I feel kinda bad for the writer, because it's a good question: no, curing patients is not a good business model, just like public transit is not a good business model.
What a lot of folks neglect are N+1-order effects, because those are harder to quantify and fail to reach the predetermined decision some executive or board or shareholder has already made. Is curing patients a bad business model? Sure, for the biotech company it is, but those cured patients are far more likely to go on living longer, healthier lives, and in turn contribute additional value to society - which will impact others in ways that may also create additional value. That doesn't even get into the jobs and value created through the R&D process, testing, manufacturing, logistics of delivery, ongoing monitoring, etc. As long as the value created is more than the cost of the treatment, then it's a net-gain for the economy even if it's a net loss for that singular business.
If all you're judging is the first-order impacts on a single business, you're missing the forest for the trees.
~public~ transit can be a good business model if it's setup correctly. The majority of Japan's 100 train companies are setup such that they own both trains and complementary interests. Office buildings, shopping centers, super markets, apartments. The better their trains are the better their other businesses do by delivering people to them. The better their other businesses are the more people want to use their trains.
While public transit is a good business model, corrupt public transit is an even better business model. The amount of public funds that some US public transit funnels away is astounding.
Yup. North American public transit is frequently a terrible business model because North American land use is designed to push everyone’s daily destinations further and further apart, making all transportation more expensive, and making transit uncompetitive with anything else.
Saying that curing diseases is a bad business model is like saying discovering the world's largest gold mine would be a bad business because you'd eventually run out of gold. The underlying argument doesn't make sense.
The argument only makes sense under certain assumptions: you can't protect the IP from being copied (leading to competition and eroding economic rents), or the government will place a price ceiling (price controls).
Otherwise, the demand will be highly inelastic, so you cannot really invent a better business model. The pricing power you would wield as the monopoly provider of life & death would be tremendous.
It would be fruitful to put the example in the article under closer scrutiny.
The longer someone lives, the more potential value they can contribute to a society. The opportunity cost is something we've figured out from a medical perspective, but shareholders want returns today, not returns fifty years from now.
The FDA needs to declare death a disease that patentable drugs can be developed against. All of a sudden the flood gates get opened to encouraging drug research on anything that keeps people alive longer.
Treat vs cure. You treat them so you can go on treating them. If you cure them, maybe you’ll treat them later and or maybe you won’t - but that’s outside the current bonus cycle / opportunity window.
The issue with that logic there is those basic drugs are mostly generic now. That money is less, and goes to the PBM and generic manufacturers in India.
> If all you're judging is the first-order impacts on a single business, you're missing the forest for the trees.
The problem is our society is set up to give a lot of power and influence to businesses that are precisely interested in their own tree and not interested in the forest at all.
> As long as the value created is more than the cost of the treatment, then it's a net-gain for the economy even if it's a net loss for that singular business.
This is precisely the type of work that is best funded through government: Work that can be net positive for the populace but doesn’t have a viable business model attached.
There’s another layer to consider even with government-driven efforts: Resources are never infinite. The number of potential R&D opportunities exceeds available research dollars and even human personnel many times over. There comes a point when you need to allocate finite resources to the efforts that provide better cost to benefit ratios. I don’t think it’s helpful to go full hardcore utilitarian, but the reality can be that the cost of coming up with a cure for a rare genetic condition that impacts only a small number of people might be better spent on research toward a drug which incrementally reduces heart disease, for example.
Finding permanent cures for rare conditions is a heart-warming idea, but in reality it’s a lot harder and more expensive than most people assume. Likewise, when people become enamored with these ideas of finding permanent cures for rare genetic ideas they can be missing the big picture that it may not be one of the better uses of that money even if you took raw capitalism and investment dollars out of the picture. There are so many more opportunities for widespread health improvement in the boring conditions and even lifestyle diseases than in hypothetically curing the rare genetic conditions. It may not feel as heart-warming to talk about things like reducing obesity, but we’re witnessing an incredible society-wide health improvement with GLP-1 drugs that is orders of magnitude more benefit across society than something like curing a rare genetic disease.
Public transit is a good business model if you don't have to compete with government subsdized roads and you don't have government limits on what you can charge. Good luck finding anyplace without those.
Public Transit was very much thrown in there as an example of the kinds of societal-good projects that often are "bad" business models or run at a loss (Japan being a very notable exception, kinda). Thing is, anyone even casually looking at n+1-order effects sees that the value created isn't for the transit system itself, but all the components that make it function (jobs, logistics, and materials for trains, rails, signals, ports, tunnels, etc) and all the effects of easing people movement (more money to spend, more job opportunities, cleaner air, safer streets, etc). Real estate is one such effect, provided communities recognize the benefit of real estate near stations and not let naysayers constrict development around them (like you see in much of America, for some reason).
yeah but the pharma comapnies are only in the business of selling drugs so they would need to diversify into retirement homes or somnething to profit from actually curing people
I mean, that's one way to look at it I suppose, and it's why you see Healthcare Insurers and Private Equity diversify into elder care for a captive audience.
In reality though, I was not-so-subtly trying to suggest that if something is necessary for the public good (curing diseases) but a bad business model, then perhaps Capitalism itself is the wrong vehicle for that segment of industry and a different option - be it an incentive structure, government-owned pharmaceutical research, or managed economy - is needed.
Society fundamentally needs things that are simply bad business - sheltering everyone (lowers long-term housing revenue), feeding everyone (lowers long-term food revenue), healing everyone (lowers long-term healthcare revenue), educating everyone (lowers the value of degrees/credentials). If our economic model prohibits or discourages achieving optimal resource usage and human outcomes, then it's our obligation to explore and identify alternatives that may improve those outcomes respectively.
I think it's the opposite. I think people are very aware of those effects, and that's actually why they ask the question in the first place.
They ask it "is this good business" not just because they care about the answer itself but because they want to start a debate on how society should promote the invention of cures.
Like I think most people in most industries are passionate people that really want to do good, but they do need to eat too.
> I feel kinda bad for the writer, because it's a good question: no, curing patients is not a good business model, just like public transit is not a good business model.
Betteridge's law of headlines: "Any headline that ends in a question mark can be answered by the word no."
Energy123's law of headlines: Any headline that ends in a question mark will have an associated comments section mentioning Betteridge's law, despite that law having being empirically falsified.
Not sure if this is just a misunderstanding but Uber is not "public transit" (a term of art), which is what GP is talking about. Uber is just not relevant to the point GP was making.
Uber's business model is to be a loss leader to hamper competition, then jack up rider rates and lower drive rates. This is technically a 'working' business model, but hardly one that benefits the people.
Of course it's sustainable. Gilead Sciences is a $155B company originally built on a single drug (Sovaldi) that literally cures Hepatitis C. Now they are more diversified and have a stacked pipeline. The business model just changes to one like oil or mining exploration where you find a deposit with a limited lifespan and you have to keep the treadmill going to find new ones before the mother lode that funds your firm is all tapped out and you go bust.
But while it makes for amazing ragebait and threads full of grievances aired against the healthcare system in general, I think the question isn't very relevant because in Biotech, this is dynamic already essentially forced, cure or not, because of *patent life*. A perfect example of this is Lipitor and Pfizer. Lipitor was not a cure. Statins do not cure you. But it was the most profitable drug of all time. But it eventually went off-patent and now the average price on GoodRX for a 30 day supply is only $6. Pfizer stock has never recovered from that success, though they certainly have a sustainable business.
The modern-day Pfizer is Merck. Merck has probably the most profitable drug in world history (Keytruda) which is far more profitable than Lipitor, and which has massively increased remission rates for a wide range of cancers, so it's somewhat of a cure as well. But that patent life is about to expire, and 46% of Mercks revenue will disappear with it. Of course, new people are diagnosed with cancer every day, and Keytruda will continue to be prescribed in the millions, but Teva and others will sell the generic version and Merck will lose out on the revenue. So the race is on to get more things through their pipeline, acquire some promising assets, and keep the treadmill going. There are 100+ year old mining and oil companies. None are mining the same asset they had one day one, but this doesn't make the industry unsustainable.
It doesn’t matter if it is a sustainable business. People will do what they can to maximize their income now. If 10 companies are withholding a cure to milk the patients, any one of them can break from that strategy at any time, with near-instant financial reward and competitive advantage. It is not a stable equilibrium.
It shouldnt be limited to companies within the country. Any foreign company can be a market disruptor here. Assuming the drug approval admin isnt working alongside the 'cartel'.
Yet meanwhile, women entered the legal profession in the 1920's but wages did not catch up until the 1960's when the Equal Pay Act was passed. Economics 101 would say you could snap up competent female lawyers for a little more than they were paid at their current firm and thus wages would creep up, yet this would not happen.
This reminds me of the new-ish treatments that promise to regrow tooth enamel or prevent the growth of bacteria that causes cavities. These won't get widespread adoption until the American Dental Association or whatever says they're safe/effective, but there's a clear conflict of interest because it would have a huge negative impact on their members' business model.
There's money to be made selling a cure, but the creative destruction that it can bring will mean entrenched interests will fight tooth and nail (pun intended) to delay it.
The problem with investors these days is that too many of them seem so focused on short-term gains and showing their numbers increase quarter-over-quarter that we seem to be incapable of looking at an investment over a longer period of time.
That questions belies a misunderstanding of how the pharmaceutical industry works and I'm having a hard time figuring out if the journalist made a mistake or the report was written by someone with little experience in the industry (I haven't read it).
Since we've mostly run out of small molecule drugs, the (vast?) majority of drugs are developed outside the pharmaceutical industry by biotechs funded by VCs and public investors. It's a well understood pipeline now that takes IP from university tech transfer to VC biotech to pre-revenue* IPO with the final exit being an acquisition by a pharmaceutical company, which comes in with the manufacturing infrastructure to take the drug from phase III trials or approval to the mass market. Once a drug is approved (or the phase III is very promising like Sofosbuvir), pharmaceutical companies trip over each other trying to buy the IP. The industry has offloaded most of the scientific risk to VCs and the public while sharing the rewards with those investors.
As long as the number of pharmaceutical companies doesn't drop to oligopoly/cartel levels and capture the regulators completely, the incentives are strong for one pharmaceutical company to buy a cure and take it to market to undercut a competitor's treatment. Even if an oligopoly develops, since there's no "product market fit" risk and zero scientific risk once a drug is approved, financing the purchase is trivial and starting a new pharmaceutical company to compete with the oligopoly is relatively easy. The manufacturing bit is no joke but the amount of money involved even with a single drug makes starting up a new pharmaceutical competitor totally worth it, since the manufacturing and quality control is a well understood engineering problem.
On top of that, it's practically impossible for every pharmaceutical company to have a drug that treats the same thing without a ton of consolidation in the market. Drug approvals often use active-comparators and standard of care controls that raise the bar for each new drug on the market that treats the same thing. A cure on the other hand is essentially just competing against a single golden standard (there are many exceptions but it's a good rule of thumb).
Another factor is pricing. Treatments are generally priced based on how they impact quality of life because that decides how much insurers are willing to pay, especially the big state healthcare providers that have to do hard cost benefit calculations. If a treatment is making bank, the ceiling for what you can charge for a cure is a significant fraction of the lifetime cost of the treatment, and not just based on the QOL impact. It creates a strong incentive for both investors and insurers to get the cure to market.
* If you think unprofitable tech IPOs are bad, most biotechs that IPO do so with zero revenue, let alone profit. Usually to fund clinical trials.
We get threads about this on HN a couple times a year, and I feel like people have never thought this through. The company that cures T1D or MS will make approximately eleventy jillion dollars. The mustache-twirlers engineering MS into a chronic manageable disease rather than curing it would simply be outcompeted and put out of business by the straight-mustached cure owners. If you believe the mustache-twirlers are capable of suppressing knowledge of a viable cure, I'm going to have fun selling you on a lot of more-plausible conspiracy theories; for instance, the faked moon landing, which would have required less collusion and been less impactful to the world.
In a strict sense, curing a single disease isn't a long term "sustainable business", because you'll eventually push the population of affected patients below a threshold of profitability. The premise of a major pharma company is that they keep finding other treatments.
Also like, ~everyone who works in pharma, from the grunts up to the C suite, is genuinely interested in making people's lives better and improving health. Profit is a strong motive, but it is not the only motivating force.
Thats simply not true. To argue to an absurd reduction, if that were true the NHS would preference amputation and wooden limbs over all other treatments for infected limbs. They still preference paths short of amputation.
It's a race to a medium. the problem is the medium is lower than rich people want, and the masses of poorer people who benefit from being lifted above amputation and a wooden leg don't appear in the cashflow as benefactors.
Getting used to a happy medium being lower than many people are used to, is hard.
“Solution 1: Address large markets: Hemophilia is a $9-10bn WW market (hemophilia A, B), growing at ~6-7% annually.”
“Solution 2: Address disorders with high incidence: Spinal muscular atrophy (SMA) affects the cells (neurons) in the spinal cord, impacting the ability to walk, eat, or breathe.”
“Solution 3: Constant innovation and portfolio expansion: There are hundreds of inherited retinal diseases (genetics forms of blindness) … Pace of innovation will also play a role as future programs can offset the declining revenue trajectory of prior assets.”
It's easy to handwave "capitalism makes curing patients unsustainable" but here we have three strategies for sustainable cures that have a positive impact on society.
e.g. Curing blind children is profitable, since there's so many genetic reasons a child would be blind that you can keep introducing new cures reapplying the same technology.
Curing blind children is profitable. If cured, they will likely have more children. Surely some of their children will also be blind, so the company profits will increase.
The analyst is stuck in the past. Genomic solutions are personalized medicine. As long as there are new people, and new combinations of genes, there will be problems to solve.
>Where an incident pool remains stable (eg, in cancer) the potential for a cure poses less risk to the sustainability of a franchise.
Precisely. Sustainable tech and research must focus on long term disease development, and not merely those already available to the medical industrial complex for continuous revenue. When was the last time we developed a truly new and novel lifelong, chronic but not overly debilitating illness with profitable methods of providing minor alleviation of symptoms? Diabetes is mostly tapped out, cancers are too unpredictable.
Frankly? Covid-19 was a squandered opportunity. There was ample raw material to work with truly innovative medical developments in both pharmaceuticals and medical equipment: long term wearable ventilators with expensive filters that must be regularly replaced; new over the counter medications with rapid half lives for maximum daily dose consumption— heck, bring back otc cough medicine with opioids! Damned effective and great stickiness of user base with only minor churn even after the cough is gone! Instead? Vaccines. Such a waste. The only saving grace there is the massive boost the anti vax community got out of it, so I can at least cross my fingers on a measles come back tour.
The report-writer must have been from Goldman Sachs' B-team. It takes five minutes to turn up ample evidence which demonstrates that curing patients can be extremely profitable.
Take, for instance, Harvoni -- a drug introduced in late 2014 which cures Hepatitis C following a single course of treatment. It has done something like $100B in revenue for Gilead Biosciences, and, minimally, earned them $7-10B in profit. (Possibly much more than that.) Its pricing was scandalous, but that's not the issue here; the point is that it was unequivocally one of the most profitable drug launches in history.
Sure, the eradication of Hep C might make it "unsustainable" -- but it's not as though there's a lack of other diseases or maladies to contend with. Take the profits and plant new seeds, buy new technologies, develop new drugs. Besides, the research and development of new drugs has never been a stable business model, and never truly sustainable off one discovery, on account of patent expiry terms, generic competition, etc.
What is the significance of 7-10B if it is "possibly much more than that"? Even if it was $15 billion that's a 15% margin. How is that scandalous pricing?
They could have priced it lower and still have turned a healthy profit. Still, they played the rules of the game as those rules were set, which a Goldman Sachs analyst, at least, ought to appreciate. There's nothing inherently unprofitable about cures, and the nature of the drug development business is inherently unsustainable.
So if the pricing hadn't been "scandalous" by your definition, would it still have been profitable? You do realize that the profits are there because of the pricing, right?
Meanwhile over in the world where the government sinks a lot of money and energy into its citizen's healthcare, government-funded labs are exploring permanent cures for all kinds of problems via genetic therapy.
But not here. Someone's gotta make mad bank off of every aspect of this shit here.
The question is: If a capitalist (or agent in a capitalist system) has a choice between a) investing to produce/producing a cure, or b) investing to produce/producing a more-or-less working symptomatic relief, how many agents/capitalists (in decision-making positions) go for choice B, which essentially turns them into legal drug pushers with a money-printing license?
No not really. Just allow euthanasia and be done with it. Yes. there are moral grounds to it. You don't want to live life, why can't you just do it peacefully?
I barely want to live another day of life at the age of 36 :/
I feel kinda bad for the writer, because it's a good question: no, curing patients is not a good business model, just like public transit is not a good business model.
What a lot of folks neglect are N+1-order effects, because those are harder to quantify and fail to reach the predetermined decision some executive or board or shareholder has already made. Is curing patients a bad business model? Sure, for the biotech company it is, but those cured patients are far more likely to go on living longer, healthier lives, and in turn contribute additional value to society - which will impact others in ways that may also create additional value. That doesn't even get into the jobs and value created through the R&D process, testing, manufacturing, logistics of delivery, ongoing monitoring, etc. As long as the value created is more than the cost of the treatment, then it's a net-gain for the economy even if it's a net loss for that singular business.
If all you're judging is the first-order impacts on a single business, you're missing the forest for the trees.
> ~public~ transit is not a good business model.
~public~ transit can be a good business model if it's setup correctly. The majority of Japan's 100 train companies are setup such that they own both trains and complementary interests. Office buildings, shopping centers, super markets, apartments. The better their trains are the better their other businesses do by delivering people to them. The better their other businesses are the more people want to use their trains.
https://ir.tokyu.co.jp/ja/ir/news/auto_20251111595684/pdfFil...
While public transit is a good business model, corrupt public transit is an even better business model. The amount of public funds that some US public transit funnels away is astounding.
Yup. North American public transit is frequently a terrible business model because North American land use is designed to push everyone’s daily destinations further and further apart, making all transportation more expensive, and making transit uncompetitive with anything else.
Saying that curing diseases is a bad business model is like saying discovering the world's largest gold mine would be a bad business because you'd eventually run out of gold. The underlying argument doesn't make sense.
This was kind of true for Spain: they imported so much silver that they had inflation causing massive economic destabilization.
It does make sense if you turn it around
"Having permanent patient by treating only symptoms is better than curing them right away"
Basically living (comfortably, or at all) as a subscription service
The argument only makes sense under certain assumptions: you can't protect the IP from being copied (leading to competition and eroding economic rents), or the government will place a price ceiling (price controls).
Otherwise, the demand will be highly inelastic, so you cannot really invent a better business model. The pricing power you would wield as the monopoly provider of life & death would be tremendous.
It would be fruitful to put the example in the article under closer scrutiny.
When the supply runs dry, demand will naturally increase. Hoarders will be golden at that stage.
If a person dies from a disorder in their 20s, they'll never buy your heart medication in their 70s. Today's patient is tomorrow's patient.
The longer someone lives, the more potential value they can contribute to a society. The opportunity cost is something we've figured out from a medical perspective, but shareholders want returns today, not returns fifty years from now.
That is what we need to address.
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The FDA needs to declare death a disease that patentable drugs can be developed against. All of a sudden the flood gates get opened to encouraging drug research on anything that keeps people alive longer.
Treat vs cure. You treat them so you can go on treating them. If you cure them, maybe you’ll treat them later and or maybe you won’t - but that’s outside the current bonus cycle / opportunity window.
The issue with that logic there is those basic drugs are mostly generic now. That money is less, and goes to the PBM and generic manufacturers in India.
> If all you're judging is the first-order impacts on a single business, you're missing the forest for the trees.
The problem is our society is set up to give a lot of power and influence to businesses that are precisely interested in their own tree and not interested in the forest at all.
> As long as the value created is more than the cost of the treatment, then it's a net-gain for the economy even if it's a net loss for that singular business.
This is precisely the type of work that is best funded through government: Work that can be net positive for the populace but doesn’t have a viable business model attached.
There’s another layer to consider even with government-driven efforts: Resources are never infinite. The number of potential R&D opportunities exceeds available research dollars and even human personnel many times over. There comes a point when you need to allocate finite resources to the efforts that provide better cost to benefit ratios. I don’t think it’s helpful to go full hardcore utilitarian, but the reality can be that the cost of coming up with a cure for a rare genetic condition that impacts only a small number of people might be better spent on research toward a drug which incrementally reduces heart disease, for example.
Finding permanent cures for rare conditions is a heart-warming idea, but in reality it’s a lot harder and more expensive than most people assume. Likewise, when people become enamored with these ideas of finding permanent cures for rare genetic ideas they can be missing the big picture that it may not be one of the better uses of that money even if you took raw capitalism and investment dollars out of the picture. There are so many more opportunities for widespread health improvement in the boring conditions and even lifestyle diseases than in hypothetically curing the rare genetic conditions. It may not feel as heart-warming to talk about things like reducing obesity, but we’re witnessing an incredible society-wide health improvement with GLP-1 drugs that is orders of magnitude more benefit across society than something like curing a rare genetic disease.
Public transit is a good business model if you don't have to compete with government subsdized roads and you don't have government limits on what you can charge. Good luck finding anyplace without those.
if there was a way to support this say in taxes, it would make good business sense.
But the devil is in the details of implementing that.
With public transit, value capture is possible if you have the right business model. Public transit is ultimately real estate development.
However, I prefer that the value capture is by the public rather than a private corporation.
Public Transit was very much thrown in there as an example of the kinds of societal-good projects that often are "bad" business models or run at a loss (Japan being a very notable exception, kinda). Thing is, anyone even casually looking at n+1-order effects sees that the value created isn't for the transit system itself, but all the components that make it function (jobs, logistics, and materials for trains, rails, signals, ports, tunnels, etc) and all the effects of easing people movement (more money to spend, more job opportunities, cleaner air, safer streets, etc). Real estate is one such effect, provided communities recognize the benefit of real estate near stations and not let naysayers constrict development around them (like you see in much of America, for some reason).
yeah but the pharma comapnies are only in the business of selling drugs so they would need to diversify into retirement homes or somnething to profit from actually curing people
Or some kind of organization, some kind of union of all people, could pool their money and invest in such a thing.
I mean, that's one way to look at it I suppose, and it's why you see Healthcare Insurers and Private Equity diversify into elder care for a captive audience.
In reality though, I was not-so-subtly trying to suggest that if something is necessary for the public good (curing diseases) but a bad business model, then perhaps Capitalism itself is the wrong vehicle for that segment of industry and a different option - be it an incentive structure, government-owned pharmaceutical research, or managed economy - is needed.
Society fundamentally needs things that are simply bad business - sheltering everyone (lowers long-term housing revenue), feeding everyone (lowers long-term food revenue), healing everyone (lowers long-term healthcare revenue), educating everyone (lowers the value of degrees/credentials). If our economic model prohibits or discourages achieving optimal resource usage and human outcomes, then it's our obligation to explore and identify alternatives that may improve those outcomes respectively.
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I think it's the opposite. I think people are very aware of those effects, and that's actually why they ask the question in the first place.
They ask it "is this good business" not just because they care about the answer itself but because they want to start a debate on how society should promote the invention of cures.
Like I think most people in most industries are passionate people that really want to do good, but they do need to eat too.
> I feel kinda bad for the writer, because it's a good question: no, curing patients is not a good business model, just like public transit is not a good business model.
Betteridge's law of headlines: "Any headline that ends in a question mark can be answered by the word no."
Energy123's law of headlines: Any headline that ends in a question mark will have an associated comments section mentioning Betteridge's law, despite that law having being empirically falsified.
>just like public transit is not a good business model.
Uber has almost a 200B market cap for offering private transit. There is a working business model for transit.
Not sure if this is just a misunderstanding but Uber is not "public transit" (a term of art), which is what GP is talking about. Uber is just not relevant to the point GP was making.
Uber's business model is to be a loss leader to hamper competition, then jack up rider rates and lower drive rates. This is technically a 'working' business model, but hardly one that benefits the people.
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Previously:
2018: 448 points, 370 comments https://news.ycombinator.com/item?id=27184116
Looks like an old article which has been on HN a few times now. I guess the situation hasn't changed since 2018.
This, in a nutshell, is the problem with for profit medicine. If the training signal is money then money will be optimized.
Of course it's sustainable. Gilead Sciences is a $155B company originally built on a single drug (Sovaldi) that literally cures Hepatitis C. Now they are more diversified and have a stacked pipeline. The business model just changes to one like oil or mining exploration where you find a deposit with a limited lifespan and you have to keep the treadmill going to find new ones before the mother lode that funds your firm is all tapped out and you go bust.
But while it makes for amazing ragebait and threads full of grievances aired against the healthcare system in general, I think the question isn't very relevant because in Biotech, this is dynamic already essentially forced, cure or not, because of *patent life*. A perfect example of this is Lipitor and Pfizer. Lipitor was not a cure. Statins do not cure you. But it was the most profitable drug of all time. But it eventually went off-patent and now the average price on GoodRX for a 30 day supply is only $6. Pfizer stock has never recovered from that success, though they certainly have a sustainable business.
The modern-day Pfizer is Merck. Merck has probably the most profitable drug in world history (Keytruda) which is far more profitable than Lipitor, and which has massively increased remission rates for a wide range of cancers, so it's somewhat of a cure as well. But that patent life is about to expire, and 46% of Mercks revenue will disappear with it. Of course, new people are diagnosed with cancer every day, and Keytruda will continue to be prescribed in the millions, but Teva and others will sell the generic version and Merck will lose out on the revenue. So the race is on to get more things through their pipeline, acquire some promising assets, and keep the treadmill going. There are 100+ year old mining and oil companies. None are mining the same asset they had one day one, but this doesn't make the industry unsustainable.
It doesn’t matter if it is a sustainable business. People will do what they can to maximize their income now. If 10 companies are withholding a cure to milk the patients, any one of them can break from that strategy at any time, with near-instant financial reward and competitive advantage. It is not a stable equilibrium.
As long as government regulation prevents them from forming a cartel.
It shouldnt be limited to companies within the country. Any foreign company can be a market disruptor here. Assuming the drug approval admin isnt working alongside the 'cartel'.
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Yet meanwhile, women entered the legal profession in the 1920's but wages did not catch up until the 1960's when the Equal Pay Act was passed. Economics 101 would say you could snap up competent female lawyers for a little more than they were paid at their current firm and thus wages would creep up, yet this would not happen.
This reminds me of the new-ish treatments that promise to regrow tooth enamel or prevent the growth of bacteria that causes cavities. These won't get widespread adoption until the American Dental Association or whatever says they're safe/effective, but there's a clear conflict of interest because it would have a huge negative impact on their members' business model.
There's money to be made selling a cure, but the creative destruction that it can bring will mean entrenched interests will fight tooth and nail (pun intended) to delay it.
The problem with investors these days is that too many of them seem so focused on short-term gains and showing their numbers increase quarter-over-quarter that we seem to be incapable of looking at an investment over a longer period of time.
That questions belies a misunderstanding of how the pharmaceutical industry works and I'm having a hard time figuring out if the journalist made a mistake or the report was written by someone with little experience in the industry (I haven't read it).
Since we've mostly run out of small molecule drugs, the (vast?) majority of drugs are developed outside the pharmaceutical industry by biotechs funded by VCs and public investors. It's a well understood pipeline now that takes IP from university tech transfer to VC biotech to pre-revenue* IPO with the final exit being an acquisition by a pharmaceutical company, which comes in with the manufacturing infrastructure to take the drug from phase III trials or approval to the mass market. Once a drug is approved (or the phase III is very promising like Sofosbuvir), pharmaceutical companies trip over each other trying to buy the IP. The industry has offloaded most of the scientific risk to VCs and the public while sharing the rewards with those investors.
As long as the number of pharmaceutical companies doesn't drop to oligopoly/cartel levels and capture the regulators completely, the incentives are strong for one pharmaceutical company to buy a cure and take it to market to undercut a competitor's treatment. Even if an oligopoly develops, since there's no "product market fit" risk and zero scientific risk once a drug is approved, financing the purchase is trivial and starting a new pharmaceutical company to compete with the oligopoly is relatively easy. The manufacturing bit is no joke but the amount of money involved even with a single drug makes starting up a new pharmaceutical competitor totally worth it, since the manufacturing and quality control is a well understood engineering problem.
On top of that, it's practically impossible for every pharmaceutical company to have a drug that treats the same thing without a ton of consolidation in the market. Drug approvals often use active-comparators and standard of care controls that raise the bar for each new drug on the market that treats the same thing. A cure on the other hand is essentially just competing against a single golden standard (there are many exceptions but it's a good rule of thumb).
Another factor is pricing. Treatments are generally priced based on how they impact quality of life because that decides how much insurers are willing to pay, especially the big state healthcare providers that have to do hard cost benefit calculations. If a treatment is making bank, the ceiling for what you can charge for a cure is a significant fraction of the lifetime cost of the treatment, and not just based on the QOL impact. It creates a strong incentive for both investors and insurers to get the cure to market.
* If you think unprofitable tech IPOs are bad, most biotechs that IPO do so with zero revenue, let alone profit. Usually to fund clinical trials.
Still need some anti-trust oversight to prevent the competitor with a treatment from buying out and sitting on the cure.
We get threads about this on HN a couple times a year, and I feel like people have never thought this through. The company that cures T1D or MS will make approximately eleventy jillion dollars. The mustache-twirlers engineering MS into a chronic manageable disease rather than curing it would simply be outcompeted and put out of business by the straight-mustached cure owners. If you believe the mustache-twirlers are capable of suppressing knowledge of a viable cure, I'm going to have fun selling you on a lot of more-plausible conspiracy theories; for instance, the faked moon landing, which would have required less collusion and been less impactful to the world.
In a strict sense, curing a single disease isn't a long term "sustainable business", because you'll eventually push the population of affected patients below a threshold of profitability. The premise of a major pharma company is that they keep finding other treatments.
Also like, ~everyone who works in pharma, from the grunts up to the C suite, is genuinely interested in making people's lives better and improving health. Profit is a strong motive, but it is not the only motivating force.
socialized healthcare please and thank you.
That's just a race to the bottom.
Thats simply not true. To argue to an absurd reduction, if that were true the NHS would preference amputation and wooden limbs over all other treatments for infected limbs. They still preference paths short of amputation.
It's a race to a medium. the problem is the medium is lower than rich people want, and the masses of poorer people who benefit from being lifted above amputation and a wooden leg don't appear in the cashflow as benefactors.
Getting used to a happy medium being lower than many people are used to, is hard.
If so, it's not winning, is it? Private US healthcare is winning the race to the bottom on every measure that means a damn.
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(2018)
The suggestions on making sustainable cures:
It's easy to handwave "capitalism makes curing patients unsustainable" but here we have three strategies for sustainable cures that have a positive impact on society.
e.g. Curing blind children is profitable, since there's so many genetic reasons a child would be blind that you can keep introducing new cures reapplying the same technology.
Re (1), cure renal disease and save the US alone $30B/year.
Curing blind children is profitable. If cured, they will likely have more children. Surely some of their children will also be blind, so the company profits will increase.
It's a long term investment.
Obviously a hemophilia cure is a bad investment, recurring lifelong hemophilia treatment is very much more attractive.
Maybe the insurance should pay substantial amount for drugs/treatment AFTER the patient is cured completely
That’s sort of the case. Gilead’s cure for Hep C (cited in the article) costs more than treating it.
The analyst is stuck in the past. Genomic solutions are personalized medicine. As long as there are new people, and new combinations of genes, there will be problems to solve.
Grow up Goldman.
>Where an incident pool remains stable (eg, in cancer) the potential for a cure poses less risk to the sustainability of a franchise.
Precisely. Sustainable tech and research must focus on long term disease development, and not merely those already available to the medical industrial complex for continuous revenue. When was the last time we developed a truly new and novel lifelong, chronic but not overly debilitating illness with profitable methods of providing minor alleviation of symptoms? Diabetes is mostly tapped out, cancers are too unpredictable.
Frankly? Covid-19 was a squandered opportunity. There was ample raw material to work with truly innovative medical developments in both pharmaceuticals and medical equipment: long term wearable ventilators with expensive filters that must be regularly replaced; new over the counter medications with rapid half lives for maximum daily dose consumption— heck, bring back otc cough medicine with opioids! Damned effective and great stickiness of user base with only minor churn even after the cough is gone! Instead? Vaccines. Such a waste. The only saving grace there is the massive boost the anti vax community got out of it, so I can at least cross my fingers on a measles come back tour.
Of course it's sustainable. It is just not a very good businessmodel compared to some other (cynical) options.
The report-writer must have been from Goldman Sachs' B-team. It takes five minutes to turn up ample evidence which demonstrates that curing patients can be extremely profitable.
Take, for instance, Harvoni -- a drug introduced in late 2014 which cures Hepatitis C following a single course of treatment. It has done something like $100B in revenue for Gilead Biosciences, and, minimally, earned them $7-10B in profit. (Possibly much more than that.) Its pricing was scandalous, but that's not the issue here; the point is that it was unequivocally one of the most profitable drug launches in history.
Sure, the eradication of Hep C might make it "unsustainable" -- but it's not as though there's a lack of other diseases or maladies to contend with. Take the profits and plant new seeds, buy new technologies, develop new drugs. Besides, the research and development of new drugs has never been a stable business model, and never truly sustainable off one discovery, on account of patent expiry terms, generic competition, etc.
But the article uses this exact example, or am I missing something?
What is the significance of 7-10B if it is "possibly much more than that"? Even if it was $15 billion that's a 15% margin. How is that scandalous pricing?
$7-10B was a lower bound. The actual amount of profit is difficult to determine.
Their pricing was considered high enough that it led to a Senate investigation and quite a lot of litigation. (Which likely dug into their profits.)
> https://www.nbcnews.com/health/health-news/company-put-profi...
They could have priced it lower and still have turned a healthy profit. Still, they played the rules of the game as those rules were set, which a Goldman Sachs analyst, at least, ought to appreciate. There's nothing inherently unprofitable about cures, and the nature of the drug development business is inherently unsustainable.
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I had the same impression - this article demonstrates the depth of knowledge I’d expect from someone completely unfamiliar with the industry.
Most people in the industry could name several examples of cures that are highly profitable.
Not to mention patented drugs are inherently an “unsustainable business” due to the eventual introduction of generics/biosimilars.
Depending on your development pathway, you’d be lucky to get 6-8 years to turn a profit.
> Its pricing was scandalous
So if the pricing hadn't been "scandalous" by your definition, would it still have been profitable? You do realize that the profits are there because of the pricing, right?
2018
Meanwhile over in the world where the government sinks a lot of money and energy into its citizen's healthcare, government-funded labs are exploring permanent cures for all kinds of problems via genetic therapy.
But not here. Someone's gotta make mad bank off of every aspect of this shit here.
Which governments in particular; how much funding; and what outcomes have they actually achieved?
(In general the US actually subsidizes pharma for the rest of the world.)
Source on labs not researching gene therapy "here"?
It is for startups that can absorb billions then close their doors.
It’s not sustainable for businesses who rely on sickness.
> "Is curing patients a sustainable business?"
The question is: If a capitalist (or agent in a capitalist system) has a choice between a) investing to produce/producing a cure, or b) investing to produce/producing a more-or-less working symptomatic relief, how many agents/capitalists (in decision-making positions) go for choice B, which essentially turns them into legal drug pushers with a money-printing license?
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No not really. Just allow euthanasia and be done with it. Yes. there are moral grounds to it. You don't want to live life, why can't you just do it peacefully?
I barely want to live another day of life at the age of 36 :/