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CEO of UHG Shot and Killed in NYC - WTF is wrong with you New York


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On 12/29/2024 at 6:45 PM, chainsaw said:

Do you think it needs to be?

This is where I become less sympathetic to the pharma industry. Like, we can't just quantify "the upfront risk" as some huge number as a pretext for hiking prices beyond what ordinary people can pay. We probably know more or less what percentage of drugs that enter Phase 1 Clinical Trials are going to ultimately get FDA approved, and I don't exactly think the odds are so much worse than any other business. Just pull the rip cord before jumping in to Phase 2 and save some money, or whichever phase, if you can't pass the phase you just paid for. Most of those sunk costs are probably tax advantaged.

Exclusivity, fine, but with some strings attached to ensure the monopoly isn't being abused to the public's detriment.

The reason it is expensive is complicated, and some of it for good reason. I can think of a personal example where the treatment, which provides a cure to a large percentage of patients, also is tied to a high likelihood of serious complications. Patients who get the treatment have to have it administered only in highly specialized treatment centers and have to have a bed in the ICU waiting for them (during a defined time period). Hospital costs are high.

Some of the other costs are incurred just for the trial. Hospital Safety Advisory boards, data management, the collection, shipping and analysis of clinical samples to understand how the drug is working (and for who), that is all massively expensive and while there are some ideas about how to reduce those costs, it's not always so simple or easy. Frankly, while our (and Europe's) drug development process is long, complicated and expensive the oversight is crucial to the fidelity of the results. They do a lot of things quicker and cheaper in China...and I (and many others) have a hard time believing most of the data. There's a reason why if you run your Phase 1/2 in China, and want to develop that drug in the US, you have to repeat the clinical studies.

As to 'more or less knowing what the odds are', that's not how this works...that's not how any of this works. You don't pull the plug going into phase 2 unless the drug had manufacturing issues or something hugely critical at fault. Phase 2 is where you actually start learning if it is 'hitting the target'. And even if it doesn't looks as promising as you hoped, as long as it's not unreasonably toxic, you try to learn what subpopulations of patients might benefit and expand that recruitment...in a phase 3. The complexity of cancer is that if 10 people who have lung cancer, each patient in effect can have a very different disease, and understanding those differences - and what patients stand to benefit - is critical.

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4 hours ago, Pancho said:

 

Hmm, have you been this detective like over “other” tweets and posts?

this is some peak Surly sand-in-my-vag bullshit. I have seen plenty of tweets related to a whole host of topics criticized on this board for misleading descriptors. I have no idea if Don Johnson commented on any of them, but who the fuck cares? 

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2 hours ago, Txzen said:

You don't pull the plug going into phase 2 unless the drug had manufacturing issues or something hugely critical at fault. Phase 2 is where you actually start learning if it is 'hitting the target'. And even if it doesn't looks as promising as you hoped, as long as it's not unreasonably toxic, you try to learn what subpopulations of patients might benefit and expand that recruitment...in a phase 3. The complexity of cancer is that if 10 people who have lung cancer, each patient in effect can have a very different disease, and understanding those differences - and what patients stand to benefit - is critical.

If what you're saying is that there's value in every phase of a clinical trial, doesn't that cut against the idea that prices need to be high to offset money wasted on failed research?

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19 hours ago, chainsaw said:

If what you're saying is that there's value in every phase of a clinical trial, doesn't that cut against the idea that prices need to be high to offset money wasted on failed research?

I didn't say that, and I think it's simplistic to think that the costs are to offset the losses incurred with a failed drug. On the contrary, quite a bit of that cost is offset the investment needed to get a drug to the clinic. Whether that is through the expense of the research, the purchase acquisition of a small startup with a promising candidate (who don't have the $$ to take it to the clinic), the length and complexity of the clinical trial, or even the expense and complexity of manufacturing the drug. It's all part of it.

There are other considerations too. There was a huge controversy when the first drugs to treat people with Hepatitis C. Previously, this was a horrible diagnosis - you were going to get liver cancer, and the only 'treatment' would be to manage the disease while waiting for a liver transplant. But, compared to what many are used to for other medications, the cost of new Hep C treatment - about $84k - seems like lunacy. But after 8, 16, or 24 weeks of treatment, 95% of people are cured. In reality, the pricing may be reasonable considering the costs associated with ongoing Hep C disease. It's far more expense to get a liver transplant and live with chronic disease. None of this is easy to unpack.

That last example also flies in the face of 'drug companies don't want to cure people because then they don't have patients anymore'. Again, it's a business, and business can be cutthroat, but everyplace I've worked, the goal - in oncology, autoimmunity and infectious disease - the focus has always been on bringing the best benefit to the largest number of patients. And working for the cure.

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4 hours ago, Txzen said:

compared to what many are used to for other medications, the cost of new Hep C treatment - about $84k - seems like lunacy. But after 8, 16, or 24 weeks of treatment, 95% of people are cured. In reality, the pricing may be reasonable considering the costs associated with ongoing Hep C disease. It's far more expense to get a liver transplant and live with chronic disease.

This kind of thinking is problematic, perhaps more so than the thinking that led Luigi Mangione to plan and carry out a murder. You're saying it's okay to charge someone $84k for something that doesn't need to cost more than like $350, and the reason why it's okay is because the only alternative available to the patient would also be expensive. Whatever the distinction is between that and extortion is one, I'd say, without a difference from a morality standpoint.

Edited by chainsaw
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4 hours ago, Txzen said:

I didn't say that, and I think it's simplistic to think that the costs are to offset the losses incurred with a failed drug. On the contrary, quite a bit of that cost is offset the investment needed to get a drug to the clinic. Whether that is through the expense of the research, the purchase acquisition of a small startup with a promising candidate (who don't have the $$ to take it to the clinic), the length and complexity of the clinical trial, or even the expense and complexity of manufacturing the drug. It's all part of it.

There are other considerations too. There was a huge controversy when the first drugs to treat people with Hepatitis C. Previously, this was a horrible diagnosis - you were going to get liver cancer, and the only 'treatment' would be to manage the disease while waiting for a liver transplant. But, compared to what many are used to for other medications, the cost of new Hep C treatment - about $84k - seems like lunacy. But after 8, 16, or 24 weeks of treatment, 95% of people are cured. In reality, the pricing may be reasonable considering the costs associated with ongoing Hep C disease. It's far more expense to get a liver transplant and live with chronic disease. None of this is easy to unpack.

That last example also flies in the face of 'drug companies don't want to cure people because then they don't have patients anymore'. Again, it's a business, and business can be cutthroat, but everyplace I've worked, the goal - in oncology, autoimmunity and infectious disease - the focus has always been on bringing the best benefit to the largest number of patients. And working for the cure.

Citing a pharma industry media source probably isn’t the kind of unbiased reporting you think it is.

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20 hours ago, royiv said:

Citing a pharma industry media source probably isn’t the kind of unbiased reporting you think it is.

The citation was to provide the argument from the perspective of pharma. What you make of it is your own opinion.

With regard to the Hep C drug, saying it 'cost more than like $350' - can you explain how you arrived at that valuation?

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On 1/9/2025 at 10:54 AM, royiv said:

She’s a surgeon in Austin. Looks like St. David’s in the background.

Correct! She did my wife’s partial mastectomy last year. She is an extremely nice person and a fantastic surgeon.

Edited by SquishMitten
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1 hour ago, Txzen said:

The citation was to provide the argument from the perspective of pharma. What you make of it is your own opinion.

With regard to the Hep C drug, saying it 'cost more than like $350' - can you explain how you arrived at that valuation?

like most evaluations, the pricing should consider the number of users over a time Period.  If it cost $1 billion to bring the drug to market, then charging $1000 per treatment for the 100 patients who use the drug once a year to cure the very rare disease is unreasonable.   in fact, under that scenario, I very much doubt they would approve the $1 billion effort in the first place.

On the other hand, if the drug will be sold to 1 million people who will use the drug monthly - and be charged the same $1000 - a $1000 retail price would be unconscionable.

naturally, the problem is thinking that a blockbuster billion dollar earning drug will result in voluntary price reduction once it becomes a blockbuster.  That could be seen as a violation of the board’s fiduciary duty to the shareholders.   if they have to choose between shareholders and patients, they will always fuck the patients.  It’s a feature not a bug.

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2 hours ago, Txzen said:

With regard to the Hep C drug, saying it 'cost more than like $350' - can you explain how you arrived at that valuation?

Let's just go with some fuzzy numbers

<$11 billion to develop a Hep C treatment

Spoiler

 https://www.reuters.com/article/business/gilead-bets-11-billion-on-hepatitis-in-pharmasset-deal-idUSTRE7AK0XU/

Quote

Gilead bets $11 billion on hepatitis in Pharmasset deal

November 21, 20114:03 PM CST

Updated 13 years ago


By Lewis Krauskopf and Anand Basu
(Reuters) - Gilead Sciences Inc struck a deal to buy biotechnology company Pharmasset Inc for about $11 billion in a huge and risky bet on the next generation of hepatitis C treatments.

Pharmasset, which had 82 employees as of its most recent annual report, has three hepatitis C medicines in clinical trials. Its lead candidate, PSI-7977, was recently advanced into two Phase III studies. Gilead expects PSI-7977 to be submitted for U.S. approval in the second half of 2013.

 

4 million with Hep C in the United States

Spoiler

 https://pubmed.ncbi.nlm.nih.gov/38739849/

Quote

Using the PWID adjustment model, we estimated HCV RNA prevalence of 1.6% (95% CI: 0.9%-2.2%), corresponding to 4,043,200 (95% CI: 2,401,800-5,607,100) current HCV infections.

 

50 million with Hep C worldwide

Spoiler

https://www.cdc.gov/hepatitis/global/index.html

Quote

Viral hepatitis worldwide
The World Health Organization (WHO) estimates that during 2022:

  • 1.2 million people were newly infected with hepatitis B virus (HBV).
  • 1 million people were newly infected with hepatitis C virus (HCV).
  • Approximately 254 million people have chronic hepatitis B.
  • Nearly 50 million people have chronic hepatitis C.
  • Chronic hepatitis B and chronic hepatitis C cause 1.3 million deaths each year due to liver disease and cancer.

 

So, big picture here, let's assume that only 80% of the world's Hep C patients are prescribed and can access the drug Gilead bought which we're assuming was $11bn to develop. If we amortize that to 40million patients, the mathematical expression for computing the amount each patient would need to pay for Gilead to break even:

X (each patient's fair share of the amortized R&D cost) = $11,000,000,000 (The R&D cost) ÷ 40,000,000 (The number of patients)

So, each patient's fair share of the amortized R&D cost is $275

Let's remember, however, that not all of Gilead's $11bn acquisition can be fairly apportioned to its portfolio of Hep C treatments. So it's more accurate to say:

Each patient's fair share of the amortized R&D cost is <$275

Of course there are more costs involved when you are producing and distributing Hep C medication, on top of the R&D required for it to have existed in the first place. I don't think that number, per patient, is particularly high.

Whatever the true number is, it's beside the point. What these companies are doing is morally indistinguishable from extortion. It's indefensible.

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On 1/9/2025 at 11:24 AM, Don Johnson said:

Doc not wrong about her actual complaints in her video, which were not about the surgery being called off.

But this tweet was re-tweeted and quoted thousands of times, with many of the the comments similar to ones ITT.  Encouraging/predicting more murders.

All because everyone too lazy to watch a one minute video to fact check.

Xitter sucks, in case you hadn't noticed.

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Had something of a realization on the patent tangent.  One of the most significant US patent reforms ever is the creation of the Patent Trial and Appeal Board and the Inter-Partes Review proceeding (and to a lesser extent post-grant review).

This provides a forum where challenges to the validity of patents may be brought in the PTO in an adversarial format as an alternative or adjunct to litigation.

One judge famously called the PTAB "a patent death squad."  He wasn't wrong.  In 70% of cases where a proceeding is instituted (it's not automatic that one of these is commenced, there has to be some preliminary merit) all claims of a patent are invalidated. 78% of claims considered are invalidated.  https://ipwatchdog.com/2025/01/12/ptab-70-claims-invalidation-rate-continues-source-concern/id=184956/

However, when the dataset is confined to pharma patents, the invalidation rate is much smaller, 15% of all claims invalidated, 33% of claims considered.  So half or less of the usual rate of invalidation.  It's even smaller among biologics.

This rather belies the notion that a lot of pharma patents are bullshit.  Some of them kind of are, in the sense that they cover minor variations, but they are also very limited in scope/coverage, meaning they are not essential to participating in the market for the drug in question.  That's why, when you drill down into a patent thicket, you'll find a relatively small handful are correlated to "the monopoly."  That is, it is usually the expiration of one or two patents that is regarded as opening up the market.

Edited by TwiceHorn
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I think the challenge with @chainsaw's approach is that it doesn't reflect the complexity of finance well enough.  

 

A better way would be to calculate the net present value and split the research costs across 10 years, add a discount rate (say 7%) and projected cashflow rate from the sale in years 10-30 (assuming patent protected and monopoly) and then a generic alternative for years 30-40.     If you only generated $1 billion for years 10-30, and .5 billion for years 30-40, you end up with a total revenue of $25 billion on an $11 billion investment.  However, the NPV is negative, meaning you will be in the hole about $2.5 billion.  The IRR for this project is ~5%.    So if the investors only required 5% return, then this is a coin flip of a project.     

Now this excludes the foreign markets were price controls and approvals will vary.    In that case, those 4 million US souls will pay $26 billion over the course of 30 years of being on the market to company X, which works out to about $6500 (very quick and dirty estimate) per treatment.  Assuming no new people get sick.   No inflation is assumed as well.  

This is also overly simplistic, with numbers, strategy, and distribution of costs all pulled from a hat.  

 

 

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2 hours ago, TwiceHorn said:

This rather belies the notion that a lot of patents are bullshit.  Some of them kind of are

In the software/tech world there's a mountain of bad and shitty patents - the Oracle/Google fight over "APIs" springs to mind as a recent example.

Patents by and large have stopped being a mechanism to give inventors a window to profit off their idea, and are now a cudgel used against competitors to drag them down and stop innovation. 

It's not that patents in and of themselves are a bad thing, but they are THE weapon of choice in effectively killing competition in a durable and sustainable manner

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1 hour ago, Nivek said:

This is also overly simplistic, with numbers, strategy, and distribution of costs all pulled from a hat. 

Always has been. We're merely illustrating an idea here, so it's okay to go with fuzzy math and pulling numbers from a hat. $84k is still an extortionate price when the break-even price is almost certainly less than $1k.

 

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42 minutes ago, chainsaw said:

Always has been. We're merely illustrating an idea here, so it's okay to go with fuzzy math and pulling numbers from a hat. $84k is still an extortionate price when the break-even price is almost certainly less than $1k.

 

Well, I think my example pushes the costs an order of magnitude higher.  ~$7k is strictly for recouping the investment and research of $11 billion, assuming that is all purely company sponsored internally (cash) and not financed through debt/equity or offset by research grants.   The cost of manufacturing should also be included but I have no idea where to even start with numbers here.  But it does seem to indicate that if the costs per treatment were $80k/treatment than that would be pretty absurd in a vacuum.   

I suppose the question is the cost of failures (those never made it out of trial/research) and possibly offsetting costs for research into other diseases which have far fewer patients to spread the costs among.    

 

I simply do not know enough about this industry to give a credible and honest critique.  But like you, I do suspect the industry which also gave us the opioid epidemic might not be so benevolent across the board.

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8 minutes ago, Nivek said:

Well, I think my example pushes the costs an order of magnitude higher.  ~$7k is strictly for recouping the investment and research of $11 billion, assuming that is all purely company sponsored internally (cash) and not financed through debt/equity or offset by research grants.   The cost of manufacturing should also be included but I have no idea where to even start with numbers here.  But it does seem to indicate that if the costs per treatment were $80k/treatment than that would be pretty absurd in a vacuum.   

I suppose the question is the cost of failures (those never made it out of trial/research) and possibly offsetting costs for research into other diseases which have far fewer patients to spread the costs among.    

 

I simply do not know enough about this industry to give a credible and honest critique.  But like you, I do suspect the industry which also gave us the opioid epidemic might not be so benevolent across the board.

I have my doubts that any treatment's break-even price is $7k, even if we're subsidizing or trying to offset a bunch of failed research initiatives. You're correct to observe that even if we make that charitable assumption in favor of big pharma, the ratio of $84k/$7k (12:1) is, to understate things, "pretty absurd."

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6 hours ago, Captainant said:

It's not that patents in and of themselves are a bad thing, but they are THE weapon of choice in effectively killing competition in a durable and sustainable manner

Well. Walk without rhythm, and it won’t attract the worm.

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On 1/11/2025 at 3:15 PM, chainsaw said:

Let's just go with some fuzzy numbers

<$11 billion to develop a Hep C treatment

4 million with Hep C in the United States

50 million with Hep C worldwide

So, big picture here, let's assume that only 80% of the world's Hep C patients are prescribed and can access the drug Gilead bought which we're assuming was $11bn to develop. If we amortize that to 40million patients, the mathematical expression for computing the amount each patient would need to pay for Gilead to break even:

X (each patient's fair share of the amortized R&D cost) = $11,000,000,000 (The R&D cost) ÷ 40,000,000 (The number of patients)

So, each patient's fair share of the amortized R&D cost is $275

Let's remember, however, that not all of Gilead's $11bn acquisition can be fairly apportioned to its portfolio of Hep C treatments. So it's more accurate to say:

Each patient's fair share of the amortized R&D cost is <$275

Of course there are more costs involved when you are producing and distributing Hep C medication, on top of the R&D required for it to have existed in the first place. I don't think that number, per patient, is particularly high.

Whatever the true number is, it's beside the point. What these companies are doing is morally indistinguishable from extortion. It's indefensible.

Given your verbiage, I'm not sure that we're capable of a rational conversation here. That said I will agree that when it comes to healthcare, and the pricing of drugs (and services) things get emotional and sticky quickly.

But to think that you'd be able to treat 40m patients is a lark.

That deal was approved in 2011. I can't find more recent numbers, but 6 years later that drug (PSI-7977, sofosbuvir) Gilead had treated 1.4 million patients. Assuming each paid $7-8k for the treatment (and all that money went back to the parent company), I'm not sure that's breaking even as the 11b is only the acquisition cost, not counting clinical trials, manufacturing, marketing, etc. I'm sure it continued to generate revenue, but there were certainly other compounds competing for that market share, including additional approaches within their own pipeline (based on the article).  I do think there's a real question for many of these acquisitions - and this is absolutely not the only example - of simply paying too much or overvaluing the asset or the market.

But I think it's also true that in many cases the goal is not necessarily to even get back the entire cost of the development for the drug, as much as it is for particular companies to try and build a franchise in a particular disease area. Gilead has certainly done so with Hep C, BMS with multiple myeloma, etc.

This is also one of those drugs, given the cost, that really pulled in some questioning regarding public funding for the clinical trials which according to this article was around $60m.

As much hand-wringing as the industry has done over the past year(s) in anticipation of the Inflation Reduction Act, and how it impacts drug pricing, it's clear that change had to start somewhere.

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1 minute ago, Txzen said:

Given your verbiage, I'm not sure that we're capable of a rational conversation here. That said I will agree that when it comes to healthcare, and the pricing of drugs (and services) things get emotional and sticky quickly.

But to think that you'd be able to treat 40m patients is a lark.

That deal was approved in 2011. I can't find more recent numbers, but 6 years later that drug (PSI-7977, sofosbuvir) Gilead had treated 1.4 million patients. Assuming each paid $7-8k for the treatment (and all that money went back to the parent company), I'm not sure that's breaking even as the 11b is only the acquisition cost, not counting clinical trials, manufacturing, marketing, etc. I'm sure it continued to generate revenue, but there were certainly other compounds competing for that market share, including additional approaches within their own pipeline (based on the article).  I do think there's a real question for many of these acquisitions - and this is absolutely not the only example - of simply paying too much or overvaluing the asset or the market.

But I think it's also true that in many cases the goal is not necessarily to even get back the entire cost of the development for the drug, as much as it is for particular companies to try and build a franchise in a particular disease area. Gilead has certainly done so with Hep C, BMS with multiple myeloma, etc.

This is also one of those drugs, given the cost, that really pulled in some questioning regarding public funding for the clinical trials which according to this article was around $60m.

As much hand-wringing as the industry has done over the past year(s) in anticipation of the Inflation Reduction Act, and how it impacts drug pricing, it's clear that change had to start somewhere.

The company Gilead had acquired already did this R&D and FDA process. Don't confuse two different things. There's the market (estimated 40M could be more though) and there's the patients who had adopted the treatment in the short time it had been made available. The particulars are less important than the big picture here, which is that people are being extorted.

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Some of y’all’s breakeven price estimates are assuming that each drug captures 100% of the market share, ignoring patients who don’t take medication, stick with competitors’ products, or often cannibalizing sales from one of their own legacy products. 
 

1 hour ago, chainsaw said:

The company Gilead had acquired already did this R&D and FDA process. Don't confuse two different things. There's the market (estimated 40M could be more though) and there's the patients who had adopted the treatment in the short time it had been made available. The particulars are less important than the big picture here, which is that people are being extorted.

In acquisitions, it is common for the acquirer to assume the debt of the acquired company in addition to the purchase price and any future royalties. There could be million$ of r&d, regulatory, and marketing debt that needs to be paid. Every situation is unique. 

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Some of y’all’s breakeven price estimates are assuming that each drug captures 100% of the market share, ignoring patients who don’t take medication, stick with competitors’ products, or often cannibalizing sales from one of their own legacy products. 
 
In acquisitions, it is common for the acquirer to assume the debt of the acquired company in addition to the purchase price and any future royalties. There could be million$ of r&d, regulatory, and marketing debt that needs to be paid. Every situation is unique. 

Qualifiers were present, there is so much uncertainty around the figures that adding conditions such as some people not having access or a competing treatment option is akin to the Sex Panther efficacy statements.
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