investigating the feasibility/cost of getting this through the FDA approval process for biosimilar molecules.
I think the real magic of this project is its open nature, which I find to be lacking in the scientific community. This is research that anyone can make meaningful contributions to. Science (specifically biology) can learn a lot from open source software.
It isn't today, but it may be at some point. We tend to underestimate the effects of monumental shifts like we've had in IT. This project represents the first steps in that direction.
> The sort of thing that a single undergrad could do in a few days.
Even if this were true, the OpenInsulin project doesn't have a large institution's lab facility. Nor does the project have a government grant as benefactor. They are operating only off crowdfunding. It's obviously not enough to get through the FDA approval process, but IS enough to construct a roadmap to that end and make headway on a functional insulin producing organism. The project already has E. coli making proinsulin. The experimental focus has now moved to methods of purification. They are also investigating the feasibility/cost of getting this through the FDA approval process for biosimilar molecules.
I think the real magic of this project is its open nature, which I find to be lacking in the scientific community. This is research that anyone can make meaningful contributions to. Science (specifically biology) can learn a lot from open source software.
> construct a roadmap
I just don't understand what this means here. Cloning a gene and expressing it in e.coli is something that has been routine for decades. Literally. These simple experiments won't provide a roadmap to do anything that we haven't known how to do for a long time. It's like a crowdsourcing project to raise money to write a "hello world" program. Seriously.
Open-ness is great. But "meaningful contributions" are generally made at the cutting edge of scientific research. The experiments described are nipping at the heels of science that was worked-out in the early 80s, so I fail to see how a meaningful contribution will be made here. Open source is great, but making headway in drug discovery or development is a Hard Problem and this doesn't strike me as a serious effort. Just my two cents.
I just don't understand what this means here. Cloning a gene and expressing it in e.coli is something that has been routine for decades. Literally. These simple experiments won't provide a roadmap to do anything that we haven't known how to do for a long time. It's like a crowdsourcing project to raise money to write a "hello world" program. Seriously.
Open-ness is great. But "meaningful contributions" are generally made at the cutting edge of scientific research. The experiments described are nipping at the heels of science that was worked-out in the early 80s, so I fail to see how a meaningful contribution will be made here. Open source is great, but making headway in drug discovery or development is a Hard Problem and this doesn't strike me as a serious effort. Just my two cents.
I think you're being disingenuous for the sake of argument. There is a non-trivial scientific challenge of characterizing both proinsulin subunits and developing a protocol that works for public domain without adverse effects. Specifically, getting the sequence right to get the folding right.
Yeah, it's been done before but with different variations. To do so in a way that isn't locked up in IP is worthwhile. And it's a challenge that faces an uphill battle in terms of incentive and payoff. The crowdfunding covers that risk capital gap that would otherwise make this impossible. You could say their approach is a road not taken.
Yeah, it's been done before but with different variations. To do so in a way that isn't locked up in IP is worthwhile. And it's a challenge that faces an uphill battle in terms of incentive and payoff. The crowdfunding covers that risk capital gap that would otherwise make this impossible. You could say their approach is a road not taken.
Fair-enough. I'm not an insulin expert so perhaps I don't appreciate the particular challenges here. But the way it was described on the website didn't make the task sound too impressive.
I was also struck by the money involved. ~$15k will pay for an experiment or two, as they indicate on the website. It takes many thousands of experiments to get anywhere in Biopharma.
So... it's a nice start, and maybe a worthwhile challenge, but it hardly seems like a serious effort. And not everyone realizes that, so I thought it was worth pointing out.
I was also struck by the money involved. ~$15k will pay for an experiment or two, as they indicate on the website. It takes many thousands of experiments to get anywhere in Biopharma.
So... it's a nice start, and maybe a worthwhile challenge, but it hardly seems like a serious effort. And not everyone realizes that, so I thought it was worth pointing out.
Yes, $15k would not be the same for a biopharma company, but they explicitly do not have the same goals of a biopharma company, nor are they a biopharma company, nor do their people come biopharma, nor are their users biopharma companies. Biopharma companies do not benefit from this, so why does it even matter what the status quo or state of the art of "doing science" is?
It's easy to be a cynic on HN, it's harder to think critically about why someone else would believe that it could work. You don't really get rewarded for empathy on here.
It's easy to be a cynic on HN, it's harder to think critically about why someone else would believe that it could work. You don't really get rewarded for empathy on here.
>It isn't today, but it may be at some point. We tend to underestimate the effects of monumental shifts like we've had in IT. This project represents the first steps in that direction.
But what makes pharma expensive and time-consuming is the regulatory process. Producing drugs is easy - meth dealers do it all the time. But spending a decade getting your drug through the federal system is expensive, and there's no technological shortcut. I'll take more interest when they stop "investigating the feasibility/cost of getting this through the FDA" and publish a plan to actually do it.
But what makes pharma expensive and time-consuming is the regulatory process. Producing drugs is easy - meth dealers do it all the time. But spending a decade getting your drug through the federal system is expensive, and there's no technological shortcut. I'll take more interest when they stop "investigating the feasibility/cost of getting this through the FDA" and publish a plan to actually do it.
> In much of Europe, insulin costs about a sixth of what it does here. That’s because the governments play the role of pharmacy benefit managers. They negotiate with the manufacturer directly and have been very effective at driving down prices. In the United States, we rely on the private sector and a free market for drug pricing.
Cartels are an emergent phenomenon[1] and it is in the interest of a fair market to not be "free market," whenever it leads to rackets.
[1] https://news.ycombinator.com/item?id=3494224
Cartels are an emergent phenomenon[1] and it is in the interest of a fair market to not be "free market," whenever it leads to rackets.
[1] https://news.ycombinator.com/item?id=3494224
But couldn't you argue that the problem is in the patent system, not in the free market? 3 companies holding on to patents longer than normal doesn't sound like a free market to me.
As the article says, if the patents didn't exist, we could have a generic brands.
As the article says, if the patents didn't exist, we could have a generic brands.
Patents aren't free market, since they require the government to play a role (enforcement) in favour of patent holders. A free market wouldn't be able to protect the IP, it would use DRM and peer-to-peer contracts, and as soon as the receipe gets out, they'd be in for ther investment. A socialist government would define a type a company that is allowed to conduct medical research and fix the bounds within which the company can invest or the sale prices.
That's stretching the definition of free market a bit. You could apply it to real estate property rights too and argue that a corner shop isn't in a free market because the owner has paid for a monopoly on access to that building which is most suited to selling things from. His property rights are protected by the police to stop competitors sending their goons in to take over the building. The same goes for any business that owns any sort of valuable property, especially if their ownership gives them exclusive access to it. So I think a useful definition of free market has to include various property rights, including IP. As long as people can trade those rights among each other, whoever holds the patent would probably have spent a fair amount of money to either invent or buy it.
There is always debate over the extent of "free". At the extreme, the state doesn't enforce land property and the landlord is responsible for hiring an army to protect some land.
In a more moderate situation land and property are organized and enforced by the state, because this protection is more efficient for everyone.
Intellectual property is incredibly hard to enforce, because anyone can copy an idea, or bits on a hard drive, so you'll have to come up with convoluted solutions to check for the presence of information at every point in a network, and we're expecting citizen to pay taxes to pay the police force who will enforce those rights in favour of the owners.
There are other, more efficient means, but they involve the richest to get a smaller cut (e.g. instead of the state enforcing DRMs for free, they have to pay for good DRM themselves), so it's very valuable for them to leverage the state to enforce their self-proclaimed rights.
In a more moderate situation land and property are organized and enforced by the state, because this protection is more efficient for everyone.
Intellectual property is incredibly hard to enforce, because anyone can copy an idea, or bits on a hard drive, so you'll have to come up with convoluted solutions to check for the presence of information at every point in a network, and we're expecting citizen to pay taxes to pay the police force who will enforce those rights in favour of the owners.
There are other, more efficient means, but they involve the richest to get a smaller cut (e.g. instead of the state enforcing DRMs for free, they have to pay for good DRM themselves), so it's very valuable for them to leverage the state to enforce their self-proclaimed rights.
There's a fundamental difference between physical property and intellectual "property": an owner of the former can conceivably hire guards to protect or restrict access to that property, since physical objects are generally localized phenomena.
But there is no conceivable way to enforce things like copyright or patents without something at least as powerful as a government, since they are supposed to be binding on every single person, everywhere, all the time.
IMO the concept of "intellectual property" is at best orthogonal to that of a "free market".
But there is no conceivable way to enforce things like copyright or patents without something at least as powerful as a government, since they are supposed to be binding on every single person, everywhere, all the time.
IMO the concept of "intellectual property" is at best orthogonal to that of a "free market".
If we just put someone else in charge of the market, things will be better? Maybe I can vote them out if they mismanage the market, eh?
Or, rather, I can vote out the people who delegated the appointment of top-level bureaucrats to their senior staff, who suggested industry insiders intent on regulatory capture?
I can vote out those people after the fact? Gee, that'll fix it.
If you're concerned with insulin prices, tear down the bureaucracy that prevents some Indian manufacturer from undercutting the pricing regime with product that costs 3 cents on the dollar.
Or, rather, I can vote out the people who delegated the appointment of top-level bureaucrats to their senior staff, who suggested industry insiders intent on regulatory capture?
I can vote out those people after the fact? Gee, that'll fix it.
If you're concerned with insulin prices, tear down the bureaucracy that prevents some Indian manufacturer from undercutting the pricing regime with product that costs 3 cents on the dollar.
This is a clear example of a cartel that's only possible because of bad intellectual property laws. Without these dubiously long patents, there would be plenty of new competitors who would want a piece of that $12 billion.
There's nothing "dubiously long" about the patents here. Drug companies are lucky to get 10 years out of a patent (in a field where things change far more slowly than people in the tech industry are used to). Injectable insulin is long out of patent. What's patented are the iterative improvements to manufactured insulin drug manufacturers have been developing over decades: http://www.medscape.com/viewarticle/841669.
Serious question: what stops a company in the US from, tomorrow, setting up shop and making the insulin recipe from 14 years ago? Is it FDA regulations?
Nothing much. FDA regulations are a major hurdle though, and means you'd need to sell a pretty high volume to break even, but nothing insane.
Problem: You set up shop, you make up a big batch of generic insulin and then...you don't sell any, because doctors aren't prescribing it. Why would they? Most probably haven't heard of it, and the ones who have will also know (correctly) that the patented improvements may be minor improvements, but they are improvements. All you've got to compete on is cost, but the doctors aren't paying the cost. Nor are the majority of their customers; they have insurance. The minority who are paying the cost directly would probably prefer a cheaper option, but that would require them to hear of it, and it's not clear there's enough of them to cover your overheads even if they did hear of it, and your generic drug margins don't cover the cost of the massive marketing campaign you'd need; you're not selling Viagra here.
Your success will rely on getting the big insurers to stop covering the better forms of insulin, or at least stop covering it in the general case. Which they absolutely should do! And the second one of them tries the "insulin cartel" will do a little lobbying, and some patient groups will express outrage, and a congressman will start talking about hearings, and the NYT will run an nominally balanced news piece about insurance company greed forcing diabetics onto archaic, inferior forms of insulin, and the insurance company will give up, because hell, they just pass the costs on in the form of premiums; it's no skin off their nose.
And you'll go under. And the worst part is, there's no big conspiracy or villain. The system is just incredibly screwed up.
Problem: You set up shop, you make up a big batch of generic insulin and then...you don't sell any, because doctors aren't prescribing it. Why would they? Most probably haven't heard of it, and the ones who have will also know (correctly) that the patented improvements may be minor improvements, but they are improvements. All you've got to compete on is cost, but the doctors aren't paying the cost. Nor are the majority of their customers; they have insurance. The minority who are paying the cost directly would probably prefer a cheaper option, but that would require them to hear of it, and it's not clear there's enough of them to cover your overheads even if they did hear of it, and your generic drug margins don't cover the cost of the massive marketing campaign you'd need; you're not selling Viagra here.
Your success will rely on getting the big insurers to stop covering the better forms of insulin, or at least stop covering it in the general case. Which they absolutely should do! And the second one of them tries the "insulin cartel" will do a little lobbying, and some patient groups will express outrage, and a congressman will start talking about hearings, and the NYT will run an nominally balanced news piece about insurance company greed forcing diabetics onto archaic, inferior forms of insulin, and the insurance company will give up, because hell, they just pass the costs on in the form of premiums; it's no skin off their nose.
And you'll go under. And the worst part is, there's no big conspiracy or villain. The system is just incredibly screwed up.
From your story, it sort of sounds like doctors are the villains. Isn't it their job to choose the best medicine for their patients. If an uninsured patient asks for a cheaper older one, then they should be prepared to find that. But then perhaps you could pass the buck to the patient for not finding a doctor willing to search for cheap drugs. It just goes round in circles.
For insulin, is there even such as thing as "better"? It's not treating a disease with some probability of success that you want to maximize. It either works or it doesn't. At least that's my limited understanding.
For insulin, is there even such as thing as "better"? It's not treating a disease with some probability of success that you want to maximize. It either works or it doesn't. At least that's my limited understanding.
Well presumably, if current regulations did not turn out to be a lethal roadblock and a pharma company was lucky enough to become successful - and new regulations were not created as a response to new market entrants (via lobbying/agency collusion) nor were illegal marketing practices utilized [1] - then they will likely just get acquired by the big corps.
There are plenty of good reasons there are only ever ~6 pharma companies and most have been around for 150yrs. There are few markets where oligopolies have maintained power for as long and as consistently as pharma. A few reasons why:
- Plenty of capital to support M&A
- Legendary regulatory hurdles for new entrants
- An obedient judicial system where the annual major legal cases for illegal marketing by big pharma cos result in a slap on the wrist
[1] https://en.wikipedia.org/wiki/List_of_largest_pharmaceutical...
There are plenty of good reasons there are only ever ~6 pharma companies and most have been around for 150yrs. There are few markets where oligopolies have maintained power for as long and as consistently as pharma. A few reasons why:
- Plenty of capital to support M&A
- Legendary regulatory hurdles for new entrants
- An obedient judicial system where the annual major legal cases for illegal marketing by big pharma cos result in a slap on the wrist
[1] https://en.wikipedia.org/wiki/List_of_largest_pharmaceutical...
they should just list it under preventive care and make it free to those who need insulin and then cap payments to providers of it.
The fact that drugs are cheaper in Europe does not mean the market there is fairer or more efficient: https://en.wikipedia.org/wiki/Monopsony. European governments have monopsonist power: through negotiating with manufacturers directly, they drive prices below the efficient level.
If the OP allegation that just three companies control the insulin market is correct, then it doesn't seem appropriate to use the term "efficient" to describe the equilibrium condition that exists without the monopsony. Of course, we'd all probably be better off with a well functioning market free from monopolies or monopsonies.
Is that a monopsony though?
The market for drug companies is global. If you were talking about doctors or some type of medical provider that was limited to providing goods and services within a single jurisdiction, you might have a point.
The market for drug companies is global. If you were talking about doctors or some type of medical provider that was limited to providing goods and services within a single jurisdiction, you might have a point.
Even if it is a monopsony, the questions are 1) do they abuse its monopsony powers, and 2) what factors go ino defining 'efficient' and 'abuse'?
No, the monopsony designation is key to the comment I was responding to and the point I was trying to make.
If there is no monopsony power, it's hard to make any claim of abuse on the part of the government. Single payer governments are leveraging their bargaining power like any rational market participant. Drug companies are not required to sell to them. They do so of their own volition at a price favorable to their bottom line, otherwise they wouldn't do it.
If there is no monopsony power, it's hard to make any claim of abuse on the part of the government. Single payer governments are leveraging their bargaining power like any rational market participant. Drug companies are not required to sell to them. They do so of their own volition at a price favorable to their bottom line, otherwise they wouldn't do it.
Most shareholders would be up in arms if instead of a 5% loss in profit due to government monopsony, the company CEO decided to shut down the company and not sell anything at all, so the statement "not required" isn't that relevant.
"They do so of their own volition". No. You are expressing the Panglossian viewpoint that just because something happened it was the best choice.
We know from experimental economics that people make decisions different than rational market theory would predict. The heads of large pharmaceutical companies are not exempt from this irrationality.
Nor are all people in government short-sighted pennypinchers. The price negotiations also include the reality that some of the profits are turned into more research for future drugs. Hence the questions of what "efficient" and "abuse" means, which go into the pricing negotiations.
"They do so of their own volition". No. You are expressing the Panglossian viewpoint that just because something happened it was the best choice.
We know from experimental economics that people make decisions different than rational market theory would predict. The heads of large pharmaceutical companies are not exempt from this irrationality.
Nor are all people in government short-sighted pennypinchers. The price negotiations also include the reality that some of the profits are turned into more research for future drugs. Hence the questions of what "efficient" and "abuse" means, which go into the pricing negotiations.
I think the "monopsony==inefficient market" argument is a fig leaf for the shibboleth that state economic actors are somehow "tainted" because they're not "private" enterprises. If a pharmaceutical firm were "negotiated" (tortured?) below their break-even somehow by state actors, they would simply fold. The entire concept of "below efficiency levels" is questionable here.
"below efficiency levels" isn't some sort of moral statement, it's a mathematical one. It's not a question of moving sellers below their break-even point (you're correct that would obviously never happen). It's about transferring producer surplus to consumer surplus and introducing deadweight loss into the system.
https://en.wikipedia.org/wiki/Monopsony#Welfare_implications explains it pretty clearly for the example of labor.
https://en.wikipedia.org/wiki/Monopsony#Welfare_implications explains it pretty clearly for the example of labor.
"A mathematical one" in a simplified analysis which assumes a rational actor model which doesn't model what people actually do.
Or if you want to use the model, the deadweight loss in your evaluation can instead be interpreted as the price that people are willing to pay for the good feelings of knowing that everyone in the country has accessible and affordable basic health care.
Or if you want to use the model, the deadweight loss in your evaluation can instead be interpreted as the price that people are willing to pay for the good feelings of knowing that everyone in the country has accessible and affordable basic health care.
> assumes a rational actor model which doesn't model what people actually do
Sure, but in the case of drug prices in countries with national health systems we don't really have any reason to think that the model doesn't reflect reality.
> the deadweight loss in your evaluation can instead be interpreted
Yes, this is exactly my point! The science of economics makes no judgement about the relative moral values at play here. That may very well be a tradeoff people want to make. Or it might not. Economics doesn't comment on that question one way or another, it nearly provides data on the practical outcome of the decision.
Sure, but in the case of drug prices in countries with national health systems we don't really have any reason to think that the model doesn't reflect reality.
> the deadweight loss in your evaluation can instead be interpreted
Yes, this is exactly my point! The science of economics makes no judgement about the relative moral values at play here. That may very well be a tradeoff people want to make. Or it might not. Economics doesn't comment on that question one way or another, it nearly provides data on the practical outcome of the decision.
Which is why I wrote: Hence the questions of what "efficient" and "abuse" means, which go into the pricing negotiations.
People don't consume health care as a typical commodity. Choices you make around health care are existential. It's not just a cost calculation. So without a state actor you would still not have the behavior of an efficient market.
Besides. Even if companies are forced below their break even point by strong consumers so that they need to stop selling to some market and even if they die because of it then it's still ok.
Companies unlike people should be allowed to die. That's one of the ways market evolves. One of the way market avoids local optima. Companies dying because they cannot provide the market at the prices market expects is the normal thing.
People dying because cartel prices essential good above what consumers can afford is not.
Companies unlike people should be allowed to die. That's one of the ways market evolves. One of the way market avoids local optima. Companies dying because they cannot provide the market at the prices market expects is the normal thing.
People dying because cartel prices essential good above what consumers can afford is not.
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Better yet become monopoly an monopsony at the same time. You don't even need to be government for that. Isn't US beautiful: http://www.beckershospitalreview.com/hospital-management-adm...
I was a member of a very large public sector health plan that was extremely aggressive about negotiations, to the point that for awhile any maintenance medication had to be shipped from Canada. They get good prices, but not that good -- iirc my blood pressure medication total cost was 10-15% less than the shitty small business HMO that I had previously.
Generally speaking, the US government demands most favored pricing and gets it. No way we would pay more than France.
Europe does better because they have the ability to prevent sale of a drug and the drug company can just raise the price in the US. If the US gets in the game, I would expect European prices to spike, especially in smaller countries.
Generally speaking, the US government demands most favored pricing and gets it. No way we would pay more than France.
Europe does better because they have the ability to prevent sale of a drug and the drug company can just raise the price in the US. If the US gets in the game, I would expect European prices to spike, especially in smaller countries.
> Generally speaking, the US government demands most favored pricing and gets it. No way we would pay more than France.
I though the US government, except for the VA, was "not permitted to negotiate prices of drugs with the drug companies" due to Medicare Part D. (Quoting https://en.wikipedia.org/wiki/Medicare_Part_D#Criticisms .) Was that prohibition removed?
If it's still there, then wouldn't that prevent the US government from demanding most favored pricing, as that would be a negotiation.
I though the US government, except for the VA, was "not permitted to negotiate prices of drugs with the drug companies" due to Medicare Part D. (Quoting https://en.wikipedia.org/wiki/Medicare_Part_D#Criticisms .) Was that prohibition removed?
If it's still there, then wouldn't that prevent the US government from demanding most favored pricing, as that would be a negotiation.
I was referring to the hypothetical cases where the Federal government does negotiate.
My guess is they do not because hey would put companies out of business and impact many countries.
My guess is they do not because hey would put companies out of business and impact many countries.
Probably depends on the cost of medication to begin with. My HBP medication is like 25 cents a pill even without insurance. I figure it can't really go much lower than that given that all those folks at the pharmacy need to be paid. Now if something is $25 a pill, there's definitely more room for negotiation.
A simple fix could go a long way - disallow really minor improvements and work hard to get rid of evergreening.
http://www.nature.com/news/indian-court-rejects-novartis-pat...
http://www.nature.com/news/indian-court-rejects-novartis-pat...
How do you define "minor"? These insulins have dramatically different serum half lives (for example there are fast acting ones for postprandial administration, others that are optimized for pumps, etc) and so there is a clear pharmacological difference. Moreover, discovering these variants is nontrivial, as each insulin must be checked against igf-1 receptor cross reactivity, lest it become teratogenic. Making matters worse, the exact binding of insulin and igf-1 to their receptors is not known making this endeavor especially difficult to predict.
What is not clear is whether these modifications are an over optimization over "the original". For each patient the cost/benefit calculation will be different and based on many variables.
What is not clear is whether these modifications are an over optimization over "the original". For each patient the cost/benefit calculation will be different and based on many variables.
http://theconversation.com/explainer-evergreening-and-how-bi...
I'm not an expert and I can't comment on specifics. But I'm of the opinion that a small enhancement is not the same as an invention of a drug and it doesn't come anywhere close to extending the life of the patent - unless that tiny change actually makes a big different in effectiveness.
Any good patent system should find a good balance between the two seemingly conflicting goals of incentivizing companies to innovate and keeping the price down for patients.
I'm not an expert and I can't comment on specifics. But I'm of the opinion that a small enhancement is not the same as an invention of a drug and it doesn't come anywhere close to extending the life of the patent - unless that tiny change actually makes a big different in effectiveness.
Any good patent system should find a good balance between the two seemingly conflicting goals of incentivizing companies to innovate and keeping the price down for patients.
These insulin changes are like the difference between a spanner and a torque wrench, or a spanner and a ratcheting wrench. The torque wrench is definitely more effective for certain use cases, as is the ratcheting wrench, both are nontrivial, but 99% of the time the spanner would do just fine / maybe be a bit more of a hassle.
[deleted]
One thing I don't understand about drug patents: how does evergreening work? Doesn't the original patent still expire, allowing anyone who wants to make the old version?
That is correct. From here[1]:
"[The authors] describe the history of insulin as an example of “evergreening,” in which pharmaceutical companies make a series of improvements to important medications that extend their patents for many decades. This keeps older versions off the generic market, the authors say, because generic manufacturers have less incentive to make a version of insulin that doctors perceived as obsolete. Newer versions are somewhat better for patients who can afford them, say the authors, but those who can’t suffer painful, costly complications."
This isn't really a story about patents, it's about marketing and a chicken-and-egg problem. You could buy dirt cheap generic insulin if anyone made it, but they don't, because nobody wants to buy it, probably because nobody makes it.
[1]: http://www.hopkinsmedicine.org/news/media/releases/why_peopl...
"[The authors] describe the history of insulin as an example of “evergreening,” in which pharmaceutical companies make a series of improvements to important medications that extend their patents for many decades. This keeps older versions off the generic market, the authors say, because generic manufacturers have less incentive to make a version of insulin that doctors perceived as obsolete. Newer versions are somewhat better for patients who can afford them, say the authors, but those who can’t suffer painful, costly complications."
This isn't really a story about patents, it's about marketing and a chicken-and-egg problem. You could buy dirt cheap generic insulin if anyone made it, but they don't, because nobody wants to buy it, probably because nobody makes it.
[1]: http://www.hopkinsmedicine.org/news/media/releases/why_peopl...
I don't really believe that there isn't a lot of low- and middle-income people with diabetes that wouldn't buy drastically cheaper insulin if it was still rather effective, especially pre-Obamacare. It's clear that there's collusion to keep cheap product out of the market.
This is exactly spot on. I would also add that "nobody wants to buy it" refers to the "doctors", not the "patient" - which is a very restricted and more easily targetted channel for marketing versus the patients.
There are so many people on both insulin and government health insurance that it's probably in the taxpayers' interest to build an insulin factory to supply the low-end.
That won't happen, the government is the one preventing it because of the patent restrictions. If the patents were limited then companies would spring up instantly to manufacture it cheaply.
They're also the ones holding back generics to a dramatic degree via the FDA approval process, which would stop a biosimilar insulin from making it through. The government has entirely rigged the game. The statistical change in approvals is so dramatic and inverted, as to be implausible to be anything but intentional fraud on the part of the FDA. (why fraud you might ask? deceit for monetary gain: user fees paid by big pharma)
http://www.statnews.com/2015/12/29/generic-drugs-backlog/
http://www.statnews.com/2015/12/29/generic-drugs-backlog/
I had a similar thought a few years ago that it would have been in the government's interest to buy Pharmasset when they sold for $11B to Gilead based on the future potential of Sovaldi (the infamous $1,000/pill, 12-week treatment for Hepatitis C). The government through Medicare / Medicaid is currently spending upwards of $4B/year on the drug and private insurers and international buyers are spending billions more. It would've been an absolute net-win for humanity had the USGov or someone else just bought the company rather than giving Gilead billions in annual profits.
When it comes to Medicare, there is a much easier win: just allow the government to negotiate prices. The government should have massive bargaining power.
> When Congress created the Medicare drug benefit in 2003, it specifically prohibited the government from negotiating prices with drugmakers.
http://www.bloomberg.com/news/articles/2015-02-02/drug-price...
Imagine making a deal with a company where you are one of their largest clients but you are specifically prevented from negotiating any prices with them at any point in the future.
> When Congress created the Medicare drug benefit in 2003, it specifically prohibited the government from negotiating prices with drugmakers.
http://www.bloomberg.com/news/articles/2015-02-02/drug-price...
Imagine making a deal with a company where you are one of their largest clients but you are specifically prevented from negotiating any prices with them at any point in the future.
Hah, never happen since the people who would vote on this are all on the Pharma take. Both parties, an equal opportunity bribery, which means nothing will ever change.
NHS does this in the UK, access to 60 million people through one customer is a hell of an incentive to negotiate, not perfect but then what is?
I'll take our system every single time though.
I'll take our system every single time though.
The only way Medicare will have an negotiating leverage with respect to price is if they create a formulary and deny access to certain drugs.
I can't see Medicare doing that.
I can't see Medicare doing that.
Well, it's more complicated than that though, economic considerations-wise. You can treat Hepatitis C now (and it's the rare case where the drug actually cures something like this with high probability), or you can treat liver disease in a terminally ill patient later. It's up for debate what's more expensive. That's one of the reasons why they can charge so much. The second reason is, they're just dicks.
The problem is deciding where to put your billions without the benefit of hindsight. If Sovaldi hadn't worked out, the purchase would be hailed as a disaster.
You're definitely right, but I think government should be taking more risk.. It's hard to fight off the 'Solyndra!' shouts when something goes wrong, and costs are hard to quantify when things go right (what's the $ return of all the USGov's investments in the early internet?) but braver politicians could pull it off and we'd all be better for it.
Or just enter into a long term contract with a generic manufacturer (hopefully striking a balance between a longer term that ensured the manufacturer covered their fixed costs and a shorter term that would invite more competition).
in France, in UK, and probably rest of Europe
people with Type 1 and 2 diabetes are taken in charge 100%
that means whatever amount of insulin you need, you get it for free
and it's not only the insulin, it's also all the rest: test strips, glycemic reader, etc.
I'm pretty sure the article is wrong about
"had Type 2 diabetes for over 30 years. She takes several injections of insulin each day."
this more describe Type 1 situation
anyway, I'm pretty sure the price of insulin went up also in Europe, except the government paid the bill, not the patient, a bit more civilised but still the problem stay the same:
big pharma corporation are abusing the situation and make money from it, it is disgusting and criminal
first, about the patent and why there is no generic insulin, read http://www.medscape.com/viewarticle/841669
second, most people are uneducated about diabetes, they think it concern only fat people or other countries, and other BS like that
nope, it is worldwide major public health problem, many studies show the amount of people with diabetes rising , for ex
http://www.nytimes.com/2015/06/08/health/research/global-dia...
"reported a 45 percent rise in the prevalence of diabetes worldwide from 1990 to 2013"
finally, why it is disgusting and criminal for pharma corp to make ppl pay for insulin ?
it as simple as that: if you don't take insulin you die, period.
It's not curable, there is no alternative diet, nothing, zilch, nada
and those big pharma corporation they made a business to profit from that, and when profit is not high enough, simple, raise the price.
that means whatever amount of insulin you need, you get it for free
and it's not only the insulin, it's also all the rest: test strips, glycemic reader, etc.
I'm pretty sure the article is wrong about
"had Type 2 diabetes for over 30 years. She takes several injections of insulin each day."
this more describe Type 1 situation
anyway, I'm pretty sure the price of insulin went up also in Europe, except the government paid the bill, not the patient, a bit more civilised but still the problem stay the same:
big pharma corporation are abusing the situation and make money from it, it is disgusting and criminal
first, about the patent and why there is no generic insulin, read http://www.medscape.com/viewarticle/841669
second, most people are uneducated about diabetes, they think it concern only fat people or other countries, and other BS like that
nope, it is worldwide major public health problem, many studies show the amount of people with diabetes rising , for ex
http://www.nytimes.com/2015/06/08/health/research/global-dia...
"reported a 45 percent rise in the prevalence of diabetes worldwide from 1990 to 2013"
finally, why it is disgusting and criminal for pharma corp to make ppl pay for insulin ?
it as simple as that: if you don't take insulin you die, period.
It's not curable, there is no alternative diet, nothing, zilch, nada
and those big pharma corporation they made a business to profit from that, and when profit is not high enough, simple, raise the price.
Type 2 diabetics often progress to insulin treatment as their pancreas becomes exhausted and ceases proper function.
The low insulin sensitivity in type 2 means the pancreas produces large amounts of insulin in a futile attempt to reduce blood sugar. Initial treatments focus on insulin sensitizing agents to try and assist the natural insulin to be effective. Despite the amazing capabilities of the body, it eventually becomes too much and people have to start insulin replacement therapy at that point.
The low insulin sensitivity in type 2 means the pancreas produces large amounts of insulin in a futile attempt to reduce blood sugar. Initial treatments focus on insulin sensitizing agents to try and assist the natural insulin to be effective. Despite the amazing capabilities of the body, it eventually becomes too much and people have to start insulin replacement therapy at that point.
no problem, it's like the honey moon period for a type 1 patient
I was saying "maybe", in general I see type 2 ppl who are just on pills and have no need to take insulin, but yeah the diabetes can progress in different way, no problem with that
I was saying "maybe", in general I see type 2 ppl who are just on pills and have no need to take insulin, but yeah the diabetes can progress in different way, no problem with that
If you've had type 2 diabetes for more than 30 years, you may well be on insulin by now. Also, blaming big pharma for making people pay for insulin makes no sense. You can argue that they're charging too much, certainly, or that government should step in to pay for it. But arguing that they shouldn't make a profit? That's like blaming farmers for making a profit from farming. We all need food to live, but it's not their job to give me free food.
did you read the article about the patent and how insulin been discovered ?
here some quotes
"Insulin's Canadian discoverers sold the patent to their university for $1, stating that profit was not their goal."
"Discoverers Didn't Intend Insulin to Become a Profitable Monopoly"
so yeah I blame big pharma
they took over a cheap patent, made some modification and abused the patent system on a non-curable illness that affect more and more people
and when the profit is not enough, they raise the price
what's your arguments again ?
that they are entitled to makea profit ?
when they did not discovered or produced the original patent ?
are you saying that seriously ?
here some quotes
"Insulin's Canadian discoverers sold the patent to their university for $1, stating that profit was not their goal."
"Discoverers Didn't Intend Insulin to Become a Profitable Monopoly"
so yeah I blame big pharma
they took over a cheap patent, made some modification and abused the patent system on a non-curable illness that affect more and more people
and when the profit is not enough, they raise the price
what's your arguments again ?
that they are entitled to makea profit ?
when they did not discovered or produced the original patent ?
are you saying that seriously ?
Is the currently produced insulin by 'big pharma' as you term them, significantly different from the original formulation?
If it is, then it cannot be termed abuse of the patent system.
If it is not, then our current situation can be termed a side-effect of a broken patent system.
Yet all that is orthogonal to the above poster. Even if pharmaceutical companies were only using the original formulation, they would still be entitled to make a profit under any capitalist mode of thought.
Simply because something is required for life is no barrier to morally or economically, for allowing someone to profit from it.
Granted, anything that is required for life will be tightly regulated by the government. For instance, I'd think its impossible for farmers to collude to withhold their produce and simply starve a country.
If it is, then it cannot be termed abuse of the patent system.
If it is not, then our current situation can be termed a side-effect of a broken patent system.
Yet all that is orthogonal to the above poster. Even if pharmaceutical companies were only using the original formulation, they would still be entitled to make a profit under any capitalist mode of thought.
Simply because something is required for life is no barrier to morally or economically, for allowing someone to profit from it.
Granted, anything that is required for life will be tightly regulated by the government. For instance, I'd think its impossible for farmers to collude to withhold their produce and simply starve a country.
this more describe Type 1 situation
Generally speaking companies "extend" their patent by making a slight tweak to get a new patent. But that doesn't stop their old patent from expiring. And the old formula from becoming open to a generic.
So why aren't there generic versions of old formulations? Who cares if it doesn't have the latest tweak? The complain about such tweaks is that their minor and unimportant. Meaning the previous version should be just fine.
So why aren't there generic versions of old formulations? Who cares if it doesn't have the latest tweak? The complain about such tweaks is that their minor and unimportant. Meaning the previous version should be just fine.
Just one data point:
I have Crohn's Disease. Up until a few years ago, I took Asacol for this. This is one of a whole class of drugs based on the active ingredient "mesalamine": Asacol is specialized in that it's got a coating that keeps it from dissolving until it gets to the colon. Somebody found that this coating (notice: not the drug itself, just an enteric coating) might be a risk for pregnant mothers - something that I will never be. So they stopped making Asacol, and came out with a new "Asacol HD", which is still good old-fashioned mesalamine, but with a slightly different enteric coating - and with a brand new patent.
Although I don't have any evidence to support the idea, it seems suspicious that this revelation about the coating being questionable during pregnancy, came to light not very long before the expiration of the patent on original Asacol.
So there exists a small group of patients (pregnant moms) who might have had trouble with original-packaging Asacol. Rather than putting these patients on other mesalamine meds (like Pentasa or Delzicol) for 9 months, that was parlayed into a need to discontinue the entire Asacol product and come out with a new one.
In this case, it seems that a desire (or a pretense) to make something safe for all sub-groups, even those that are small and easily segmented, becomes the engine for renewing the patent, and thus keeping generics out of the market.
I have Crohn's Disease. Up until a few years ago, I took Asacol for this. This is one of a whole class of drugs based on the active ingredient "mesalamine": Asacol is specialized in that it's got a coating that keeps it from dissolving until it gets to the colon. Somebody found that this coating (notice: not the drug itself, just an enteric coating) might be a risk for pregnant mothers - something that I will never be. So they stopped making Asacol, and came out with a new "Asacol HD", which is still good old-fashioned mesalamine, but with a slightly different enteric coating - and with a brand new patent.
Although I don't have any evidence to support the idea, it seems suspicious that this revelation about the coating being questionable during pregnancy, came to light not very long before the expiration of the patent on original Asacol.
So there exists a small group of patients (pregnant moms) who might have had trouble with original-packaging Asacol. Rather than putting these patients on other mesalamine meds (like Pentasa or Delzicol) for 9 months, that was parlayed into a need to discontinue the entire Asacol product and come out with a new one.
In this case, it seems that a desire (or a pretense) to make something safe for all sub-groups, even those that are small and easily segmented, becomes the engine for renewing the patent, and thus keeping generics out of the market.
But as forrestthewoods pointed out, if the improvements in the new version are so marginal, then you'd think there would be a booming market for the old version if it was cheaper (generic). So what's stopping the generic manufacturers from cranking out the old versions? Seems like there would be lots of money to be made, unless patients (the market) actually did value the incremental improvements and would likely chose not to purchase the original formulation.
[deleted]
Well, in my example, it seems like the manufacturer hasn't just moved onto an abstractly nicer formulation, but in the process they've left some FUD that the previous version might be problematic (for some subgroup).
I'm sure most people outside that subgroup would jump at the chance to get a cheaper substitute.
Asacol HD is $600 - $700 for 90 pills: http://www.goodrx.com/asacol-hd
Asacol HD is $600 - $700 for 90 pills: http://www.goodrx.com/asacol-hd
You should see the other stuff I take, Entyvio[1], at around $25K/dose (which is every other month). I don't know why they list it for various pharmacies, since you can't buy it - it has to be administered by an infusion center. I'm the reason that healthcare insurance is so expensive.
[1] http://www.goodrx.com/entyvio
[1] http://www.goodrx.com/entyvio
Generics could still be made on the old formula, that's not the issue.
The issue is that generics have thinner margins due to unrestrained competition, not sufficient for a substantial marketing campaign against a well-funded adversary. Especially if said adversary has fear-mongering on their side.
There are other situations where too much competition drives margins so thin as to make all participants starve, most notable being the Apple's App Store.
The issue is that generics have thinner margins due to unrestrained competition, not sufficient for a substantial marketing campaign against a well-funded adversary. Especially if said adversary has fear-mongering on their side.
There are other situations where too much competition drives margins so thin as to make all participants starve, most notable being the Apple's App Store.
not sufficient for a substantial marketing campaign against a well-funded adversary
Most states have mandatory generic substitution. That is, if you bring a Rx in for Lipitor, the pharmacy is required to fill it with the generic version.
You don't need much marketing for that.
Most states have mandatory generic substitution. That is, if you bring a Rx in for Lipitor, the pharmacy is required to fill it with the generic version.
You don't need much marketing for that.
Good point! The result should be that doctors will prescribe the "safest" drug, for which there are no generics yet due to the renewed patents. Perhaps that's even more important than the marketing thing.
Or android handset business.
But... but it's in HD now! I think I'll wait for Asacol 4k.
Another data point: there are no generic albuterol inhalers on the market right now. Switching from CFC to HFA despite literally only pharmaceutical companies being concerned about CFC usage in inhalers meant new patents all around with no more generics due to the CFC ban. I don't even remember the last time any of my inhalers, actually, was available as generic - switching the propellant/delivery mechanism seems to be a great evergreening tactic. There's gotta be a lot of money flowing around somewhere anyway regardless of patent/market exclusivity extension and expiration - there's also the fun situation where I get prescribed one of brand-only [Advair, Symbicort, Dulera] inhalers ~solely~ based on which drug company cut a better deal with my insurance company at that point.
There are some happy stories with generics, though! I save a decent chunk of money buying OTC cetirizine over UCB/Sanofi's chiral switch Xyzal.
There are some happy stories with generics, though! I save a decent chunk of money buying OTC cetirizine over UCB/Sanofi's chiral switch Xyzal.
I am tempted to believe that the pharma companies are more interested in keeping their recurring revenues from diabetics than find a one time cure.
Here in India, the medicines and tools for a diabetic (particulary IDDM) is still prohibitively expensive for most people who have it. The prices of insulins and testing strips have increased by 10% or so many times in the past couple of years. Things like CGMS, insulin pumps are not affordable even to well-off people like me.
There has always been news of research from various government and government aided organizations towards the development of low cost testing strips (at about Rs. 5 per strip compared to Rs. 17 and above for the existing products) but nothing has come out as a product. What's worse is an unknown healthcare company has acquired the technology from ICMR (Indian Council of Medical Research) a year back and till now their only product is a low cost sanitary napkin. Wouldn't be surprised of the involvement of the big pharma companies in the delay.
All this said, at least India doesn't have an insurance system like in the US which has pushed up the prices repeatedly to help the insurance companies (imho an unwanted middleman in most cases) make more and more money.
I am not very optimistic about the future.
Here in India, the medicines and tools for a diabetic (particulary IDDM) is still prohibitively expensive for most people who have it. The prices of insulins and testing strips have increased by 10% or so many times in the past couple of years. Things like CGMS, insulin pumps are not affordable even to well-off people like me.
There has always been news of research from various government and government aided organizations towards the development of low cost testing strips (at about Rs. 5 per strip compared to Rs. 17 and above for the existing products) but nothing has come out as a product. What's worse is an unknown healthcare company has acquired the technology from ICMR (Indian Council of Medical Research) a year back and till now their only product is a low cost sanitary napkin. Wouldn't be surprised of the involvement of the big pharma companies in the delay.
All this said, at least India doesn't have an insurance system like in the US which has pushed up the prices repeatedly to help the insurance companies (imho an unwanted middleman in most cases) make more and more money.
I am not very optimistic about the future.
My mom just told me in tears today it cost her over $400 rather than the normal $80-90 copay she was used to
Can anyone explain me the evergreening - even if new patent is granted for new molecule the old molecule should be free. So why is nobody producing them?
Because no one is interested in spending billions to get a generic insulin through FDA or other regulatory agencies.
Too much profit is to be made.
Too much profit is to be made.
IIRC you don't need to spend billions to get it trough FDA. That is the whole point of the generic. That the molecule is already approved and tested.
You don't need to spend money on phase 1-3 trials for safety and efficacy of the molecule but you do still need to spends tens of millions of dollars to prove that the generic drug you are manufacturing behaves like the original, within a margin of error, and that you can maintain that quality control in the future.
It depends. Sometimes it's simply more profitable to produce something else. Sometimes the market is too small to justify the bioequivalence studies. Sometimes the FDA mysteriously changes its mind on the safety of a drug the same day the patent expires [1].
[1] http://www.npr.org/sections/health-shots/2013/04/17/17760239...
[1] http://www.npr.org/sections/health-shots/2013/04/17/17760239...
According to the article, Pharmacy Benefit Managers are as much to blame for the increasing costs of drugs as the manufacturers. I suspect that's partly true, but I also suspect the "percentage of blame" is being ignored here.
No offense, but the article got PBMs entirely wrong.
Any savings from rebates is typically passed back to the one paying. In fact, it would be odd if an insurance company didn't have that in their contract.
I'd say PBMs have done a ton on keeping drug costs down. Hell, look at HCV! Express Scripts cut a deal with Abbvie on their new HCV drug and excluded Solvadi and Harvoni from their formulary.
What happened? Gilead came out and offered a 20-30% discount on their drug to pretty much every other PBM and insurance company.
Any savings from rebates is typically passed back to the one paying. In fact, it would be odd if an insurance company didn't have that in their contract.
I'd say PBMs have done a ton on keeping drug costs down. Hell, look at HCV! Express Scripts cut a deal with Abbvie on their new HCV drug and excluded Solvadi and Harvoni from their formulary.
What happened? Gilead came out and offered a 20-30% discount on their drug to pretty much every other PBM and insurance company.
A model that is more direct from business to customer sounds like it would eliminate costs. Too many people trying to put themselves in the middle and make a cut.
Who cares about the percentage of blame? I think to start reducing costs in our health care system we have to fix every problem we see.
Theoretically, the entity exists to work on behalf of the patient. A simple fix here would be to require them to pass any rebates they receive on to patients. That the rebates would go away under such a requirement is, uh, fine.
Theoretically, the entity exists to work on behalf of the patient. A simple fix here would be to require them to pass any rebates they receive on to patients. That the rebates would go away under such a requirement is, uh, fine.
At least in some states you can buy a form of insulin over the counter. It is an older formulation and apparently it is not the easiest thing to DYI figure out the correct dose. NPR had a report on it a while back. http://www.npr.org/sections/health-shots/2015/12/14/45904732...
A fair enough statement:
"The broader availability of [over-the-counter] insulin allows patients with diabetes to obtain it "quickly in urgent situations, without delays," the FDA says, and is intended to increase patient safety."
However, it seems like there are no visible protocols in place to control use in non-emergency situations like with the patient mentioned in the NYTimes article. That's certainly risky for poorer diabetics who don't necessarily know better, or are desperate enough financially to risk the long-term consequences.
However, it seems like there are no visible protocols in place to control use in non-emergency situations like with the patient mentioned in the NYTimes article. That's certainly risky for poorer diabetics who don't necessarily know better, or are desperate enough financially to risk the long-term consequences.
[deleted]
"This is true, in no small part, because the big three have cleverly extended the lives of their patents, making incremental “improvements” to their insulin."
Possibly dumb question: If the improvements really are that minor, what's stopping other companies from using the original, "unimproved" formulation in a generic? How would disallowing the "improved" patents change the situation?
Possibly dumb question: If the improvements really are that minor, what's stopping other companies from using the original, "unimproved" formulation in a generic? How would disallowing the "improved" patents change the situation?
> If the improvements really are that minor, what's stopping other companies from using the original, "unimproved" formulation in a generic?
The fact that doctors won't prescribe the unimproved formulation when the improved one is available.
The fact that doctors won't prescribe the unimproved formulation when the improved one is available.
> Insulin has been around for almost a century
> In the United States, just three pharmaceutical giants hold patents that allow them to manufacture insulin
How does this work with patent lifetimes being 25 years?
Anyway, as the article says, in countries where chronic medical conditions aren't seen as an opportunity for price-gouging, it costs much less or is free to the user.
> In the United States, just three pharmaceutical giants hold patents that allow them to manufacture insulin
How does this work with patent lifetimes being 25 years?
Anyway, as the article says, in countries where chronic medical conditions aren't seen as an opportunity for price-gouging, it costs much less or is free to the user.
This project started a while ago[1].This could pretty much change the way people approach medicine.
[1]:https://experiment.com/projects/open-insulin
[1]:https://experiment.com/projects/open-insulin
I see generic Insulin is available in India:
Actrapid 40 iu, 10ml at Rs. 145, or about US$2
so the lack of availability would seem to be down to regulatory / patent bs.
There should be some way to alter the laws in the US to favour the US people rather than the billionaires. Saunders?
Actrapid 40 iu, 10ml at Rs. 145, or about US$2
so the lack of availability would seem to be down to regulatory / patent bs.
There should be some way to alter the laws in the US to favour the US people rather than the billionaires. Saunders?
What happened to Genentech? Wasn't this their first product? Didn't this happen in the late 70's?
F. Hoffmann-La Roche AG is their parent now, not named.
F. Hoffmann-La Roche AG is their parent now, not named.
[deleted]
The cost to start a drug company to make generic insulin must be prohibitive enough that we don't see any.
Check out Dr Bernstein's Diabetes solution and use less insulin.
Shouldn't it be called patent extension racket?
It's really weird to read this kind of article from outside the USA, where healthcare is a public service.
(of course, here in the UK, the tories are doing their best to ruin the NHS, but it's still so much better than this).
(of course, here in the UK, the tories are doing their best to ruin the NHS, but it's still so much better than this).
Every time there's a health care post people chime in with the useless comment, "this is really weird to those of us not in the USA."
Jeez, really? Wow.
Jeez, really? Wow.
I agree with that.
But, as a European, I also agree with the parent comment.
It is weird in the sense that we could never think of something like that, things such as a "doughnut hole" where a few months a year you don't have an insurance.
I currently live and work in the US, love it, love the country. I have the chance to have a great plan thanks to my company. But i'm not sure how much more I can keep tacitly approving this system.
I currently live and work in the US, love it, love the country. I have the chance to have a great plan thanks to my company. But i'm not sure how much more I can keep tacitly approving this system.
The doughnut hole isn't that weird, a coverage was expanded, with a limit on how far it was expanded. The limitation is on spending, not related to the calendar beyond that:
https://www.medicare.gov/part-d/costs/coverage-gap/part-d-co...
Of course once the annual limit is reached coverage is reduced for a period of time, but there will also be cases where the limit is not reached.
And while it doesn't compare favorably to a simpler to access program that covers all expenses, enacting it didn't make anybody that ends up using it worse off.
https://www.medicare.gov/part-d/costs/coverage-gap/part-d-co...
Of course once the annual limit is reached coverage is reduced for a period of time, but there will also be cases where the limit is not reached.
And while it doesn't compare favorably to a simpler to access program that covers all expenses, enacting it didn't make anybody that ends up using it worse off.
> I also agree with the parent comment
What's not to agree with? The parent comment is simply stating nothing more than a fact we're all well aware of - that we have a different system in the US.
What's not to agree with? The parent comment is simply stating nothing more than a fact we're all well aware of - that we have a different system in the US.
Every time there's a health care post, people need to chime in with the comment, "this is really fucked up in the USA, they kill for profit."
It clearly is still necessary since HN still has it's libertarian extremists who can't believe that healthcare works vastly better under government run systems.
> except the government paid the bill, not the patient, a bit more civilised but still the problem stay the same (...)
God I hate those moral high ground stances seeping everywhere in HN comments.
You think it's more civilized, I think it's barbaric to forcefully take something from someone. Just like that, you made it that much harder for me to take anything from what you've written.
> (...) second, most people are uneducated about diabetes, they think it concern only fat people or other countries, and other BS like that (...)
And the NYTimes article you linked immediately after starts by saying "The prevalence of diabetes has been rising in rich countries for several decades, largely driven by increases in the rate of obesity."
Are they totally clueless?
>finally, why it is disgusting and criminal for pharma corp to make ppl pay for insulin ? it as simple as that: if you don't take insulin you die, period.
Well, gee, it sure sounds like food, water, vitamins, or a bunch of other stuff that are sold for profit everywhere.
>It's not curable, there is no alternative diet, nothing, zilch, nada
Except that type 2 (the one that is the rise, by your linked article) is preventable. There is a high correlation between type 2 diabetes and sugar intake.
God I hate those moral high ground stances seeping everywhere in HN comments.
You think it's more civilized, I think it's barbaric to forcefully take something from someone. Just like that, you made it that much harder for me to take anything from what you've written.
> (...) second, most people are uneducated about diabetes, they think it concern only fat people or other countries, and other BS like that (...)
And the NYTimes article you linked immediately after starts by saying "The prevalence of diabetes has been rising in rich countries for several decades, largely driven by increases in the rate of obesity."
Are they totally clueless?
>finally, why it is disgusting and criminal for pharma corp to make ppl pay for insulin ? it as simple as that: if you don't take insulin you die, period.
Well, gee, it sure sounds like food, water, vitamins, or a bunch of other stuff that are sold for profit everywhere.
>It's not curable, there is no alternative diet, nothing, zilch, nada
Except that type 2 (the one that is the rise, by your linked article) is preventable. There is a high correlation between type 2 diabetes and sugar intake.
We detached this subthread from https://news.ycombinator.com/item?id=11154983 and marked it off-topic.
> You think it's more civilized, I think it's barbaric to forcefully take something from someone.
Nothing described in the post to which you replied is being forcefully taken from anyone. You live in a society. That society has a social contract, accepted in aggregate by its citizens and periodically subject to shifts--some of them that you may prefer, others that you may not. You cannot unilaterally renegotiate this contract, but you can choose to leave if you don't want to uphold your end of the social contract--literally nobody is stopping you from doing so! If you're an American, renouncing your citizenship is a very easy act that can be done at, IIRC, any consulate. You need not be under the onerous burden of that social contract and its (frankly, meager) expectations of you if you choose not to be.
But, statistically, it's almost certain that you won't choose not to be. Because even the very, very rich benefit from statefulness and membership in a functioning society.
Nothing described in the post to which you replied is being forcefully taken from anyone. You live in a society. That society has a social contract, accepted in aggregate by its citizens and periodically subject to shifts--some of them that you may prefer, others that you may not. You cannot unilaterally renegotiate this contract, but you can choose to leave if you don't want to uphold your end of the social contract--literally nobody is stopping you from doing so! If you're an American, renouncing your citizenship is a very easy act that can be done at, IIRC, any consulate. You need not be under the onerous burden of that social contract and its (frankly, meager) expectations of you if you choose not to be.
But, statistically, it's almost certain that you won't choose not to be. Because even the very, very rich benefit from statefulness and membership in a functioning society.
zwetan(1)
Just throwing this out there, I am not sure of this myself. But aren't there studies where you could do without insulin shots if you avoided carbohydrates while feeding on protein and fat?
Nope. There's a few things involved why this is a no.
The brain can only run on glucose. Because of that, the liver produces glucose from 'whatever', including pure protein. Leftover glucose ends up in the body, which can only be dealt with insulin.
Now, things like alcohol attack the glucose emitted by the liver, as it must handle alcohol before anything else.
But no, at least for type 1s and t2's with severely degraded pancreatic function.
For me, I'm recent T2 but handling it well with protein and fats to great effect (-40 lbs, normal blood sugar) since December 7. I'm sticking to roughly 'atkins style diet' to a great effect, called "Eating to the Meter".
The brain can only run on glucose. Because of that, the liver produces glucose from 'whatever', including pure protein. Leftover glucose ends up in the body, which can only be dealt with insulin.
Now, things like alcohol attack the glucose emitted by the liver, as it must handle alcohol before anything else.
But no, at least for type 1s and t2's with severely degraded pancreatic function.
For me, I'm recent T2 but handling it well with protein and fats to great effect (-40 lbs, normal blood sugar) since December 7. I'm sticking to roughly 'atkins style diet' to a great effect, called "Eating to the Meter".
The brain and the rest of the body can run exceptionally well on ketones, which is the fuel produced by metabolizing fat. This is the fuel humans have thrived on for most of our history. True, there are a couple of functions of the body that require glucose. The liver is well capable of synthesizing the needed glucose from protein, a precess call gluconeogenesis. Consumption of carbohydrates and excess protein is not required at all for this process.
[deleted]
The brain can only run on glucose.
Now, things like alcohol attack the glucose
I believe this is the study you're thinking about http://ajcn.nutrition.org/content/early/2015/07/29/ajcn.115....
"The LC diet, which was high in unsaturated fat and low in saturated fat, achieved greater improvements in the lipid profile, blood glucose stability, and reductions in diabetes medication requirements, suggesting an effective strategy for the optimization of T2D management."
I haven't heard of any formal studies where they got off of medication 100%; I've only heard of n=1 studies (single person reporting) where that has happened. The most remarkable n=1 is this from a type 1 diabetic: https://www.reddit.com/r/keto/comments/2rnn9b/doctors_can_su... but in this case the person is still on it which isn't a surprise as they are type 1.
"The LC diet, which was high in unsaturated fat and low in saturated fat, achieved greater improvements in the lipid profile, blood glucose stability, and reductions in diabetes medication requirements, suggesting an effective strategy for the optimization of T2D management."
I haven't heard of any formal studies where they got off of medication 100%; I've only heard of n=1 studies (single person reporting) where that has happened. The most remarkable n=1 is this from a type 1 diabetic: https://www.reddit.com/r/keto/comments/2rnn9b/doctors_can_su... but in this case the person is still on it which isn't a surprise as they are type 1.
I don't know of any formal studies offhand, but for some pretty consistent anecdotal evidence you may want to read some of Maria Emmerich's work. She's a nutritionist who specializes in treating people's metabolic issues.
http://mariamindbodyhealth.com/about-me/
http://mariamindbodyhealth.com/about-me/
I don't necessarily want to suggest that when I see "nutritionist" I read "witch doctor", but if there is any field of science which has made less progress over the centuries, it is nutrition. I am not suggesting that any particular practitioners are ignorant or incompetent (per se), merely that it is a very hard problem to study. Among other issues, there is evidence to suggest that glycemic responses are highly individual[1]. However, this is also an area of political and commercial interest, and there are many actors presenting shall we say "motivated" studies, demanding an exacting scrutiny of any empirical results.
In short, not only are the self-reported anecdotes of a person with a bachelors in nutrition not adequate evidence of anything, but even formal studies are suspect. As far as my own opinions go I suspect that I would be inclined to believe what she says, but truths that mesh with one's preconceptions demand an even higher standard of evidence. Were I you, I would not be promoting this person's work, and I feel it was inappropriate as a response to the parent.
[1] http://www.cell.com/abstract/S0092-8674(15)01481-6
In short, not only are the self-reported anecdotes of a person with a bachelors in nutrition not adequate evidence of anything, but even formal studies are suspect. As far as my own opinions go I suspect that I would be inclined to believe what she says, but truths that mesh with one's preconceptions demand an even higher standard of evidence. Were I you, I would not be promoting this person's work, and I feel it was inappropriate as a response to the parent.
[1] http://www.cell.com/abstract/S0092-8674(15)01481-6
Thanks for clearing that up.
The risk of diabetes is strongly associated with obesity, and even a modest weight loss has been reported to substantially decrease the diabetic risk. According to statistics from the US Center for Disease Control and Prevention, 55% of diabetic patients are obese and 85% are overweight - [http://www.sciencedirect.com/science/article/pii/S0899900712... ]
Is it the drug companies or the sugary food makers running the racket?
Is it the drug companies or the sugary food makers running the racket?
Ahh, statistics. How do the 55% or 85% numbers compare with the population as a whole? Is it a significant increase? Is there evidence of a statistically significant correlation between obesity and being overweight? Are there any factors that might be involved that are also correlated with obesity but that might be the true cause?
PS - Study recommends a ketogenic diet which I am very much in favor for. It has done wonders for me (ymmv). But I am still on the fence about being "overweight" being a direct cause of diabetes and not an effect.
PS - Study recommends a ketogenic diet which I am very much in favor for. It has done wonders for me (ymmv). But I am still on the fence about being "overweight" being a direct cause of diabetes and not an effect.
>I am still on the fence about being "overweight" being a direct cause of diabetes and not an effect.
The parent did not bring causation into the discussion, you did.
You're right to doubt it. Metabolic syndrome is the common theme http://www.nhlbi.nih.gov/health/health-topics/topics/ms and it likely leads to both obesity and diabetes, among many other ailments.
The parent did not bring causation into the discussion, you did.
You're right to doubt it. Metabolic syndrome is the common theme http://www.nhlbi.nih.gov/health/health-topics/topics/ms and it likely leads to both obesity and diabetes, among many other ailments.
Metabolic syndrome includes obesity and diabetes along with heart disease, cancer, and a few other conditions. It is not a cause but rather the result.
I interpreted "even a modest weight loss has been reported to substantially decrease the diabetic risk" as causation. But you are right, he did not say it directly.
Type I (insulin-dependent) diabetes is an autoimmune disease. It is not caused by obesity. Most Type II diabetics do not take insulin.
Does insulin immediately make you think of type 1 diabetes? Think again. Between 30 and 40 percent of people with type 2 diabetes take insulin. In fact, there are more people with type 2 diabetes who take insulin than type 1 because of the much larger number of people with type 2. - http://www.diabeticlivingonline.com/medication/insulin/insul...
Of course the type 1 disease which is ~10% of diabetes is different.
Of course the type 1 disease which is ~10% of diabetes is different.
So...60-70% of Type II patients don't take insulin? Sounds like "most" to me.
You're conflating a whole range of issues about diabetes into a single, misleading, factor. I don't know if it's intentional misrepresentation or genuine ignorance on your part.
Type 1 diabetes is not associated with being overweight and weight loss does not help. Indeed, rapid weight loss is often an early indication of the condition. Treatment with insulin (the only method available) typically results in weight gain, as the body recovers due to the newly available injected insulin. Often these patients start at normal weight range (i.e. BMI < 25) and are often substantially below typical weights prior to development of diabetes.
Type 2 diabetes has strong genetic factors and substantial evidence shows these, combined with weight and some other factors of diet, lead to an expression as diabetes. In these cases, some people have had significant improvements in their conditions due to calorie restriction (leading to weight loss but often it also means they've switched to a healthier diet in the process and that also helps). The mechanisms here are believed to be due to improved sensitivity to insulin which is still being naturally produced.
Various ratios of diabetes are quoted, but generally 1 in 20 of the white european population has diabetes and 1 in 20 of those has type 1 (and the other 19 type 2). Figures for Indian/Pakistani origin people are dramatically different if they move to Europe or North America and research suggests this is due to very different foods consumed [the 'western' versions being significantly less healthy than those from origin countries]. Much higher numbers of type 2 diabetes are found in these populations (reinforcing the factors as both genetics and types of food are involved). Other population groups differ too.
Treatments for diabetes typically create weight control issues as increased insulin or sensitivity to insulin promotes body fat storage.
It's untrue (and frankly verging on offensive) to simply blame diabetics for their condition because they are obese or overweight. Addressing and treating the condition is significantly more complex and weight control may be one of the few elements the patient has any input to, while many other factors are entirely outwith their control and they bear no culpability for.
Type 1 diabetes is not associated with being overweight and weight loss does not help. Indeed, rapid weight loss is often an early indication of the condition. Treatment with insulin (the only method available) typically results in weight gain, as the body recovers due to the newly available injected insulin. Often these patients start at normal weight range (i.e. BMI < 25) and are often substantially below typical weights prior to development of diabetes.
Type 2 diabetes has strong genetic factors and substantial evidence shows these, combined with weight and some other factors of diet, lead to an expression as diabetes. In these cases, some people have had significant improvements in their conditions due to calorie restriction (leading to weight loss but often it also means they've switched to a healthier diet in the process and that also helps). The mechanisms here are believed to be due to improved sensitivity to insulin which is still being naturally produced.
Various ratios of diabetes are quoted, but generally 1 in 20 of the white european population has diabetes and 1 in 20 of those has type 1 (and the other 19 type 2). Figures for Indian/Pakistani origin people are dramatically different if they move to Europe or North America and research suggests this is due to very different foods consumed [the 'western' versions being significantly less healthy than those from origin countries]. Much higher numbers of type 2 diabetes are found in these populations (reinforcing the factors as both genetics and types of food are involved). Other population groups differ too.
Treatments for diabetes typically create weight control issues as increased insulin or sensitivity to insulin promotes body fat storage.
It's untrue (and frankly verging on offensive) to simply blame diabetics for their condition because they are obese or overweight. Addressing and treating the condition is significantly more complex and weight control may be one of the few elements the patient has any input to, while many other factors are entirely outwith their control and they bear no culpability for.
The article talked about type-2 patients. Our NIH estimates that 60% of them would be cured if they simply ate less: http://www.ncbi.nlm.nih.gov/pubmed/17227327
"combined with weight and some other factors of diet, lead to an expression as diabetes"
I guess I agree with you, then.
Some studies indicate that weight loss is great for fighting diabetes : http://link.springer.com/article/10.1007%2Fs13340-013-0107-1
Conclusion
Six-month obesity treatment of obese type 2 diabetic patients led to significant weight loss and the amelioration of glycemic factors. For obese type 2 diabetes, more than 3 % weight reduction is needed to improve glycemic control, and more than 15 % weight reduction and, in addition, short duration of obesity and diabetes (3.5 ± 2.5 years), are required to normalize glucose tolerance.
Some one who is "pre-diabetic" is well advised to eat right, work out and lose weight. That is their responsibility.
Check out ProgrammerGirl's censored post below for another study.
Don't be offended by advocating for personal responsibility in fighting this disease.
I guess I agree with you, then.
Some studies indicate that weight loss is great for fighting diabetes : http://link.springer.com/article/10.1007%2Fs13340-013-0107-1
Conclusion
Six-month obesity treatment of obese type 2 diabetic patients led to significant weight loss and the amelioration of glycemic factors. For obese type 2 diabetes, more than 3 % weight reduction is needed to improve glycemic control, and more than 15 % weight reduction and, in addition, short duration of obesity and diabetes (3.5 ± 2.5 years), are required to normalize glucose tolerance.
Some one who is "pre-diabetic" is well advised to eat right, work out and lose weight. That is their responsibility.
Check out ProgrammerGirl's censored post below for another study.
Don't be offended by advocating for personal responsibility in fighting this disease.
so misinformed ...
what about a 5yo kid who just got diagnosed with diabetes type 1 ?
also did you know that when you take insulin, it is the insulin that have the tendency to make you overweight ?
Correlation does not imply causation, go educate yourself about diabetes.
what about a 5yo kid who just got diagnosed with diabetes type 1 ?
also did you know that when you take insulin, it is the insulin that have the tendency to make you overweight ?
Correlation does not imply causation, go educate yourself about diabetes.
The cost of insulin over the last few years and as recently as the last few months has skyrocketed. Not just the fancy fast acting insulin, but even the regular stuff that you can buy over the counter without a prescription(R and NPH) has nearly quadrupled in the last 12 years. It's not an increase in manufacturing costs. It's price fixing by the two major players(Lilly and Novo).
You'd think that with Lilly significantly raising their prices a few months ago, that Novo Nordisk could make a killing, but no, they both did it at the same time. Funny how that worked out.