3 ms·

I’m currently on Spravato, which is fully emblematic of how broken the incentives in the US healthcare system are. Spravato is esketamine - a modified version

by dabinat 4mo ago

I’m currently on Spravato, which is fully emblematic of how broken the incentives in the US healthcare system are. Spravato is esketamine - a modified version of ketamine. Ketamine is made up of mirror image molecules and esketamine is the right-handed molecule. They did this because ketamine is off-patent so they needed to modify it in order to patent it, however there is evidence that esketamine is a less effective treatment than ketamine. It’s very cheap for me but my insurance company pays about $17k a month for this treatment. Ketamine would be a more effective treatment that would be super cheap for them, but they don’t do it because it’s not FDA-approved. So they’re paying a fortune for a less effective treatment. It would be in the insurance companies’ interests to band together to fund the research so they can save huge amounts of money in the long term but they do not do this.

pkaye 4mo ago
So in Ketamine approved as a treatment in other countries but not in the US?
tyre 4mo ago
> It would be in the insurance companies’ interests to band together to fund the research so they can save huge amounts of money in the long term but they do not do this. Insurance companies do not want cheaper care. In the US, insurance companies must spend 80% of premiums on care. So if you pay $1k/mo, they have to pay out at least $800/mo in care. (Not to you specifically, but averaged out across all subscribers.) This is a cap on their potential profits. They always have to pay out 80% of premiums for care, so how do they make more money? Well, imagine care is twice as expensive. Instead of paying $800, they have to pay $1600. That sounds worse, but, instead of $200/mo, they now $400/mo for themselves! So, no, paradoxically, it is not in the interest of people paying for the treatment to save money. Quite the opposite.
- ttoinou 4mo ago
  They operate with similar supply and demand constraints and competition, even with prices increasing
- lotsofpulp 4mo ago
  >Insurance companies do not want cheaper care. Why is there a continuous stream of healthcare providers threatening to or becoming out of network for various managed care organizations because they cannot come to an agreement on healthcare prices?
  - duskdozer 4mo ago
    I suspect it's because the insurance companies are not in control. The idea would be to drive up costs when they profit on both sides (example: United and OptumRx) and push down reimbursements elsewhere.
- lesuorac 4mo ago
  > So, no, paradoxically, it is not in the interest of people paying for the treatment to save money. Quite the opposite. I'll assume they're on company insurance. Which is often "self-insured" in that the company actually foots the bill as opposed to the insurance company. Why don't corporations just drop insurance companies that decide to not allow cheaper medicines?
  - doctorpangloss 4mo ago
    UNH is so big because its customer Apple has its own pool. Apple deducts $24k/y for your healthcare. Healthy 29 year old male doesn't use anything. UNH denies the claims anyway. It gives that money back to Apple, which doesn't give it to you. The 80% rule has a lot of loopholes. It doesn't apply to employer funded plans. There's a reason UNH is so big!
    - bonsai_spool 4mo ago
      Employer funded plans are not all the same. Large entities with a lot of money (like universities, big firms) self-insure. Thus the insurance company in those cases is simply managing all the administrative sides of insurance while the plan owner is the actual insurer of risk. There’s an article about how a Wall St employee’s expensive care came up in C-suite meetings, as a real world consequence of this
      - doctorpangloss 4mo ago
        > simply managing all the administrative sides of insurance if you punch into a chatbot questions about the employer pool insurance product, your comment is exactly how the chatbot characterizes it. of course, "administrative sides of [health] insurance" includes requiring pre-auths and approving/rejecting claims, which is, haha, all the fucking evil parts of what they do! it's not "simply" anything. they need a huge, comprehensive, defensible model of what regulations and customers will accept as valid healthcare. apple does not need to have an opinion on ten thousand treatments and the standard of care across all these things. the insurance company does. this is a line of investigation that the chatbots are absolutely terrible at informing people about. "administrative" is ALL the work, that is why UNH is big! you are starting from the wrong premise. you must always ask yourself, why are health insurance companies so big?
- digi59404 4mo ago
  It's worse than this. Their cap is 80% of the Insurer's profit. Not the Insurer's Parent company. So often the parent company will own the Insurer as a subsidiary and own the Pharmacy, Hospital, Healthcare etc under the parent company. This way as costs go up, it's really just bypassing the 80%. Because the hospital can charge the insurance subsidary X amount, and then the hospital profits to the parent company. There needs to be a law in the US that health insurance organizations cannot be owned by anyone who owns a healthcare provider. Nor can the insurance company own healthcare providers. We've allows the Ma Bell of healthcare to exist.
- radicalbyte 4mo ago
  I tried to explain to people in The Netherlands this exact problem when they were thinking about switching from single-player to a commercial insurance company model. Insurance companies always have an incentive to make healthcare services expensive. They have even more incentive to make healthcare expensive and do deals on the backside where their suppliers give them a kickback. Even better if said kickback comes via a side door. So we went for the commercial insurance companies. It took them 4 years before they change the drug choice from decentralised (Pharmacies deal with drugs companies, received small discounts which funded a good quality of care) to centralised (Insurance deal with drug companies, receives kickbacks) and the Pharmacies funding was drastically cut leading to worse quality of care and more drugs being used. Double-whammy because in the previous system the Pharmacy did medication reviews which almost always result in a reduction in drugs (the thing with drugs is that quite a lot of them are given to reduce side effects of other drugs, the original drug gets cancelled but the side effect reducer gets forgotten and just continues ad infinitum). Health insurance has been super inflationary since then when controlled for quality of care.
  - SoftTalker 4mo ago
    > Insurance companies always have an incentive to make healthcare services expensive. No, it's when their profits are capped by regulation that they have this incentive. Insurance of other types absolutely seeks to reduce claims payouts.
- maxerickson 4mo ago
  Large swaths of US insurance are underwritten by employers, with the insurance companies acting as contracted administrators. Employers don't have the incentives you list.
  - vkou 4mo ago
    Great, just work a well paying megacorp white collar job and you'll get slightly less fucked on healthcare. What about the other 90% of the country?
    - maxerickson 4mo ago
      You could get angry about anything I say, I don't really care, you do you. I guess Medicare and Medicaid also don't have the incentives. Nor does Tri-care or the VA. My employer self insures as far as I know, and we are a few hundred people. Maybe 90% is a bit off?
      - vkou 4mo ago
        I'm not angry about what you say, I'm angry at the parasites that have built this system, and the cynical bastards that work their ass off to perpetuate it.
- themafia 4mo ago
  We baked the snake charmer problem into the law? Good lord.
  - Terr_ 4mo ago
    > snake charmer problem Perhaps you mean the "cobra effect" [0]? I think that's an apocryphal story about killing snakes, rather than using them in a performance. [0] https://en.wikipedia.org/wiki/Perverse_incentive#Historicity_of_the_cobra_anecdote https://en.wikipedia.org/wiki/Perverse_incentive#Historicity...
    - themafia 4mo ago
      So the meaning of what I said was slightly obscured but actually easy to apprehend? oookay.
      - Terr_ 4mo ago
        If I guessed right, then there are probably readers who haven't heard the term/story before [0], or won't make the same jump to recall it. If I guessed wrong, then I wanted to hear about the new thing that resisted a casual web-search. [0] https://xkcd.com/1053/ https://xkcd.com/1053/
- deleted 4mo ago
  [deleted]
Natsu 4mo ago
> Ketamine is made up of mirror image molecules and esketamine is the right-handed molecule. Esketamine is their cutesy way of saying the word s-ketamine. The s- comes from the Latin word "sinister" which means this is the left-handed enantiomer, not the right-handed one. It is stupidly expensive, given how generic ketamine itself is. In our case, sleep apnea treatment proved to be a much better option than that drug, as it was just hiding an underlying condition and the treatments only last for maybe a week or two anyway. I think there have been some people using ketamine off-label, but I don't know much about that. It does need to be tightly controlled because it can cause breakthrough psychosis in some patients. They try to screen those out, but that's not as effective as one might hope given my experience of seeing that fail. And it that was very nearly a fatal mistake.
refurb 4mo ago
Blame the FDA on that one. The FDA's policy for the last couple of decades is that mixtures of mirror images will not get FDA approval unless there is a strong rationale for it. Racemic mixture of ketamine was approved decades ago. If you want a new indication for ketamine, you will need to get approval for a single mirror image, as the FDA won't approve the old drug. They did this because there are numerous examples of racemic mixture drugs having increased side effects from the less active mirror image, so the FDA decided no more racemic approvals. My guess is your insurer would be happy to pay for the old version, but your doctor is heavily incentivized to use the new version as the markup on the drug is much, much higher.
- Jblx2 4mo ago
  >but your doctor is heavily incentivized to use the new version as the markup on the drug is much, much higher. I don't think it is normal/usual for doctors to receive any benefits or profits from which drugs they prescribe. Other than golf outings with the drug company reps? Is there something I'm missing?
  - refurb 4mo ago
    For drugs administered in office, doctors can markup the cost and insurance pays it. Even Medicare pays 4.3% extra. For oncologists, it’s most of the revenue for their office since consults pay very little. The money made on administering $5 worth of ketamine is far less than a $1500 bottle of eskatamine.
- rcxdude 4mo ago
  Thalidomide being one of the more notable ones (though apparently neither chirality is truly safe)
  - RobotToaster 4mo ago
    It's worth noting that thalidomide is still approved, but only for leprosy and certain types of cancer.
RobotToaster 4mo ago
The NHS in the UK refuses to cover it in part because of the absurd cost.
VladVladikoff 4mo ago
What’s so interesting about this that I just learned after googling about Spravato that ketamine is a treatment for serious depression. Why? That’s fascinating! Is it the dissociative effects?
- kevinoid 4mo ago
  A significant effect is through opioid receptor activation, as demonstrated by Williams et al. <https://doi.org/10.1038/s41380-019-0503-4 https://doi.org/10.1038/s41380-019-0503-4> by blocking the receptor with naltrexone, which attenuated the antisuicidality effects. The Huberman Lab episode Ketamine: Benefits and Risks for Depression, PTSD & Neuroplasticity <https://www.hubermanlab.com/episode/ketamine-benefits-and-risks-for-depression-ptsd-and-neuroplasticity https://www.hubermanlab.com/episode/ketamine-benefits-and-ri...> and the referenced journal articles (including the above) have a lot of detail on it.
- pas 4mo ago
  we don't know. https://lorienpsych.com/2021/11/02/ketamine/#11_How_does_ketamine_work https://lorienpsych.com/2021/11/02/ketamine/#11_How_does_ket... the opiate receptor interaction might be important, but it seems that the antidepressant effect persists even if the opiate pathway is blocked (via naltrexone) https://pmc.ncbi.nlm.nih.gov/articles/PMC6439824/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6439824/ (though it's an open-label super small study ... n=4)

by dabinat 4mo ago

pkaye 4mo ago

So in Ketamine approved as a treatment in other countries but not in the US?

tyre 4mo ago

> It would be in the insurance companies’ interests to band together to fund the research so they can save huge amounts of money in the long term but they do not do this. Insurance companies do not want cheaper care. In the US, insurance companies must spend 80% of premiums on care. So if you pay $1k/mo, they have to pay out at least $800/mo in care. (Not to you specifically, but averaged out across all subscribers.) This is a cap on their potential profits. They always have to pay out 80% of premiums for care, so how do they make more money? Well, imagine care is twice as expensive. Instead of paying $800, they have to pay $1600. That sounds worse, but, instead of $200/mo, they now $400/mo for themselves! So, no, paradoxically, it is not in the interest of people paying for the treatment to save money. Quite the opposite.

ttoinou 4mo ago
They operate with similar supply and demand constraints and competition, even with prices increasing
lotsofpulp 4mo ago
>Insurance companies do not want cheaper care. Why is there a continuous stream of healthcare providers threatening to or becoming out of network for various managed care organizations because they cannot come to an agreement on healthcare prices?
- duskdozer 4mo ago
  I suspect it's because the insurance companies are not in control. The idea would be to drive up costs when they profit on both sides (example: United and OptumRx) and push down reimbursements elsewhere.
lesuorac 4mo ago
> So, no, paradoxically, it is not in the interest of people paying for the treatment to save money. Quite the opposite. I'll assume they're on company insurance. Which is often "self-insured" in that the company actually foots the bill as opposed to the insurance company. Why don't corporations just drop insurance companies that decide to not allow cheaper medicines?
- doctorpangloss 4mo ago
  UNH is so big because its customer Apple has its own pool. Apple deducts $24k/y for your healthcare. Healthy 29 year old male doesn't use anything. UNH denies the claims anyway. It gives that money back to Apple, which doesn't give it to you. The 80% rule has a lot of loopholes. It doesn't apply to employer funded plans. There's a reason UNH is so big!
  - bonsai_spool 4mo ago
    Employer funded plans are not all the same. Large entities with a lot of money (like universities, big firms) self-insure. Thus the insurance company in those cases is simply managing all the administrative sides of insurance while the plan owner is the actual insurer of risk. There’s an article about how a Wall St employee’s expensive care came up in C-suite meetings, as a real world consequence of this
    - doctorpangloss 4mo ago
      > simply managing all the administrative sides of insurance if you punch into a chatbot questions about the employer pool insurance product, your comment is exactly how the chatbot characterizes it. of course, "administrative sides of [health] insurance" includes requiring pre-auths and approving/rejecting claims, which is, haha, all the fucking evil parts of what they do! it's not "simply" anything. they need a huge, comprehensive, defensible model of what regulations and customers will accept as valid healthcare. apple does not need to have an opinion on ten thousand treatments and the standard of care across all these things. the insurance company does. this is a line of investigation that the chatbots are absolutely terrible at informing people about. "administrative" is ALL the work, that is why UNH is big! you are starting from the wrong premise. you must always ask yourself, why are health insurance companies so big?
digi59404 4mo ago
It's worse than this. Their cap is 80% of the Insurer's profit. Not the Insurer's Parent company. So often the parent company will own the Insurer as a subsidiary and own the Pharmacy, Hospital, Healthcare etc under the parent company. This way as costs go up, it's really just bypassing the 80%. Because the hospital can charge the insurance subsidary X amount, and then the hospital profits to the parent company. There needs to be a law in the US that health insurance organizations cannot be owned by anyone who owns a healthcare provider. Nor can the insurance company own healthcare providers. We've allows the Ma Bell of healthcare to exist.
radicalbyte 4mo ago
I tried to explain to people in The Netherlands this exact problem when they were thinking about switching from single-player to a commercial insurance company model. Insurance companies always have an incentive to make healthcare services expensive. They have even more incentive to make healthcare expensive and do deals on the backside where their suppliers give them a kickback. Even better if said kickback comes via a side door. So we went for the commercial insurance companies. It took them 4 years before they change the drug choice from decentralised (Pharmacies deal with drugs companies, received small discounts which funded a good quality of care) to centralised (Insurance deal with drug companies, receives kickbacks) and the Pharmacies funding was drastically cut leading to worse quality of care and more drugs being used. Double-whammy because in the previous system the Pharmacy did medication reviews which almost always result in a reduction in drugs (the thing with drugs is that quite a lot of them are given to reduce side effects of other drugs, the original drug gets cancelled but the side effect reducer gets forgotten and just continues ad infinitum). Health insurance has been super inflationary since then when controlled for quality of care.
- SoftTalker 4mo ago
  > Insurance companies always have an incentive to make healthcare services expensive. No, it's when their profits are capped by regulation that they have this incentive. Insurance of other types absolutely seeks to reduce claims payouts.
maxerickson 4mo ago
Large swaths of US insurance are underwritten by employers, with the insurance companies acting as contracted administrators. Employers don't have the incentives you list.
- vkou 4mo ago
  Great, just work a well paying megacorp white collar job and you'll get slightly less fucked on healthcare. What about the other 90% of the country?
  - maxerickson 4mo ago
    You could get angry about anything I say, I don't really care, you do you. I guess Medicare and Medicaid also don't have the incentives. Nor does Tri-care or the VA. My employer self insures as far as I know, and we are a few hundred people. Maybe 90% is a bit off?
    - vkou 4mo ago
      I'm not angry about what you say, I'm angry at the parasites that have built this system, and the cynical bastards that work their ass off to perpetuate it.
themafia 4mo ago
We baked the snake charmer problem into the law? Good lord.
- Terr_ 4mo ago
  > snake charmer problem Perhaps you mean the "cobra effect" [0]? I think that's an apocryphal story about killing snakes, rather than using them in a performance. [0] https://en.wikipedia.org/wiki/Perverse_incentive#Historicity_of_the_cobra_anecdote https://en.wikipedia.org/wiki/Perverse_incentive#Historicity...
  - themafia 4mo ago
    So the meaning of what I said was slightly obscured but actually easy to apprehend? oookay.
    - Terr_ 4mo ago
      If I guessed right, then there are probably readers who haven't heard the term/story before [0], or won't make the same jump to recall it. If I guessed wrong, then I wanted to hear about the new thing that resisted a casual web-search. [0] https://xkcd.com/1053/ https://xkcd.com/1053/
deleted 4mo ago
[deleted]

Natsu 4mo ago

> Ketamine is made up of mirror image molecules and esketamine is the right-handed molecule. Esketamine is their cutesy way of saying the word s-ketamine. The s- comes from the Latin word "sinister" which means this is the left-handed enantiomer, not the right-handed one. It is stupidly expensive, given how generic ketamine itself is. In our case, sleep apnea treatment proved to be a much better option than that drug, as it was just hiding an underlying condition and the treatments only last for maybe a week or two anyway. I think there have been some people using ketamine off-label, but I don't know much about that. It does need to be tightly controlled because it can cause breakthrough psychosis in some patients. They try to screen those out, but that's not as effective as one might hope given my experience of seeing that fail. And it that was very nearly a fatal mistake.

refurb 4mo ago

Blame the FDA on that one. The FDA's policy for the last couple of decades is that mixtures of mirror images will not get FDA approval unless there is a strong rationale for it. Racemic mixture of ketamine was approved decades ago. If you want a new indication for ketamine, you will need to get approval for a single mirror image, as the FDA won't approve the old drug. They did this because there are numerous examples of racemic mixture drugs having increased side effects from the less active mirror image, so the FDA decided no more racemic approvals. My guess is your insurer would be happy to pay for the old version, but your doctor is heavily incentivized to use the new version as the markup on the drug is much, much higher.

Jblx2 4mo ago
>but your doctor is heavily incentivized to use the new version as the markup on the drug is much, much higher. I don't think it is normal/usual for doctors to receive any benefits or profits from which drugs they prescribe. Other than golf outings with the drug company reps? Is there something I'm missing?
- refurb 4mo ago
  For drugs administered in office, doctors can markup the cost and insurance pays it. Even Medicare pays 4.3% extra. For oncologists, it’s most of the revenue for their office since consults pay very little. The money made on administering $5 worth of ketamine is far less than a $1500 bottle of eskatamine.
rcxdude 4mo ago
Thalidomide being one of the more notable ones (though apparently neither chirality is truly safe)
- RobotToaster 4mo ago
  It's worth noting that thalidomide is still approved, but only for leprosy and certain types of cancer.

RobotToaster 4mo ago

The NHS in the UK refuses to cover it in part because of the absurd cost.

VladVladikoff 4mo ago

What’s so interesting about this that I just learned after googling about Spravato that ketamine is a treatment for serious depression. Why? That’s fascinating! Is it the dissociative effects?

kevinoid 4mo ago
A significant effect is through opioid receptor activation, as demonstrated by Williams et al. <https://doi.org/10.1038/s41380-019-0503-4 https://doi.org/10.1038/s41380-019-0503-4> by blocking the receptor with naltrexone, which attenuated the antisuicidality effects. The Huberman Lab episode Ketamine: Benefits and Risks for Depression, PTSD & Neuroplasticity <https://www.hubermanlab.com/episode/ketamine-benefits-and-risks-for-depression-ptsd-and-neuroplasticity https://www.hubermanlab.com/episode/ketamine-benefits-and-ri...> and the referenced journal articles (including the above) have a lot of detail on it.
pas 4mo ago
we don't know. https://lorienpsych.com/2021/11/02/ketamine/#11_How_does_ketamine_work https://lorienpsych.com/2021/11/02/ketamine/#11_How_does_ket... the opiate receptor interaction might be important, but it seems that the antidepressant effect persists even if the opiate pathway is blocked (via naltrexone) https://pmc.ncbi.nlm.nih.gov/articles/PMC6439824/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6439824/ (though it's an open-label super small study ... n=4)