5 ms·

Prescriptions are a total racket. A good portion of actual medication literally costs a few dollars at most. Then there’s layer upon layer of bloat and bureaucr

by cmiles8 7mo ago

Prescriptions are a total racket. A good portion of actual medication literally costs a few dollars at most. Then there’s layer upon layer of bloat and bureaucracy that add no value but drive the cost up 10x or more. It’s totally bonkers. When these Rx cards and Marc Cuban CostPlus drugs came out where you just pay cash and a fraction of the price I thought there must be some catch or scam here. But turns out no, they’re just cutting out all the middleware bloat and selling you the meds at a defensible markup plus their logistics costs. Love what these guys are doing. The fact that something like that even exists highlights how corrupt and broken the health insurance companies have become. It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse that Joe Blogs off the street can get with cash. In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion, but the US’s challenges are all rooted in massive administrative overhead. If we got rid of that and had a lean system where healthcare providers can do their job without interference there would be plenty of money to go around for amazing care at lower cost.

Turskarama 7mo ago
> In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.
- alexfoo 7mo ago
  I guess that's because many/most countries don't have the concept of a private emergency department. It doesn't really matter how much money you have if you have a broken leg as you'll be queuing up with everyone else for the triage and initial treatment. I have amazing private healthcare coverage in the UK through my employer. I've had certain treatments done in under a week where the NHS waiting lists for the same procedure are measured in years. But if I have a serious acute illness, or break a bone, my private healthcare can't help other than give me a telephone appointment with a doctor within 10 minutes at which point they'll say "What are you doing calling us? Go to the emergency department now!" After the initial triage/treatment/stabilisation there may be a different pathway for people with private healthcare, but the doors of the emergency department are the first port of call for pretty much everyone who is in dire need. (I'm sure for people who are seriously rich there are private arrangements, most people with serious money have doctors/dentists/etc on retainer, but these are the 0.001%)
  - dabiged 7mo ago
    Australia reporting in. We have private emergency rooms. We call them urgent care and you can go and see a qualified physician with allied health services (radiology, pathology). If they can fix you up they will. If not you get transferred via ambulance to the nearest public hospital and triaged as required. I took my kid to one last weekend as they had been diagnosed by our family Dr as having pneumonia. The emergency physician ordered chest x-ray and full suite of pathology and we had results in less time than we would have waited in the public hospital waiting room. Yes we paid.
    - Aeolun 7mo ago
      Does it make sense to get an x-ray for that? I’m sympathetic to the desire, but isn’t the end result for pneumonia always antibiotics anyway?
      - SoftTalker 7mo ago
        If it's not pneumonia, antibiotics might not help.
    - glenngillen 7mo ago
      Also Australia reporting in. I've unfortunately had a number of emergency visits over the past few years. I'm a bit torn on the public vs private situation. For certain classes of issue (e.g., broken bones) my friends who work in hospitals have repeatedly said they'd go public purely because the volume of patients those surgeons have to treat daily means the teams in the public systems are typically incredibly experienced. And yet, I smashed my hand to pieces mountain biking on a holiday weekend and when I arrived at the ER the place was absolutely rammed and it was going to be a many hours wait to even get triaged. We got straight back in the car and drive to the private ER 5 minutes down the road and were seen immediately. In the moment I was incredibly appreciative of that option. It does make me feel uncomfortable that it was only an option because I could afford to pay to jump the queue though.
- youknownothing 7mo ago
  As a person who has lived in Spain, UK, and now California, I can attest to one thing: the quality of care in California (I can't speak for the whole country) is vastly superior to what I received in both Spain and UK. Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the slightest out of their parameters, tough luck. And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you. I could bore you with countless stories of doctors who have used tricks not to provide service and make it look like it was the patient's fault. The problem with private healthcare is that profits corrupts it. The problem with public healthcare is that politics corrupts it. There is no good solution.
  - nicoburns 7mo ago
    I think this is mostly a problem with state funded healthcare budgets being cut (relative to population demographics) in these countries. If the UK or Spain spent anywhere even close to what the US spends on healthcare (per capita), I have no doubt that it's healthcare provision would be just as good. In the UK, healthcare provision was notably dramatically better 20-30 years ago under the same system (except for less private finance).
    - eitally 7mo ago
      I don't think so. With state funded healthcare you get rigid rulebooks and policies. In the capitalist-ish US model, if you are a successful advocate then you can get better than average care because there's enough flexibility in the system (in many cases, physicians can individually decide to over-extend for one patient if they choose to) to allow for this. Having a private payer market absolutely helps here.
      - nicoburns 7mo ago
        Having care depend on "being a successful advocate" does not sound like a good thing to me! Albeit it's probably impossible to avoid entirely. We want good care for everyone. I'm mostly familiar with the UK system, but medical professionals make pretty much all the decisions here, with a large degree of discretion according to their professional judgement (and they never have to adjust or delay their care based on whether you can pay). Except for some particularly expensive treatments (think CAR-T for cancer) which are not available at all in the state funded system. But you can still pay for those privately if you want to.
- some_random 7mo ago
  There are people who have lived in multiple countries, and speaking with them the only place that seems to be comparable (until you factor in private healthcare of course) is Switzerland.
- LorenPechtel 7mo ago
  Simple test: The reports saying the UHC systems are better always are using statistical games. If they were really better why would they put their thumb on the scale? Things like making 20% of the score "fairness"--as in UHC. And hiding the fact that most of the life expectancy difference is infant mortality and most of the difference in infant mortality is a reporting issue: infant mortality + stillbirth produces a far flatter plot. Thus much of the difference is whether it's considered to have died before birth or after birth.
- dsr_ 7mo ago
  There are certainly locations in the US where the standard of patient care -- ignoring cost -- is world-class. And there are certainly locatioms in the US where the standard of patient care is nowhere close to that, and would be easily beaten at any major hospital in any other first-class economy.
- adrianN 7mo ago
  Patient outcomes should provide reasonably hard data for comparisons. Life expectancy at least is not vastly better in the US, how about other metrics?
PaulHoule 7mo ago
See https://pharmacy.osu.edu/news/prescription-discount-cards-who-do-they-benefit-who-do-they-hurt https://pharmacy.osu.edu/news/prescription-discount-cards-wh...
- rexroad 7mo ago
  Thanks for sharing the OSU piece, good read. A few things it surfaces that complicate the "discount cards help patients" narrative: discount card companies still contract with PBMs to set pricing, they don't bypass them entirely. The savings often come out of the pharmacy's margin rather than the PBM's: the article shows a pharmacy receiving $5 on a drug it acquired for $15, with the PBM still collecting a transaction fee either way. GoodRx was also fined by the FTC for selling patient health data to advertisers without authorization, so there's a second extraction happening on the data side. The deeper point the card market reveals: a profitable arbitrage layer can consistently undercut the insurer's "negotiated" rate, which tells you the negotiated rate isn't really a discount. Generic apixaban costs £1.16 per 30-day supply in the UK. Medicare's gross cost for Eliquis (same molecule) is $862.
anon7000 7mo ago
> It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse Maybe on paper, in reality their job is to return as much profit as possible to shareholders. Convoluted bureaucracy, complicated regulations, layers of useless middlemen… they all help to reduce competition and increase profits. There are industries where the “free” market doesn’t work, partly because “human well-being” is a non-goal for any health insurance company. The entire point of the insurance business model is to avoid paying for it as much as possible
- ethbr1 7mo ago
  > The entire point of the insurance business model is to avoid paying for [human well-being] as much as possible For-profit health insurance. Which imho should be illegal. A lot of the US' quasi free-market, in-name-only health insurance problems would be solved by: 1. Requiring all insurers to be not-for-profit (critically: also including all corporate owners of insurers too) 2. Tying financial incentives and disincentives to outcome-based KPIs
  - alistairSH 7mo ago
    Does "not for profit" actually solve anything? Aren't most private universities also not-for-profit, while also being major real estate owners, developers, managing massive investment portfolios, etc?
    - ethbr1 7mo ago
      In my experience Kaiser / the Blues have their issues (mostly inefficiency), but not nearly as many directly anti-patient incentives as United Healthcare et al. Generally speaking, you get decent outcomes with {not for profit} + {efficiency/outcome based KPI}, because the primary thing you're fighting is apathy (not for profit) instead of malicious profiteering (for profit). And capitalism doesn't particular lend itself to running an insurance company. Fundamentally, there's not that much that should change year-to-year at insurers than {actuaries / pricing}. Have pharmacy benefits or all the other kooky for-profit inventions really improved patient experience and outcomes?
hammock 7mo ago
People are waking up and a lot is happening to counteract some of this. In the FY26 omnibus bill passed by Congress and signed last month by Trump is the most aggressive federal crackdown on PBMs in history. Starting in 2028 it bans PBMs from taking a percentage cut, which is exactly what incentivized them to drive up the sticker price of your meds. It forces PBMs to pass 100% of the rebates and discounts they negotiate directly to employer health plans, stopping them from pocketing the savings. And PBMs are now mandated to provide detailed semiannual reports exposing their "spread pricing" (charging the plan more than they pay the pharmacy) and their shady practices of steering patients only to pharmacies they own Also to do what Mark Cuban did but on a national scale, the federal govt launched TrumpRx.gov, a direct-to-consumer federal platform that completely cuts out the PBMs and insurance deductibles you're talking about , allowing people to buy dozens of the most popular meds for an average of 50% off. Finally one benefit from the threats of tariffs has been that companies like Pfizer caved and signed landmark deals with the US to offer their drugs at “most favored nation” prices to Medicaid and directly to consumers
- rexroad 7mo ago
  The rebate pass-through rule (effective 2028) is a real step, and worth tracking. But rebate retention is one of six extraction mechanisms the Big 3 PBMs use. The FTC's Interim Reports I and II (2024-2025) documented $7.3B in specialty drug markups alone, separate from rebate games. The Ohio Auditor found PBM spread pricing extracted $224.8M from a single state's $2.5B Medicaid drug budget in one year. The rebate rule doesn't touch spread pricing, formulary manipulation, or self-preferencing to vertically integrated pharmacies. Issue #4 (scheduled for releases 3/22) of this series covers the full mechanism stack and what each proposed reform actually targets. Repo: https://github.com/rexrodeo/american-healthcare-conundrum https://github.com/rexrodeo/american-healthcare-conundrum
- pnutjam 7mo ago
  TrumpRx is mostly hot air. https://democrats-energycommerce.house.gov/sites/evo-subsites/democrats-energycommerce.house.gov/files/evo-media-document/e-c-democrats-trumprx-big-talk-little-savings.pdf https://democrats-energycommerce.house.gov/sites/evo-subsite...
samiv 7mo ago
"In many ways the quality of care in the US is far better than what folks get elsewhere" This comment has very strong survival ship bias though because you're only looking and ranking the treatments that did happen. How about the cases when the person was denied treatment based coverage or whatever reason. These cases should rank too.
Aeolun 7mo ago
> In many ways the quality of care in the US is far better than what folks get elsewhere Or so people keep telling themselves to not feel completely fucked?
fragmede 7mo ago
The catch is that Mark Cuban is now the one capturing the rewards instead of the now-unknown-to-me-in-the-wake-of -Luigi-Mangione healthcare tech company CEO
- dsr_ 7mo ago
  https://en.wikipedia.org/wiki/Stephen_J._Hemsley https://en.wikipedia.org/wiki/Stephen_J._Hemsley You're welcome.
- openclaw01 7mo ago
  [dead]
realo 7mo ago
"... quality of care in the US is far better ..." Care starts when you need it, at the ambulance level. Recently we saw that people who dial 911 in the US can actually die because the ambulance arrives hours (!!!) later. So no. Quuality of care in the US is not that good.
rexroad 7mo ago
[dead]

by cmiles8 7mo ago

Turskarama 7mo ago

> In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.

alexfoo 7mo ago
I guess that's because many/most countries don't have the concept of a private emergency department. It doesn't really matter how much money you have if you have a broken leg as you'll be queuing up with everyone else for the triage and initial treatment. I have amazing private healthcare coverage in the UK through my employer. I've had certain treatments done in under a week where the NHS waiting lists for the same procedure are measured in years. But if I have a serious acute illness, or break a bone, my private healthcare can't help other than give me a telephone appointment with a doctor within 10 minutes at which point they'll say "What are you doing calling us? Go to the emergency department now!" After the initial triage/treatment/stabilisation there may be a different pathway for people with private healthcare, but the doors of the emergency department are the first port of call for pretty much everyone who is in dire need. (I'm sure for people who are seriously rich there are private arrangements, most people with serious money have doctors/dentists/etc on retainer, but these are the 0.001%)
- dabiged 7mo ago
  Australia reporting in. We have private emergency rooms. We call them urgent care and you can go and see a qualified physician with allied health services (radiology, pathology). If they can fix you up they will. If not you get transferred via ambulance to the nearest public hospital and triaged as required. I took my kid to one last weekend as they had been diagnosed by our family Dr as having pneumonia. The emergency physician ordered chest x-ray and full suite of pathology and we had results in less time than we would have waited in the public hospital waiting room. Yes we paid.
  - Aeolun 7mo ago
    Does it make sense to get an x-ray for that? I’m sympathetic to the desire, but isn’t the end result for pneumonia always antibiotics anyway?
    - SoftTalker 7mo ago
      If it's not pneumonia, antibiotics might not help.
  - glenngillen 7mo ago
    Also Australia reporting in. I've unfortunately had a number of emergency visits over the past few years. I'm a bit torn on the public vs private situation. For certain classes of issue (e.g., broken bones) my friends who work in hospitals have repeatedly said they'd go public purely because the volume of patients those surgeons have to treat daily means the teams in the public systems are typically incredibly experienced. And yet, I smashed my hand to pieces mountain biking on a holiday weekend and when I arrived at the ER the place was absolutely rammed and it was going to be a many hours wait to even get triaged. We got straight back in the car and drive to the private ER 5 minutes down the road and were seen immediately. In the moment I was incredibly appreciative of that option. It does make me feel uncomfortable that it was only an option because I could afford to pay to jump the queue though.
youknownothing 7mo ago
As a person who has lived in Spain, UK, and now California, I can attest to one thing: the quality of care in California (I can't speak for the whole country) is vastly superior to what I received in both Spain and UK. Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the slightest out of their parameters, tough luck. And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you. I could bore you with countless stories of doctors who have used tricks not to provide service and make it look like it was the patient's fault. The problem with private healthcare is that profits corrupts it. The problem with public healthcare is that politics corrupts it. There is no good solution.
- nicoburns 7mo ago
  I think this is mostly a problem with state funded healthcare budgets being cut (relative to population demographics) in these countries. If the UK or Spain spent anywhere even close to what the US spends on healthcare (per capita), I have no doubt that it's healthcare provision would be just as good. In the UK, healthcare provision was notably dramatically better 20-30 years ago under the same system (except for less private finance).
  - eitally 7mo ago
    I don't think so. With state funded healthcare you get rigid rulebooks and policies. In the capitalist-ish US model, if you are a successful advocate then you can get better than average care because there's enough flexibility in the system (in many cases, physicians can individually decide to over-extend for one patient if they choose to) to allow for this. Having a private payer market absolutely helps here.
    - nicoburns 7mo ago
      Having care depend on "being a successful advocate" does not sound like a good thing to me! Albeit it's probably impossible to avoid entirely. We want good care for everyone. I'm mostly familiar with the UK system, but medical professionals make pretty much all the decisions here, with a large degree of discretion according to their professional judgement (and they never have to adjust or delay their care based on whether you can pay). Except for some particularly expensive treatments (think CAR-T for cancer) which are not available at all in the state funded system. But you can still pay for those privately if you want to.
some_random 7mo ago
There are people who have lived in multiple countries, and speaking with them the only place that seems to be comparable (until you factor in private healthcare of course) is Switzerland.
LorenPechtel 7mo ago
Simple test: The reports saying the UHC systems are better always are using statistical games. If they were really better why would they put their thumb on the scale? Things like making 20% of the score "fairness"--as in UHC. And hiding the fact that most of the life expectancy difference is infant mortality and most of the difference in infant mortality is a reporting issue: infant mortality + stillbirth produces a far flatter plot. Thus much of the difference is whether it's considered to have died before birth or after birth.
dsr_ 7mo ago
There are certainly locations in the US where the standard of patient care -- ignoring cost -- is world-class. And there are certainly locatioms in the US where the standard of patient care is nowhere close to that, and would be easily beaten at any major hospital in any other first-class economy.
adrianN 7mo ago
Patient outcomes should provide reasonably hard data for comparisons. Life expectancy at least is not vastly better in the US, how about other metrics?

PaulHoule 7mo ago

See https://pharmacy.osu.edu/news/prescription-discount-cards-who-do-they-benefit-who-do-they-hurt https://pharmacy.osu.edu/news/prescription-discount-cards-wh...

rexroad 7mo ago
Thanks for sharing the OSU piece, good read. A few things it surfaces that complicate the "discount cards help patients" narrative: discount card companies still contract with PBMs to set pricing, they don't bypass them entirely. The savings often come out of the pharmacy's margin rather than the PBM's: the article shows a pharmacy receiving $5 on a drug it acquired for $15, with the PBM still collecting a transaction fee either way. GoodRx was also fined by the FTC for selling patient health data to advertisers without authorization, so there's a second extraction happening on the data side. The deeper point the card market reveals: a profitable arbitrage layer can consistently undercut the insurer's "negotiated" rate, which tells you the negotiated rate isn't really a discount. Generic apixaban costs £1.16 per 30-day supply in the UK. Medicare's gross cost for Eliquis (same molecule) is $862.

anon7000 7mo ago

> It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse Maybe on paper, in reality their job is to return as much profit as possible to shareholders. Convoluted bureaucracy, complicated regulations, layers of useless middlemen… they all help to reduce competition and increase profits. There are industries where the “free” market doesn’t work, partly because “human well-being” is a non-goal for any health insurance company. The entire point of the insurance business model is to avoid paying for it as much as possible

ethbr1 7mo ago
> The entire point of the insurance business model is to avoid paying for [human well-being] as much as possible For-profit health insurance. Which imho should be illegal. A lot of the US' quasi free-market, in-name-only health insurance problems would be solved by: 1. Requiring all insurers to be not-for-profit (critically: also including all corporate owners of insurers too) 2. Tying financial incentives and disincentives to outcome-based KPIs
- alistairSH 7mo ago
  Does "not for profit" actually solve anything? Aren't most private universities also not-for-profit, while also being major real estate owners, developers, managing massive investment portfolios, etc?
  - ethbr1 7mo ago
    In my experience Kaiser / the Blues have their issues (mostly inefficiency), but not nearly as many directly anti-patient incentives as United Healthcare et al. Generally speaking, you get decent outcomes with {not for profit} + {efficiency/outcome based KPI}, because the primary thing you're fighting is apathy (not for profit) instead of malicious profiteering (for profit). And capitalism doesn't particular lend itself to running an insurance company. Fundamentally, there's not that much that should change year-to-year at insurers than {actuaries / pricing}. Have pharmacy benefits or all the other kooky for-profit inventions really improved patient experience and outcomes?

hammock 7mo ago

People are waking up and a lot is happening to counteract some of this. In the FY26 omnibus bill passed by Congress and signed last month by Trump is the most aggressive federal crackdown on PBMs in history. Starting in 2028 it bans PBMs from taking a percentage cut, which is exactly what incentivized them to drive up the sticker price of your meds. It forces PBMs to pass 100% of the rebates and discounts they negotiate directly to employer health plans, stopping them from pocketing the savings. And PBMs are now mandated to provide detailed semiannual reports exposing their "spread pricing" (charging the plan more than they pay the pharmacy) and their shady practices of steering patients only to pharmacies they own Also to do what Mark Cuban did but on a national scale, the federal govt launched TrumpRx.gov, a direct-to-consumer federal platform that completely cuts out the PBMs and insurance deductibles you're talking about , allowing people to buy dozens of the most popular meds for an average of 50% off. Finally one benefit from the threats of tariffs has been that companies like Pfizer caved and signed landmark deals with the US to offer their drugs at “most favored nation” prices to Medicaid and directly to consumers

rexroad 7mo ago
The rebate pass-through rule (effective 2028) is a real step, and worth tracking. But rebate retention is one of six extraction mechanisms the Big 3 PBMs use. The FTC's Interim Reports I and II (2024-2025) documented $7.3B in specialty drug markups alone, separate from rebate games. The Ohio Auditor found PBM spread pricing extracted $224.8M from a single state's $2.5B Medicaid drug budget in one year. The rebate rule doesn't touch spread pricing, formulary manipulation, or self-preferencing to vertically integrated pharmacies. Issue #4 (scheduled for releases 3/22) of this series covers the full mechanism stack and what each proposed reform actually targets. Repo: https://github.com/rexrodeo/american-healthcare-conundrum https://github.com/rexrodeo/american-healthcare-conundrum
pnutjam 7mo ago
TrumpRx is mostly hot air. https://democrats-energycommerce.house.gov/sites/evo-subsites/democrats-energycommerce.house.gov/files/evo-media-document/e-c-democrats-trumprx-big-talk-little-savings.pdf https://democrats-energycommerce.house.gov/sites/evo-subsite...

samiv 7mo ago

"In many ways the quality of care in the US is far better than what folks get elsewhere" This comment has very strong survival ship bias though because you're only looking and ranking the treatments that did happen. How about the cases when the person was denied treatment based coverage or whatever reason. These cases should rank too.

Aeolun 7mo ago

> In many ways the quality of care in the US is far better than what folks get elsewhere Or so people keep telling themselves to not feel completely fucked?

fragmede 7mo ago

The catch is that Mark Cuban is now the one capturing the rewards instead of the now-unknown-to-me-in-the-wake-of -Luigi-Mangione healthcare tech company CEO

dsr_ 7mo ago
https://en.wikipedia.org/wiki/Stephen_J._Hemsley https://en.wikipedia.org/wiki/Stephen_J._Hemsley You're welcome.
openclaw01 7mo ago
[dead]

realo 7mo ago

"... quality of care in the US is far better ..." Care starts when you need it, at the ambulance level. Recently we saw that people who dial 911 in the US can actually die because the ambulance arrives hours (!!!) later. So no. Quuality of care in the US is not that good.

rexroad 7mo ago

[dead]