Mark Cuban's pharmacy started with a cold email(beckershospitalreview.com) |
Mark Cuban's pharmacy started with a cold email(beckershospitalreview.com) |
It sounds to me like this is less of a vertically integrated drug manufacturer and more of a website to resell generics at a 15% markup plus pharmacy fee plus shipping and handling.
Looking at his website I see a "powered by truepill" logo at the bottom. Truepill seems to be a company that does online pharmacies... So, Cuban Cost Plus is, possibly, a digital storefront for truepill?
>15% markup plus pharmacy fee plus shipping and handling.
This is the intent, and still cuts out at least 2 middle men between consumers and manufacturers: the insurance company and pharmacy benefit managers.
Or at least allow people to continue to renew their medications after prescribed one time, rather than requiring further doctor's visits.
Most things in medicine are expensive due to legal monopolies/improper regulations. e.g. no reason you shouldn't be able to buy prescription glasses for $10-20 dollars off the shelf. The main problem with medical costs is that it's not a free enough market, with sufficient competition.
If you look up details about his factory it's supposed to be built sometime next year. On Google maps, looking at the address, I wasn't able to see any evidence of this place existing. It's also supposed to employ 60-80 people, which, seems small to take on drug manufacturing.
Pharmacies pay the acquisition price for the drugs. Then, they make up a fictitious price (called the Usual & Customary price). The U&C is intentionally very high, because it forms the basis for negotiating with pharmacy benefit managers (PBMs).
The Cuban-funded venture uses this as their price comp, calling it the “retail price”. However, the U&C price is only the retail price for one group of people: those without insurance who do not know of drug discount “cards” (nowadays mostly mobile apps such as GoodRx nowadays).
Basically, anyone with insurance or a (free) discount card will get a hefty discount on the U&C (always compare the two before using insurance, as sometimes, the “regular” discount is higher than the insurance one). Just plug some of the expensive drugs into GoodRx et al to compare and you’ll find that in some geographies, the Cuban-funded co is cheaper, while in others, it is more expensive (drug discounts vary across pharmacy geo. locations).
Pharmacies give non-PBM entities discounts bec they make money regardless. Let’s say, you start an Rx discount biz. You can go to pharmacies and negotiate a discount plus a small margin for yourself. This is how GoodRx is making (lots of) money, for example.
Now, the innovation with this new co is that previously, drug discount cards and pharmacies were usually two different parties. All they did was to partner with a mail order pharmacy, negotiate a discount (acquisition + 15% is the classic Costco pharmacy price btw), set up a website, and tell everyone “look at how much cheaper we are!”.
The future vertical integration comes from taking this a step further and partnering with generic drug makers. I also suspect that at some point, they’ll start their own pharmacy.
I’ve been waiting for GoodRx or another discount provider to bundle these 2-3 steps in the distribution chain, but they have never done this. Perhaps they worried about competing with their pharmacy customers, as their model is going wide, rather than deep, while this new Cuban-funded venture is going deep instead, partnering with a single pharmacy.
Beats me why their pharmacy partner (or other such cos) wouldn’t just start adding their own discount biz. But perhaps they’re doing that and they had other reasons to do this…
Generic drugs are pumped out for pennies a pill by a pre-existing infrastructure across the globe. Mark will be buying from them, not spending billions trying to replicate manufacturing plants and FDA agreements.
In essence it’s a cash-only pharmacy for cheap generic drugs - not that different than what Walmart and Target do with their $4/month prescription drug program.
Big pharma won’t give a shit because Mark can’t make his own generic versions due to IP.
He might make a difference for those weird edge cases like Daraprim (sp?) where the market is so small, supply is constrained, so mark ups are huge. But those are weird edge cases that don’t last long.
Of course there's no IP protection; that's the definition of "generic." But that doesn't mean big pharma won't care. 20 years ago they might not have cared. Nowadays big pharma has learned how to game the generics industry to become sole-source generic providers and set prices as high as they wish, even without IP protection. It's this abuse of the generic marketplace that Cuban seems to be taking on.
https://khn.org/morning-breakout/mark-cuban-unveils-plan-to-...
On the other hand, I'm increasingly uncomfortable with just how much free marketing and PR is being applied to the "Mark Cuban Pharmacy" without much critical examination of what's going on here.
Taking one of the examples straight from their homepage: They will sell you 30 Prozac tablets for $3.90: https://costplusdrugs.com/medications/fluoxetine-10mg-capsul... They list the "Retail price at other pharmacies" as $22.80 and claim to save you $18.90. Fantastic, right?
Except nobody should actually be paying $22.80 for generic Prozac. You can drive to any local Walmart and get it for $4 and they will bill your insurance, which will count toward your deductible. (Walmart has a list of their $4 and other cheap prescriptions here: https://www.walmart.com/cp/4-prescriptions/1078664 )
Mark Cuban's pharmacy, however, refuses to deal with your insurance and they're going to charge an extra $5.00 shipping at checkout. So now you're paying basically twice as much to Mark Cuban's pharmacy even though they're telling you the entire way that you're actually saving money.
I also checked my personal insurance and my negotiated rate for the same medication is also less than $5 at local pharmacies.
Now of course it's likely that other drugs will work out to be cheaper on Mark Cuban's pharmacy than any other combination of your personal insurance and local pharmacies, but that's far from guaranteed.
I'm concerned that Mark Cuban is capitalizing on people's lack of understanding about how insurance works and how easy it can be to look up drug prices (use your insurance company's website or just pick up the phone and call your pharmacy, they'll check for you). His profit margins, however small, rely on people skipping their insurance and going straight to Mark Cuban's pharmacy. That could be fine in some circumstance, but in others, perhaps many other cases, the customer would come out behind by opting out of their insurance.
I wish some media outlets would actually dig into this instead of endlessly recycling the company's own talking points verbatim.
I remember once when I was volun-told to work for new program that handled "rebates". They needed a nerd to support the servers/databases. There was a presentation explaining the program and how it worked. At the conclusion, I asked, "So, this is a kick-back?", and the room went silent. "No, it's not a kick-back. It's a rebate." Hmmm. "Well, it sounds like a kick-back. What's the difference?" We went back-and-forth for a minute or two. Then, finally, some suit spoke up and said "Kick-backs are illegal. Rebates are not." And that was that.
So, I applaud Mark Cuban for his efforts here. I hope this succeeds.
Truly hope that's an honest statement, wish them the best if that's the case.
The root problem is having for profit companies involved in providing critical medical treatments. The solution is for people to band together and create an entity (the government) to provide these treatments at cost without the incredible inefficiency of for profit business.
I don't know that this level of fatalism is appropriate, and if it sets the new level for the rest of the industry at a lower rate that would be good!
A co-op can do what you are describing, seems like someone should send Mr. Cuban a cold email asking him to re-incorporate his venture as a co-op!
I want Amazon, Facebook, Google, Apple, Walmart, all the so called evil multinational corps, billionaires like Cuban, Gates, Musk, Zuckerberg & Co. and the the government to get into American healthcare industry and dismantle the multi trillion dollars racket, change it into something functional and useful for the people.
I don't care if it will mean millions of people in the insurance, hospital administration, public and private health policies will be out of jobs. Sorry I don't. Also for doctors, medical schools, state medical license issuing bodies, you are gonna allow minimum 10x increase in new doctors entering your field. The gravy train must stop. The system must work for the people, not at the expense of the people.
Should it be socialized healthcare or free market healthcare? At this point, I don't care. Anything else is better than this heap of trash. I've experienced both systems in my life and both systems are superior to the American system. But these discussion are distractions to what's really causing the problem in the American health care system. There are trillion dollar protected class of people who make the entire system unworkable. This system needs to collapse and be replaced with something new.
I also learned from that book that generic drugs are not produced by the same process as the brand-name drugs. I thought it was basically an open-sourcing of the drug and it's not that at all. They use the same ingredients, but the generic manufacturers need to reverse-engineer the proprietary manufacturing processes of the big brands, because important details are often deliberately omitted from the patents.
The same thing costs less than $2 in Pakistan for the Glaxo Smith Kline version. https://www.emeds.pk/ventolin
I have so many antibiotics and controlled substances you’d be better off raiding me over your local Walgreens in a zombie apocalypse.
Seriously, sometimes I read about people dying of lack of access to insulin and it blows my mind. It’s one payday loan spent on the round trip flight and 30 hrs and you have cheap medication.
Even when folks here were whining that HCQ was going to be in “a shortage”, I just bought some Plaquenil from there. Folks really like building cages and then just die in them. Frankly confusing but hey it’s your life.
https://costplusdrugs.com/medications/
A quick search of 2-3 drugs shows it comparable to Goodrx. And with Goodrx I can go to my local pharmacy and get it today.
As others have pointed out, Cuban is basically running a lead gen operation that then services customers drug needs via a white labeled site/fulfillment operation run by TruePill.
Any idea who is funding TruePill?
One of the largest PBMs in the industry - https://www.optumventures.com/portfolio/
Many ways to make money in pharma!
Brian's pretty public about it. Wrote a whole (and great) book, "The Addicted Lawyer," telling his story in depth. Granted there's nothing Big Pharma in there from what I remember, but I could see me being motivated in a similar direction if a sibling had to fight that fight.
So far we have
goodrx, singlecare, etc.
amazon.com/primerx
walmart.com/pharmacy (walmart.com/cp/pharmacy-mail-order/1042239)
geniusrx.com
ro.co/pharmacy
costplusdrugs.com/medications
That certainly hasn't been my experience. Most pharmacies I've tried this with need to actually 'fill' the script and run it through insurance to get a final price. And, in the era of 'COVID-related staffing shortages', good luck calling the pharmacy and actually getting someone on the line.
The sad thing is, all these pharmacies know about GoodRx and other discount providers. They could stop playing games and just run all scripts through these providers to get a 'cash price', but they don't. It's honestly like shopping at Kohls where if you aren't stacking coupons, you're the sucker paying too much.
I don't know about Cuban's mechanics here, but a website that shows you the final price, no games/codes, is a great addition to the market.
They aren’t allowed to contractually. The PBMs and insurance companies make pharmacies sign contracts that forbid them from doing this. They also forbid pharmacies from telling customers if it would be cheaper to pay cash.
Most states have only a few major insurance companies and getting caught and losing the ability to serve a large portion of clients would put most pharmacies out of business.
It’s probably the US government that’s the sucker here. Probably a rule that they have to get the “best price” and that’s probably the cash price that no human pays because they all show up with a discount card/insurance.
Maybe you can do the analysis you mention and publish it? The worst that will happen is that all us laypeople will be better informed.
I think though that CostPlus, if nothing else, has opened the eyes of a great many people who just assumed medicine was like any other product where the manufacturer controls the price and if someone is making obscene profit, it's an outlier like the Shkreli douchebag. Now a lot more people know that it's possible to pay a lot less. Even on TikTok I'm seeing people paying much less for their prescriptions when they bypass the insurance company and pay full retail price, which is counterintuitive as hell, and I personally would have never guessed.
So all in all, I think it's hugely positive that the secrets are getting out, and CostPlus is invariably a large part of that.
Like any other product? There are zero products like that. Manufacturers aren't legally able to control the price even if they propose a contract with a resale price clause. That's why everything has a "manufacturer's suggested retail price" printed on it.
[0]: https://www.census.gov/library/publications/2021/demo/p60-27....
Nobody seems to be even checking the basic facts on this story. Everyone is so eager to dismiss anything insurance-related that they'll take all of the talking points at face value.
OK. Is your point Mark should be trying to build a single insurance offering or marketplace that could serve them all? Not being confrontational, just genuinely curious if think his efforts are better spent there?
I don't see a problem with this. Some insurance plans are can be hard to deal with. My personal experiences involve requiring step therapy (trying a cheaper, possibly less effective drug) before approving the prescription. Another experience is that a drug may only be covered for one condition but not for another (e.g. finasteride for hair loss vs finasteride for enlarged prostate).
If Cuban wants to avoid the headache of dealing with formulary lists, I don't blame him. Obviously consumers should compare prices whenever possible, but if the difference is only a few dollars I'd probably rather pay Cuban directly than deal with the Walmart retail experience.
FYI, Mark Cuban's pharmacy only deals in generic medications. Most of the "step therapy" programs exist to gate the non-generic medications, so you wouldn't be finding them at Mark Cuban's pharmacy anyway.
Also, you don't need insurance to use a traditional pharmacy. You should still cross-shop online regardless.
I think too many people have misinterpreted Mark Cuban's PR as having solved all of the problems with insurance, but it's really just another retailer of generic medications like countless others online.
They said they plan to do their own manufacturing in the future, but at the moment they're buying from the same wholesalers as all the other online discount pharmacies. They've just attached Mark Cuban's name to this one.
I'd say driving to wallmart and dealing with insurance can be as much as $5 worth of gas and time for some.
In some instances, doctors in private practices have told me that taking Medicare or Medicaid means making less than minimum wage for certain procedures because the rates are fixed at such low values. In other cases, ER and intensive care units make nothing because they cannot legally turn anyone away for not being able to pay.
All of that has to be made up somewhere, and bilking insurance companies when they can are how they stay afloat.
Big companies can take the hit on high insurance rates. Drug makers live in boom and bust cycles (drugs are either fabulous money makers or bottomless pits that suck money from research, to testing, to the famously expensive FDA approval process).
The people hurt the worst are the small business employees and owners, the self employed, and the part time workers who can't afford to have the hospital come after them.
I've avoided simple things like up voting stories about it for exactly this reason. Sure the headline sounds great but without actually going through the math and how the site works who knows if it's actually good.
It’s Costco for generic meds. No one calls Costco a charity, but their employees and customers love them for being fair and their business is held up as an example of how to create value from customer loyalty. And they still generate value for their shareholders.
If you have insurance, this is likely not for you. If you are uninsured, this could be huge for you. Perspective is important.
Can you elaborate on how this works? Are they giving you 30 days' supply of drugs for only $4, even if you have no insurance? Are they charging both insured/uninsured people $4, but billing the insured people more (via insurance) to make up the difference?
Yes, the 30-day supply of those drugs is literally just $4 whether or not you have insurance.
Many (but not all) generic drugs are actually super cheap to manufacture. Certain chemicals are basically pennies for a dose, and the production at scale is essentially automated away.
For the cheapest drugs, you're paying for the pharmacy to inventory it, dispense it, call your doctor if something goes wrong, and so on. Mark Cuban's pharmacy cuts costs by refusing to do any of the legwork with your doctor or insurance company. Your local neighborhood grocery store pharmacy doesn't mind doing it because they can sell you groceries while they fill it.
>Mark Cuban's pharmacy, however, refuses to deal with your insurance
I would say this is a net good. It significantly reduces their costs.
Also there are many, possibly the majority of, cases where their prices are substantially cheaper than Walmart.
OTOH, this seems like a blessing for the un[der]insured. But I took OP's comment to be one of critical optimism, not an attack on the company itself.
People generally go to the store to buy groceries anyway, so it's not a big deal to pick up a prescription while shopping.
You extrapolate your privileged position to create a whole criticism of a more viable and affordable way of buying medicine that many people outside your situation would maybe embrace because they lack the same options.
IIRC Meijer does free antibiotics and some maternal health stuff, Costco just generally has pretty low prices that are published, Walmart is linked in the parent, Kroger has a variety of free/$3/$6 medications in some kind of association with GoodRX, I didn't see anything for Albertson's on a quick search but there may be one.
So - while you may be able to get nearish the same price (before the shipping) <-- But am I consuming less of my insurance and also paying less to insurance companies, which are just hedge funds anyway...
So, if Mark Cuban the Billionaire can start a pharmacy model such as this, not dealing with insurance, then what precludes market competition with his pharmacy?
Franchise license with supply chain to open ones own brick and mortar etc...
Serious questions.
Brick and Mortor stores selling without dealer discounts?
Or others copying and marking up only 10% or 5%?
I guess nothing but greed stopped this before.
Your entire criticism seems to be "there may be specific circumstances in which this isn't actually cheaper, and that's bad because Mark Cuban."
A cool plot twist would be if your pharmacy purchased the drugs from Walmart, and just put them in a cute orange box with a nice sticker showing their name :)
It's 2022, and if your prices are not on a web page, they're clearly not a selling point.
> Except nobody should actually be paying $22.80 for generic Prozac. You can drive to any local Walmart and get it for $4 and they will bill your insurance, which will count toward your deductible.
FWIW I thought this meant that it was $4 because of “your insurance” or “deductible” but I think you meant it’s $4 for people that aren’t insured? And people that are insured get it for free?
No, it's $4 retail at Walmart. $10 for a 3-month supply.
People with insurance might also pay the $4 if they haven't reached their insurance deductible (same concept as car/home insurance deductible).
Insured people still pay some co-insurance, up until their out-of-pocket maximum.
Except people can, and do, all the time. Source: they lady in front of me at the pharmacy counter today, who didn't want any "risky generics".
https://www.hindustantimes.com/columns/the-scary-truth-behin...
I guess the wait time and complexity of ADC might not make sense for those without insurance.
TL;DR: writing news is hard and journalists are overworked and underpaid. Media firms for companies basically write these articles for journalists, and since they aren't technically false everybody wins (except the reader) because the news agency gets a lot of "news" and the companies get exactly the spin they want.
But did you even read the comparison? The drug I showed (which was highlighted on Mark Cuban's pharmacy's home page) was still half as expensive by going to a local Walmart.
They're relying on a marketing campaign that "all other pharmacies are evil!" and they're hoping none of the media outlets bother to double-check their talking points. So far, it's working.
A kick-back would go to the doctor or pharmacist for pushing the customer toward a medication. The problem in this scenario is the monetary incentive to mislead the customer.
With medication rebates, the customer is getting the drug one way or another. The rebate just discounts the effective price and sends the discount to the customer. The only party not aligned is the insurance companies (who, IMO, probably hate this system more than anyone)
Why is it not a kick-back if the customer’s insurance company is the one being paid to push the customer toward a medication, via differential coverage/co-pays/etc?
PBM rebates are not illegal. They aren’t transparent to patients (which is a problem) but they aren’t illegal.
I don't think this is as much as a problem with normal kickbacks since the party being directly "harmed" here is an insurance company not getting as good a deal as they could and their whole job is to set prices for policies to account for that. Of course, this could lead to a bigger problem, because insurance companies could account for programs like this in rates, and now you have an arms race where your policy only makes cost sense if you are getting these incentive payments.
If a middleman gets the money it's probably a kickback.
The chain of money goes from managed care/insurance buyer (individual/employer/government) to MCO to healthcare provider, whether it be a pharmacy, a drug manufacturer, a hospital, or a doctor. The fact that the middle has a tiny profit margin means there is not much juice to squeeze there.
As someone who works in this industry, though for a non-profit medical practice group, we want it gone as much as the patients. It's an absolute nightmare to do anything. We have a staff of twenty people just to deal with the paperwork side of the business, and that doesn't include answering phone calls from patients. All of those people could be put to far more productive use doing anything else; half of them are people who wanted to get into medicine but not through a full-fledged medical degree and are now toiling away shuffling forms. We would love to move them to patient care assistants or anything else but we have to have them in order to get paid.
(I know for sure we would like to have them do other things and they would like to do this because our group has a role rotation program where people can rotate in and out of groups to try other things. The insurance/paperwork group has virtually no one want to rotate in and almost the entire group is on the list to rotate out for a month or two a year to do something different.)
> Also for doctors, medical schools, state medical license issuing bodies, you are gonna allow minimum 10x increase in new doctors entering your field.
I also completely agree with this. It's frustrating to deal with the regulatory issues, too. We had to move a practice office (that is, where patient care is provided) from a place we leased to an office we bought as part of a commercial condominium a few years ago. Getting that approved took months of back and forth because the rules of the licensing body didn't fully contemplate an "office condominium" like we purchased.
For example, prescription glasses can be made for a few dollars, but often cost over $100 and you have to pay to see the optometrist for a prescription.
In reality, you could walk up to an automated machine, have it assess your vision, and pay $10-$20 for a pair of glasses. This has actually been proven in other countries that allow you to buy glasses without a prescription. In a competitive market, price of a good tends to trend towards marginal cost of production... which is clearly not the case in a lot of medicine/vision etc.
Also, my copay for one of the medicine's on Cuban's site is $50, but on the site it's $3. Why is this? Seems some exploitation of incomplete information... could be fixed through regulation... like requiring pharmacies to show pricing of generics when filling prescriptions.
Also hospitals don't list pricing... though there was a rule passed under the Trump admin that requires them to do so. Not sure if this is in an easily consumable format yet.
So I agree with your sentiment, but don't think it can be disrupted without changes in law. Primarily there is way too much information asymmetry in all areas of medical care
To make it even better, the folks on the street who hear you work there think you are übersmart superstar solving the world’s problems.
There are probably tens of millions of people hoping they do something like what you’re asking for.
Of course, I don’t think it fits in their wheelhouse. We’ll see.
Self-prescribing antibiotics is not great for antibiotic resistance - Al Jazeera has done some great reporting on how Indian pharmacies loose prescription checks or doctors overambitious antibiotic prescriptions have caused a rise in antibiotic resistant superbugs (https://www.aljazeera.com/program/101-east/2016/8/9/the-rise...) - sure they're easy to get, but there's been a tremendous health cost in India because of that
But not only "suckers and rich people" pay American rates - the people who were born here without foreign ties do it all the time!
And finally, India just recently opened for tourism, plus they're not doing visa on arrivals yet, how can people get a payday loan, passport, visa via embassy, and a whole trip in so casually?
Edit: can't you just do everything you mentioned above in Mexico anyways?
If that’s incorrect hopefully someone can correct.
I had to go through PA for 2 generic drugs that cost ~10-15 each a month from Costco (according to GoodRX). Cost Plus is actually a bit more expensive with shipping. If its $5 shipping total and not per drug its a small saving but wouldn't count towards my deductible. Was a huge hassle. I'm pretty sure if you were to take the time*wage my pharmacist, my doctor and myself spent on getting it done it would have paid for the prescriptions for at least a decade.
Oh and I'm on a high deductible plan so it will probably never cost them anything because I probably won't hit my coinsurance/out of pocket max.
This is wrong.
The coding for a given procedure should be standardized and priced as such.
This simple change could do great things for leveling the playing field for the nation of healthcare ;
If regardless of your volume of encounters on a particular code, the price should be set.
This may do several things:
Make rural hospitals/clinics more competitive with a major hospitals.
In my experience though - the big spending in non-medical areas that hospitals have are around "comfort aesthetics" (Art, pretty buildings etc)
Hospitals which cost $400MM -- to $1B facility (2009) spent a LOT on art. They seek donors constantly...
Maybe they should have the rich donors, as a requirement for their contribution, also require they provide a loaner art install.
This way - lets say you donate $1MM to a hospital, 100% of that donation should go to actual clinical build etc.. and the hospital should be precluded from your financial donation from being used to pay a digital arts company from being paid their ~250K fee through your donation...
I've built quite a few big facilities and art is a HUGE aspect in the health aesthetics of an environment ; but the cost is always exorbitant. Personally, having managed the install of such - I think that this should be outside of what the hospital should spend money on - unless the donation is specifically for art/aesthetics...
This lightens the build cost for large hospitals.
Source designer/TPM/etc on:
- El Camino CA (I just got this today: https://i.imgur.com/KFCX4N0.jpg)
- UCSF CA
- NOME AK
- Sequoia CA
- Methodist CA
- Others I cant even recall now...
---
All of these costs get baked into the overall cost of the facility - and guess who pays for that? (not only in monetary costs)
My brother was the head of the VA for AK - commander of 10th medical wing for the USAF and is currently the CMO for the largest hospital group in AK.
Familiar with both sides of the table on price-fixing...
I don't have pharma exp WRT drug costs... just sunk costs in the facilities I build - but I get info from my brother on certain things...
but pharma prices need to be heavily reg'd
This is basically standard in 2022.
My local pharmacy will even let me convert prescriptions to mail-order with automatic refill with a few clicks online.
They'll also phone up my doctor and ask for a 90-day prescription to make it easier if I want. They'll also call the doctor and request refills when the prescription is up.
> OTOH, this seems like a blessing for the un[der]insured.
Yes, but only if people read the fine print. As in my example above, it's actually more expensive to use Mark Cuban's pharmacy than your local Walmart for many prescriptions.
They are relying on people's assumption that it's the cheapest pharmacy around, and nobody in the media seems to be doing anything to investigate that claim. A couple minutes of research shows it's not really true.
I listed two, do you disagree that they are removed?
You can usually pay cash at a pharmacy, skipping insurance
> "People always ask, well why didn't somebody do this before? The reality is there's so much money there, it's hard not to be greedy," Mr. Cuban said
> "But I won't. I've got enough money. I'd rather f— up the drug industry in every way possible."
Some people like to max their points in videogames. Other like to max their $ in real life.
The beauty of capitalism is that the effort of the latter end up benefiting us all.
I like that sentiment!
I also like it's coming from a capitalist VC, with a profit incentive!
And I love I won't have to bother with insurance and stuff: yes, I could save $5 here and there, but no, I don't really care, and I'm not sure it's worth dealing with the insurance company who'll gather the information and look for various creative ways to compile and use the information against their clients (say, if you take tobacco cessation drugs, birth control, etc)
Yes, I know there are various laws on the books that in theory protect patients against that, but as we've seen with the consequences for say Experian data leaks, the reputational risk for Cuban himself look like a much stronger incentive that for say, Walmart or Costco or whatever company doesn't bear the investor name.
So I think Cuban will have my business!
I honestly don’t know what this sentence means, and I’m glad I don’t need to deal with such things in the UK.
See also: https://en.wikipedia.org/wiki/High-deductible_health_plan
In the case of the drugs, it's fine because the person ultimately paying for the drugs is the insurance company, which also happens to be the entity receiving the "kickback".
[1] https://www.justice.gov/usao-ndca/pr/former-netflix-executiv...
Here is a tip for killing a product at a walmart store:
Buy a product out for 2/3 months. Inventory will raise. Stop buying the product. Walmart will delist. Do this at a few stores and get it delisted regionally. Do this to a few regions to kill it nationally. It could be a product that walmart carried for years.. they will still delist.
That definitely passes a smell test.
Somehow all these excuses are still not jiving.
These may all be standalone operations, or one corp with its hands in each pocket: PBM, pharmacy, insurer and distributor.
(2) Costco actually does shit. They build buildings, hire pharmacists, buy inventory in bulk, and sell it to you in the store. Cuban has a website that takes 3 months to build and a little bit of transaction risk.
What I've heard (not researched) is that they typically have the lowest drug prices.
Aren't the two in equilibrium though? The price of the kickback is priced into the MSRP of the drug, and the kickback you get is priced into the cost of the policy. If the kickback disappears, both would cancel out.
My understanding is that your policy funds are effectively "mixed" with other people covered by your insurance company.
So, I think it could very easily be a net transfer of money from people who aren't using that drug category but have insurance policies used by people who do use that drug, to the drug company at the end of the day.
This is now illegal in the US.
https://www.aarp.org/health/drugs-supplements/info-2018/gag-...
For many or most employed people medication will be cheaper through their insurance.
Also there's a ton of stuff that I can buy for $5 at the store and get shipped to me for $10 (I don't own a car so am very aware of this sort of thing), so I'm not sure what the general complaint is here.
The price at Walmart is less than half, regardless of whether or not insurance is involved. The deal is worse for the consumer whether or not insurance is involved.
So why would I eat a prescription / OTC drug that's made there?
https://www.india.com/business/india-becomes-pickle-king-of-...
Some medications require regular monitoring to ensure that bad side effects aren't happening; PrEP requires checkups every 90 days to make sure kidney function is not getting impacted.
People can easily seek out prescriptions as it is today, they just need to find a doctor and say the right things. This is common with TRT, Modafinil, Cannabis etc the barrier as it exists today is mostly artificial.
We allow people to drink alcohol, so any drug less dangerous than that shouldn't be gated
Saying that kidney function usually involves Estimated Glomular Filtration Rate which means they measure the creatinine. Now if you happen to supplement with creatine, creatinine being the metabolised form will alter the eGFR! So if a dr doesnt ask you if you are supplementing with vitamins, minerals and other supplements, you could skew some medical tests and end up with a medical condition that doesnt exist!
You can also get quite alot off your pharmacy, but you need to know what to say, so some online pharmacys are better to use to work out what to say.
For example, if you want to get hold of Testogel here in the UK, for males its a nice pick me up and its being used in South Africa for dementia treatment, you need to say your T levels are below a certain amount. If you get rejected, you lower the amount on another website and then you can eventually work out what the level is that lets you have a testogel prescription!
Its not too hard to game the medical system for low risk drugs, for everything else you have various people who already qualify and through word of mouth have been known to sell on their meds because the Dr might sometimes up the dose if there is no response or told there is no response. SSRI's are like this. In theory a blood test measuring the 5-Hydroxyindoleacetic acid from the jugular vein will test if someone is taking SSRI's but they also do other things which go undocumented until some published scientific study highlights it.
To be honest though, the best drugs are vitamins and supplements, the number of medical studies I've read highlighting negative effects is quite shocking. Take https://en.wikipedia.org/wiki/Bisphosphonate#History It was first used for bone problems in the 1960's but the technology wasnt around to explain exactly what it was doing until the 1990's! Loads of studies slate the use of Bisphonates but these are recent like post millennium studies.
In fact you go through Google Scholar, you can see a trend from the first studies published in the 1800's where medicine was largely using what was found in the body, so B12 deficiency was eating raw liver, then from WW1 to WW2 patented drugs started to appear and thats when modern medicine started, but it is a case of medicine is restricted by the technology so AI in medicine is big business.
This gives you an idea of how the medical profession work, drug companies develop something run a battery of tests and then see if they can get it licenced and sold as a treatment.
https://en.wikipedia.org/wiki/Bupropion#History This is another drug designed for one thing but they noticed it had smoking cessation properties so it got relicensed.
Painkillers even the common ones like ibuprofen and paracetamol are also dangerous drugs. Paracetamol will destroy your bones and your kidneys dont like ibuprofen.
This is the history of Ecstasy aka molly aka mdma TLDR,
1912 German pharma Merck developed the compound for blood clotting, didnt work so got shelved.
1950's US Army dust off the compound and get university of Michigan to study it.
1973 results declassified.
1978 https://twitter.com/DrAShulgin a former Dow chemicals chemist into his psychoactive drugs looks at it and publishes a report "the drug appears to evoke an easily controlled altered state of consciousness with emotional and sensual overtones. It can be compared in its effects to marijuana, to psilocybin devoid of the hallucinatory component, or to low levels of MDA"
Psychotherapists start using it.
1980's its getting popular and DEA start to take notice.
1985 DEA get it banned, people having too much fun! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3931692/
Medicine is like chemical hacking of the body.
My clinic’s backend used to have a slightly easier ‘refill prescription’ form but they changed it to only work with their integrated pharmacies. The closest one is an hour away.
And of the big problems in medicine - a prescription for glasses (which isn’t really a medical service in the US - optometry is not a medical profession) just doesn’t register for me - you can order glasses online without a prescription if you are so inclined.
Meanwhile there isn’t any realistic libertarian solution to allocation or access to complex medical care - and just hand waving “free markets” doesn’t make it so.
Contacts would certainly be much cheaper without that hurdle.
And I bring up vision, because it's a common problem and for less well off folk with families it can be a big expense, basically entirely unnecessarily so. Imagine making 20k/year and you have to pay $500-$1000 a year for vision correction for your family. That's 2.5-5% of your pretax compensation
There's no handwaving here. Competitive markets require complete information. Information about costs to the consumer is basically entirely opaque. Over 90% of medical costs are non emergency, so if people could comparison shop, costs would go down. Also requires skin in the game (e.g. marginal cost per visit).
Look at plastic surgery for a good example of how free market/non insurance based medicine can fare. Many procedures are quite cheap, and while many are still expensive, much cheaper than necessary medical care covered by insurance. Also the number of doctors is still limited by the AMA, so even this is not fully competitive. There's an arbitrary cap on number of providers
This is an old trope but hasn’t even been superficially true for years. The AMA does not have the authority to limit the number of doctors. In any event their political influence has become less and less relevant for decades now, so even their ability to influence the number of docs is quite limited - I am not even am AMA member - I was only during medical school to get discounts on test prep. I don’t believe most of my peers are AMA members either - they belong to their specialist groups. Meanwhile the number of medical schools and students in the US has increased substantially in part due to AMA and AAMC. Meanwhile internal medicine residencies still have to fill their ranks with imported talent (foreign medical graduates) - only the lucrative subspecialties are the ones that remain limited and competitive. There are also forces at work to limit the number of MD jobs available that have nothing to do with the supply of MDs (replacement of positions with midlevels). The limit on residency positions is a partisan federal funding issue going on for years and only recently has much headway been made.
On eye care, I can of course self prescribe but even so for contact lenses I usually end up purchasing overseas from reputable retailers because of the price fixing of contact lenses - and I’ve never been asked for a prescription. It’s not that hard to get eyewear without a prescription.
Combine education and free access to everything with reasonable daily unit limits and per-substance licensing. You want meth, you go through meth safety training and get a yearlong endorsement allowing you to buy up to the daily limit at a pharmacy, no prescription involved.
Set up due process that limits or eliminates legal access to substances based on criminal or medical situations.
Drug abuse - using in inappropriate situations leading to misbehavior - can be treated as a medical issue. Misbehavior that rises to the level of criminality is already handled.
It's absurd to think that any adult in a free country has any business whatsoever telling other adults what they can ingest or do in private.
Some variation on these notions are already demonstrated across the world. The current schedule system and drug laws in America serve only the bad guys, whether it's commercial prison slave labor, drug cartels, big Pharma, or the alphabet jackboots.
I believe they were referring to the snake oil craze of the 19th century, not prohibition:
> The term comes from the "snake oil" that used to be sold as a cure-all elixir for many kinds of physiological problems. Many 19th-century United States and 18th-century European entrepreneurs advertised and sold mineral oil (often mixed with various active and inactive household herbs, spices, drugs, and compounds, but containing no snake-derived substances whatsoever) as "snake oil liniment", making claims about its efficacy as a panacea. Patent medicines that claimed to be a panacea were extremely common from the 18th century until the 20th, particularly among vendors masking addictive drugs such as cocaine, amphetamine, alcohol and opium-based concoctions or elixirs, to be sold at medicine shows as medication or products promoting health.
A doctor could easily tell a patient “if you go to this hospital for surgery, I’ll give you $100”
That’s still a kickback.
If the doctor is getting any of the money, then that part is the kickback.
If the doctor really gets nothing extra, and the hospital gets nothing extra, then that's not a kickback, it's just weird.
So if a $5 grocery rebate a kick-back?
Going to a store costs money. It also costs time. It's pretty easy for that to hit $5.
People need groceries. They're going to the store anyway.
If you can wait for a mail-order prescription to arrive, you can probably wait until your next grocery shopping trip to get it filled in person.
You haven't found a drug that's "more expensive", you've just found that shipping is a cost.
Try finding a doctor while on Medicare; depending on region and specialty, only 2/5 to 2/3 doctors will take patients on Medicare.
One other thing you may have missed: salaries are for doctors working at hospitals or clinics. Doctors working at private practices typically are self employed (or co-operate as a partner) and so are much more directly impacted by low payment rates.
Edit: it is worth pointing out that the requirements to become a doctor are pretty extreme. You first need a 4 year bachelor's degree, then need to go to medical school (costing a total anywhere from 150k to 400k on the extreme high end), followed by residency (basically, a paid internship at a salary lower than a full doctor) lasting 3-7 years.
One thing that I've noticed is that there are private practice doctors that will take Medicare/Medicaid but the wait time for an appointment is longer compared to private insurance. It's like they decided to space out the less-profitable patients to maintain their margins. (I knew a few people who had the same primary care physician but different insurances.)
https://www.physiciansweekly.com/how-do-us-physician-salarie...
https://www.oecd-ilibrary.org/sites/a44d2e24-en/index.html?i...
Physicians per capita: https://www.motherjones.com/kevin-drum/2013/11/why-are-ameri...
I also spend all of my time and energy trying to get more points.
There are countless examples of that not being the case. At best, it benefits some other people most of the time and, arguably most people only some of the time.
Keep in mind that all of the current issues with US healthcare are also caused by individuals trying to maximize their personal dollars - at the expense of the general public.
The US has a particularly horrible hyper regulated, government shielded, cartel-based healthcare system and has for decades - the time during which its healthcare costs have skyrocketed out of control.
The US could hardly be further away from Capitalism in how its healthcare system is structured.
Countries with more regulation and more control by the state have... prices that are a fraction of the US. Surprise. Just like countries with stricter environmental restrictions have fewer clear-cut forests, less polluted water, etc. Unbridled capitalism means more money at the top at the cost of everyone else. There's a balance to be found between making money and having some restraints.
Per Wikipedia:
> Capitalism is an economic system based on the private ownership of the means of production and their operation for profit. Central characteristics of capitalism include capital accumulation, competitive markets, price system, private property, property rights recognition, voluntary exchange, and wage labor.
All of these things are true of the US healthcare market.
Why the government hasn’t stepped in, is pure corruption.
That's just what capitalism is. There is no ideal world where people max out their earnings and say "haha i'll be a friendly competitor and work for the benefit of the people :))))". People with vested interests will always push for less regulation, and the consequence of a successful push is never "everyone is better off and paying less!" Other developed countries have more regulation and lower prices. That's simply a fact.
Note that refusing to sell to people was already legal before 2007.
Many normal pharmacies also have mail-order options. My neighborhood pharmacy includes free shipping, whereas Mark Cuban charges an extra $5.
I'm baffled that so many people are consuming Mark Cuban's marketing/PR without questioning if it's really the cheapest option. It's like everyone read the press releases and just decided it sounds correct.
Which are often very annoying to use. I have tried many times to get my pharmacy to deliver by mail. It typically works for a few months, then they stop bothering, or fail to request a refill until I call them, or mumble something about the drug not being legal to ship even though it was successfully delivered earlier by this pharmacy and by other mail-order pharmacies I've tried.
There always seems to be some reason why it's necessary for me to drive down to the pharmacy, stand in line with a bunch of other customers during a pandemic, and grope around with various pens, styluses, and touchscreens that were previously handled by someone with who-knows-what infectious condition. Funny how that works. This business is well past ripe for disruption.
It's like everyone read the press releases and just decided it sounds correct.
Do you have any stake or interest in the pharmacy trade? It's like you're making the most negative possible assumption at every step of your argument, so turnabout seems to be fair play.
I'm triple vaxxed and have no problem with mask or vaccine mandates where they make sense. But stuff like "oh you want me to use a stylus in a pandemic?!?" or putting on a mask while you walk 10 feet to a restaurant table are just silly.
In anycase, it's generics and price comparisons online are pretty easy. Iff it is cheaper I'll buy from them, if not I won't.
Fully free markets can lead to negative externalities like monopolies, pollution etc.
What leads to good societal outcomes is competitive markets. It just happens that free and competitive overlap a lot of the time. Information hiding makes a market less competitive, but is permitted under a full free market mentality. This is an area where regulations are warranted and useful.
Competitive capitalism should be the goal for most areas in modern society. Which in almost all cases only requires light regulation.
If you were in another industry, and went to a judge and said "this person defaulted on their agreement to pay me whatever I want." Then I think the judge would basically tell you to get lost. And that is a good thing. The only oddness here is that somehow the medical industry has been getting away with this for a long time.
That is what the fix should be too, IMO. Basically, legislation that states unless someone expressly agrees to a price for a medical procedure, they are not liable for it.
Certainly there's a good case to be made for having safety nets for those that can't afford, but for the vast majority of people, a competitive system would bring down costs substantially. The US actually pays the most for healthcare per capita than any other country, I believe. Largely goes to inefficiencies rather than health outcomes. A truly well structured and competitively designed healthcare system could greatly improve QOL for the public.
Whether it's "libertarian" or not is a matter of semantics. The free market extreme would have no regulations at all... but clearly that can lead to certain negative outcomes (monopoly being classic example). Certainly there are different flavors of libertarian... and I would consider myself one, but am in favor of regulations that encourage competition between businesses. However, not needed in most spaces, healthcare in particular seems very warped/not rationally structured.
A rule of thumb for whether a sector is competitive/efficient are whether margins are broadly high across the board. I'm definitely a capitalist and not anti-business, but in a competitive market you should expect margins to be relatively constrained in the long run. Of course first movers, and those that truly out compete the rest can attain high margins... but over time these advantages should erode as new and better players come along.
Certain SaaS is pretty interesting example, because cost of switching can be high, creating "utility-like" businesses. DocuSign, for example, is really easy to dump for a competitor, low cost of switching. But something like AWS is much more difficult... need to invest potentially millions of dollars and months of time to rewrite your systems/design learn a new cloud environment, very high and painful costs of switching. It's often cheap to choose one of many competitors, but then you're entrenched in that environment.
Anyway, long tangent, but I expect law to recognize these kind of things eventually...
But please link me to a US site where I can legally buy contacts without providing proof of prescription, if there is one!
That said, for normal eyeglasses, there are many sites that offer eyeglasses without proof of prescription. I've been buying eyeglasses from Zenni Optical for almost a decade for my whole family. Most recently in 2021. I have never once even been asked for proof of prescription, I just punch in my numbers and hit order.
One province de-regulated dispensing of corrective lenses and anyone could get in the game, and many did!
But good to hear you can in Canada!
If a doctor took money to steer you to a specific hospital, that would be a kickback.
If a hospital gives you a rebate and you're paying, that's not a kickback. But if a hospital gives you a rebate and your insurance is paying based on the non-rebated price, that's probably a kickback.
If the PBM buys something themselves and gets money back, that wouldn't be a kickback.
Just like a customer buying something and getting money back.
But when you have a buyer on one side, and a separate entity getting the money back, that's probably a kickback.
Just an annoying experience, COVID or no COVID. It's time for the pharmacy business to either review and improve its practices, or be replaced.
Most of these regulations don't exist in countries because there are top down price negotiations and/or universal healthcare.
The US regulation is the worst of both worlds.
Funny enough, the quality and ease of access (delays for procedures etc) also "are a fraction of the US"
As an American, my longest waits and worst care were all in the US. I pay just a couple bucks in Japan and get far better, far faster care. Pissing blood from a major kidney infection and hospitals politely turning me away because my insurance was out of network and "oh this is too expensive for you. Try (next hospital that rejected me)" wasn't fun. Never had an experience like that outside the US. Here it’s “Do you have an appointment? No? Okay, we’ll see you in a few minutes.”
Not sure why Americans believe this meme, but it's very apparent that someone hasn't spent any significant time outside the country and is informed exclusively by facebook fearmongering when they say that. It's always "yeah, I know a guy who knows a guy who read an article saying the UK is worse!" America has massive delays for procedures already--the excuse doesn't work anymore.
But yes, the delays in Japan and the cost are a fraction of the US, and it's because there's more regulation. It's wonderful.
Well I guess now I know a person on hackernews with a story?
No one is saying that (at least on this thread).
All I'm saying laypeople assume the mfg is the bad guy when it comes to high drug prices. Time and time again on the news we are told that X drug costs $$$$$ in the US and the exact same drug costs orders of magnitude less in some other country. Everyone points the finger at the drug mfgs.
What I'm saying is that it's good that the secret is getting out that the mfgs are not necessarily the bad guys, and there's all these other companies involved in the drug price crisis.
Then you've never bothered to compare the price of a branded drug with a generic in the same pharmacy.
The optometrist I went to recently put me in the strongest prescription I'd ever had. Instead of using that prescription, I ordered contacts using the prescription of the glasses that I thought were fine.
There's two numbers on the contacts... diameter of the pupil (doesn't matter for most people I think) and an angle (Edit: 'Base Curve'. The third number is the power of the contact, aka 'sphere'. Glasses prescriptions have power and astigmatism, but don't have diameter or base curve). I got these off my prescription. If you don't already know how to use contacts it's important to get instructions and a followup. I read of a guy who didn't know he had to take the contacts out at night - the contacts had started to grow into his eyes?
(Edit: you can get a set of "trial lenses" from Ebay if you want to try to come up with your own prescription, or to try out your prescription before buying glasses.)
My previous comments on ordering contacts:
https://news.ycombinator.com/item?id=13691768 / https://news.ycombinator.com/item?id=29366816
Edit: I live in the United States.
Other parties are still free to mark up their goods for resale. But drugs they bought for cheap get sold for (less) cheap, and drugs they bought at a high price get sold at a high(er) price. When you see an eye-popping price, that's because the manufacturer charged an eye-popping price.
