If you start a pharmaceutical startup anywhere on earth, your business model is "sell to America". There is no other market. Every other developed country has price controls and refuses to pay, so the business plan is "sell to America and make whatever pennies we can internationally".
This is absurdly expensive. On top of this most plans have very high deductibles, often $5 to $10k, so a healthy family gets very little of the $25k put into it. This also is what dents salaries and raises, because employers are picking up 10 to 20% annual increases in insurance costs.
Furthermore America has very strange anto-competitive practices baked directly into our pay-for-service model, such as paying more for the same procedure done in a hospital, which is the most expensive place to get anything done. This disincentivizes private operators from creating clinics to do things cheaper.
I would recommend the following. "Health Insurance" should change to be actual insurance - meaning you pay a small amount to protect yourself from a rare outcome, just like life insurance. This would be like catastrophic coverage against accident or expensive illness.
Then, we take the $25k per year, and put it directly into a health savings account, and let customers actually choose hospitals and clinics based on price.
There is simply no true competition in American healthcare.
ch4s3 · 1d ago
> There is simply no true competition in American healthcare.
This is a point a lot of people miss. We have an deep under supply of both facilities and providers. Then things like CON laws make it even dumber.
rickydroll · 1d ago
As I mentioned the last time this topic came up, competition is not feasible in healthcare because there are circumstances that demand immediate treatment. You don't have time to make your choices—you have to take what you get, as well as in situations where there are no other providers within reach, creating a healthcare desert, as it were.
The heart attack I had back in 2018 occurred when I was hiking a local mountain. I had to walk out the last couple of tenths of a mile to a road where a ranger could get me. Then I drove myself 40 minutes to the nearest hospital with a cath lab.
The local hospital was 20 minutes in the other direction, and they would have seen me, said, "Yep, it's a heart attack," and shipped me to the hospital with a cath lab via expensive ambulance ride, which would have come out of my pocket. From a competitive perspective, the other nearest hospitals with cath labs were 90 minutes and 120 minutes away.
This experience with the local hospital, as well as others by myself and family members, is an example of medical care in most of America. However, it is only near a major city, such as Boston, that medical care can be competitive.
The heart attack I mentioned was billed to my insurance company at $145,000. If I were on a cash-based medical system as you advocate for, I would have turned to bankruptcy as soon as I got the bill. Some groups would call bankruptcy and income-based payments for crushing medical debt a "moral hazard" and use that as a justification for providing no relief.
Fortunately, we don't have to rely on anecdotes. We have a wonderful natural experiment around the world with current medical systems showing how the different systems provide different patient outcomes and give us practical examples of societal and individual costs.
franktankbank · 1d ago
They aren't advocating for cash based system. They are advocating for insurance against rare life threatening circumstances, and insurance fucking off out of the rest of it e.g. flu treatments, broken bones etc.
rickydroll · 23h ago
Then how do you cover expenses that are not covered by insurance, if not by cash? Credit cards?? Personal loan? Making your doctor act as your bank?
franktankbank · 20h ago
That part is cash yes. A heart attack would be covered under your insurance.
monero-xmr · 23h ago
In my vision, you would have catastrophic insurance to cover such an event and the recovery. But not insurance to cover annual checkups and other “routine” things
apwell23 · 1d ago
how can USA make EU pay their fair share for drugs? They seem to be getting a free ride atm.
ceejayoz · 1d ago
Are they getting a free ride, or are they getting a reasonably cost ride while we get hosed by corporations?
apwell23 · 1d ago
> If you start a pharmaceutical startup anywhere on earth, your business model is "sell to America". There is no other market.
what should these 'corporations' do instead?
ceejayoz · 1d ago
Yes, startups tend to be corporations.
And really, the model is "sell the startup to American corporations, who then milk Americans". Pfizer bought BioNTech's (Turkish/German) mRNA tech, for example.
Insulin's price skyrocketed, despite being a hundred years old. It didn't get harder to make, distribute, sell. They just wanted more.
Or Shkreli's purchase of Daraprim (https://www.bbc.com/news/business-34917918), a ~70 year old drug. They hiked the price from $13.50/pill to $750/pill. Did it get 55x harder to make suddenly? Of course not. It still costs $1/pill to make.
apwell23 · 1d ago
> And really, the model is
Thats not the model. You've made this about something completely different that i am not particularly interested in discussing atm. later.
s_dev · 1d ago
EU manufactures said drugs. Nobody is getting a free ride, Americans are getting shafted by American companies.
justonceokay · 1d ago
Drag them into the pit with us!
piva00 · 1d ago
Fair share? Why don't you focus on understanding why you pay so much, where the money goes, and other aspects that allow companies to absolutely fleece you?
After the data collection you can figure out how you are being exploited. You are being abused, fight that, not trying to force others to patch up the abuse you suffer, we have done the work to not be abused through political will, don't try to fuck with that because you got fucked.
apwell23 · 1d ago
> Why don't you focus on understanding why you pay so much, where the money goes, and other aspects that allow companies to absolutely fleece you?
hope you didn't you invest all your life savings into pharma startups .
resource_waste · 1d ago
For some reason we only focus on the names of corporations when it comes to corruption in Medical.
There is almost no criticism of Physicians in all of this. They are a top 4 lobbying group with a half a billion dollars in bribes. They use their private, unelected group ACGME to reduce supply of workers... and on-topic: the billing of insurance maximum rates seems wrong.
Yes things get 'adjusted', but it creates a culture where you cannot pay out of pocket and there is no competition for reduced rates.
I don't even mean to pick on Physicians here. If you look at the top lobbyists, pharma, pharmacists, pharmacies, insurance companies, and hospitals all make top 10.
I cannot see the path to reform, there is too much non-partisan money here. The electorate is divided on solutions, so there is little appetite by serious politicians to make this a major campaign plan.
Maybe there are historical examples of how to reform. Tragedy?
asdfj999 · 1d ago
ACGME reducing supply hasn't been true for at least 10 years. Medical schools and residency positions are exploding and quality of training is decreasing. Medical schools are now finding it hard just to place their students into adequate clinical rotations because hospitals are saturated with learners. Despite that, we even have to bring in more than 5,000 international physicians every year just to fill the available residency positions because there literally aren't enough American graduates. Meanwhile, reimbursements keep getting cut and physician liability increases.
spacemadness · 1d ago
You’re confusing me here. The hospitals are overloaded with learners but there aren’t enough graduates?
asdfj999 · 1d ago
Both can be true at the same time. Just some rough numbers.
There are approximately 30,000 American medical graduates each year. There are about 40,000 residency spots per incoming class each year. Both of these numbers continue to go up at least several hundred per year, it's just that always residency spots > American graduates. That answers the "not enough graduates" question.
Each year, that 10,000 resident surplus is filled with approximately 4,000 US citizens who went to international schools and 6,000 non-US citizens who went to international schools.
Now for hospitals being saturated with learners. There are at least 162,000 residents and fellows and 60,000 medical students (3rd and 4th year students) in total in the hospitals, not counting students in other disciplines such as nursing, physician assistant, etc. That means there are at least 222,000 residents/fellows/medical students in the hospitals. I am saying that to accommodate 222,000 learners getting enough exposure to all the nuances of medicine is extremely difficult and, as medical schools continue to grow, many schools are finding it hard to place students into environments with adequate opportunities to learn.
I'm a doctor. When I was in medical school, I literally had to call and send applications begging other physicians to take me as a student, otherwise the school threatens to dismiss you for not meeting graduation requirements. Many students don't have that problem, however many do and the number is increasing. It is just very hard to scale massively complex infrastructure while maintaining quality.
programmertote · 1d ago
Spouse of an oncology trainee here. This is an accurate statement. But whenever you mention similar thing on public forums like HN or Reddit, you get downvoted. I have a feeling that a lot of pre-meds, current medical residents and doctors (and their families) hang out in those forums and downvote everything that is stating the truth.
My wife is going to make $400K+ minimum (if she does more than one day per week on-call, she will make easily $500K/year; on-call for oncology aren't difficult btw) when she's done with the fellowship. We both came from Burma (Myanmar), and she told me how unnecessarily expensive everything with medicine in the US is (including the number of years required to train to become a generic/internal medicine doctor in the US).
She is also unhappy with the fact that doctors are acting as unnecessary gatekeeper for a lot of medicines that are fairly safe to use (and are available for over-the-counter purchase in other countries like India and Burma). We have a lot of doctor friends in the US, so we know the "industry" very well. Doctors (along with pharma and insurance companies) are at least somewhat complicit in the ever-increasing prices in the US. AMA (American Medical Association) spent $24M+ in 2024 for lobbying [ https://www.opensecrets.org/federal-lobbying/clients/summary... ] while pharma spent 30-40x more in lobbying [ https://www.opensecrets.org/news/reports/layers-of-lobbying ].
Side note: yesterday, my wife's department (a fairly large hospital in LA metro area) was treated with steaks by pharma reps from cancer medicine company. A lot of doctors, residents and fellows were delighted with that meal to say the least. I have been to expensive (Wagyu-beef expensive) hot pot dinner hosted by another pharmacy company when my wife was just an intern at a private clinic.
egberts1 · 1d ago
Doesn't help when un-degreed 18yo UnitedHealth callbank worker answers phone with an accent and perform the decline of such medical claim.
Doesn't help when UnitedHealth patient's child off their CEO for declined service either.
ch4s3 · 1d ago
> Doesn't help when UnitedHealth patient's child off their CEO for declined service either.
I'm sorry, what?
[*EDIT]I clarified what was meant here, and no neither Mangione nor his norther were ever denied care by United. This is a verifiable fact.
codyb · 1d ago
Reference to Luigi Mangione killing the CEO
ch4s3 · 1d ago
Well then it's factually wrong. He wasn't denied care, he was some spoiled prep school kid whose family got wealthy running scummy nursing homes that were probably themselves scamming medicaid/medicare.
egberts1 · 1d ago
Not he, his mother.
ch4s3 · 1d ago
That's not true either[1]. Neither he nor his mother were customers of or covered by United. Again, his parents are very wealthy people who own a cut rate nursing home, they are the kind of villains he was claiming to attack.
Healthcare costs so much in America because we don't have insurance, per se. We have a pay-as-you-go model because the average family of 4 is $25k per year https://www.kff.org/report-section/ehbs-2024-section-1-cost-...
This is absurdly expensive. On top of this most plans have very high deductibles, often $5 to $10k, so a healthy family gets very little of the $25k put into it. This also is what dents salaries and raises, because employers are picking up 10 to 20% annual increases in insurance costs.
Furthermore America has very strange anto-competitive practices baked directly into our pay-for-service model, such as paying more for the same procedure done in a hospital, which is the most expensive place to get anything done. This disincentivizes private operators from creating clinics to do things cheaper.
I would recommend the following. "Health Insurance" should change to be actual insurance - meaning you pay a small amount to protect yourself from a rare outcome, just like life insurance. This would be like catastrophic coverage against accident or expensive illness.
Then, we take the $25k per year, and put it directly into a health savings account, and let customers actually choose hospitals and clinics based on price.
There is simply no true competition in American healthcare.
This is a point a lot of people miss. We have an deep under supply of both facilities and providers. Then things like CON laws make it even dumber.
The heart attack I had back in 2018 occurred when I was hiking a local mountain. I had to walk out the last couple of tenths of a mile to a road where a ranger could get me. Then I drove myself 40 minutes to the nearest hospital with a cath lab.
The local hospital was 20 minutes in the other direction, and they would have seen me, said, "Yep, it's a heart attack," and shipped me to the hospital with a cath lab via expensive ambulance ride, which would have come out of my pocket. From a competitive perspective, the other nearest hospitals with cath labs were 90 minutes and 120 minutes away.
This experience with the local hospital, as well as others by myself and family members, is an example of medical care in most of America. However, it is only near a major city, such as Boston, that medical care can be competitive.
The heart attack I mentioned was billed to my insurance company at $145,000. If I were on a cash-based medical system as you advocate for, I would have turned to bankruptcy as soon as I got the bill. Some groups would call bankruptcy and income-based payments for crushing medical debt a "moral hazard" and use that as a justification for providing no relief.
Fortunately, we don't have to rely on anecdotes. We have a wonderful natural experiment around the world with current medical systems showing how the different systems provide different patient outcomes and give us practical examples of societal and individual costs.
what should these 'corporations' do instead?
And really, the model is "sell the startup to American corporations, who then milk Americans". Pfizer bought BioNTech's (Turkish/German) mRNA tech, for example.
Insulin's price skyrocketed, despite being a hundred years old. It didn't get harder to make, distribute, sell. They just wanted more.
Or Shkreli's purchase of Daraprim (https://www.bbc.com/news/business-34917918), a ~70 year old drug. They hiked the price from $13.50/pill to $750/pill. Did it get 55x harder to make suddenly? Of course not. It still costs $1/pill to make.
Thats not the model. You've made this about something completely different that i am not particularly interested in discussing atm. later.
After the data collection you can figure out how you are being exploited. You are being abused, fight that, not trying to force others to patch up the abuse you suffer, we have done the work to not be abused through political will, don't try to fuck with that because you got fucked.
hope you didn't you invest all your life savings into pharma startups .
There is almost no criticism of Physicians in all of this. They are a top 4 lobbying group with a half a billion dollars in bribes. They use their private, unelected group ACGME to reduce supply of workers... and on-topic: the billing of insurance maximum rates seems wrong.
Yes things get 'adjusted', but it creates a culture where you cannot pay out of pocket and there is no competition for reduced rates.
I don't even mean to pick on Physicians here. If you look at the top lobbyists, pharma, pharmacists, pharmacies, insurance companies, and hospitals all make top 10.
I cannot see the path to reform, there is too much non-partisan money here. The electorate is divided on solutions, so there is little appetite by serious politicians to make this a major campaign plan.
Maybe there are historical examples of how to reform. Tragedy?
There are approximately 30,000 American medical graduates each year. There are about 40,000 residency spots per incoming class each year. Both of these numbers continue to go up at least several hundred per year, it's just that always residency spots > American graduates. That answers the "not enough graduates" question.
Each year, that 10,000 resident surplus is filled with approximately 4,000 US citizens who went to international schools and 6,000 non-US citizens who went to international schools.
Now for hospitals being saturated with learners. There are at least 162,000 residents and fellows and 60,000 medical students (3rd and 4th year students) in total in the hospitals, not counting students in other disciplines such as nursing, physician assistant, etc. That means there are at least 222,000 residents/fellows/medical students in the hospitals. I am saying that to accommodate 222,000 learners getting enough exposure to all the nuances of medicine is extremely difficult and, as medical schools continue to grow, many schools are finding it hard to place students into environments with adequate opportunities to learn.
I'm a doctor. When I was in medical school, I literally had to call and send applications begging other physicians to take me as a student, otherwise the school threatens to dismiss you for not meeting graduation requirements. Many students don't have that problem, however many do and the number is increasing. It is just very hard to scale massively complex infrastructure while maintaining quality.
My wife is going to make $400K+ minimum (if she does more than one day per week on-call, she will make easily $500K/year; on-call for oncology aren't difficult btw) when she's done with the fellowship. We both came from Burma (Myanmar), and she told me how unnecessarily expensive everything with medicine in the US is (including the number of years required to train to become a generic/internal medicine doctor in the US).
She is also unhappy with the fact that doctors are acting as unnecessary gatekeeper for a lot of medicines that are fairly safe to use (and are available for over-the-counter purchase in other countries like India and Burma). We have a lot of doctor friends in the US, so we know the "industry" very well. Doctors (along with pharma and insurance companies) are at least somewhat complicit in the ever-increasing prices in the US. AMA (American Medical Association) spent $24M+ in 2024 for lobbying [ https://www.opensecrets.org/federal-lobbying/clients/summary... ] while pharma spent 30-40x more in lobbying [ https://www.opensecrets.org/news/reports/layers-of-lobbying ].
Side note: yesterday, my wife's department (a fairly large hospital in LA metro area) was treated with steaks by pharma reps from cancer medicine company. A lot of doctors, residents and fellows were delighted with that meal to say the least. I have been to expensive (Wagyu-beef expensive) hot pot dinner hosted by another pharmacy company when my wife was just an intern at a private clinic.
Doesn't help when UnitedHealth patient's child off their CEO for declined service either.
I'm sorry, what?
[*EDIT]I clarified what was meant here, and no neither Mangione nor his norther were ever denied care by United. This is a verifiable fact.
[1] https://www.cnn.com/2024/12/13/us/ceo-shooting-luigi-mangion...