PBMs are the only entity trying to bring down drug costs. Every drug that the government forbids them from negotiating is expensive as shit.
When the government started negotiating drug prices in 2026 it literally did significantly worse than PBMs get on all the big drugs. Trump did better in 2027 but it's not a needle mover.
All of this boils down to, “we should steal value from the company that developed the patent by force, having already told them to invest billions developing a drug in exchange for the patent.”
That’s not a good take. If anyone should get rich on this it’s the people who make these drugs.
If you think that the health benefits are high then you can lobby congress to buy out the patent or subsidize the cost. These debates literally happen. I’ve been in them. People present studies and argue that congress should allocate more resources.
The hard part is simply that congress does not believe that the health benefits are worth subsidizing the cost. They believe this based on studies that show as much. I’m skeptical of these studies long term, but they have been convincing to congress. They don’t want to cough up the funds.
I can only assume you don't understand anything about the drug market to not equate several of your suggestions with my summary.
"Basically, the idea is to lower the margins associated with the on-patent drug the government wants to buy by as much as possible."
This is literally in writing. The goal is to violate their patent to lower the price!
"Then, Congress could approach, say, Novo Nordisk with an offer that’s not just reasonable, but cheap given all the value low-cost GLP-1s would produce."
Congress already approached the manufacturers. It negotiated a price of $245 a month in exchange for expanding indications and $50 a month fixed copays. This was still a little high to make the medicare math pencil out for carriers post IRA reform (GLPs used to benefit a lot from dinging the CAT phase and passing on big rebates, but that went away, things like eliminating rebates make the math pencil even less).
I pushed for a lower price because the carriers still wouldn't want to carry it at $245. We suggested the government kick in some money to get the carriers to the point where $245 would pencil, but congress couldn't come up with the money. As is usual in the drug space each side doesn't want the other to "get a win" so the out of power party usually blocks things. Nobody wants to go to congress to pass legislation and deal with the filibuster. The studies out there just don't show enough savings to get a good enough CBO score to do it without legislation.
They passed coverage of weight loss indications through the next 18 months and will try again next year.
If you'd suggest that, then you're obviously daft given what you're replying to is direct evidence against your view.
The goal is obviously not to violate their patent. That's an egregious misreading of what I've said and it doesn't make any sense given the suggestion is to *buy their patent*.
Unless you think making an offer, or affirming the existing legal state of affairs, or using available tools for obtaining good prices is some sort of IP violation (it isn't), what you've said doesn't follow.
>Congress already approached
For something entirely different than what the post is about. Irrelevant comment.
Give into whatever price I offer you or I will just shred your patent and let any knock off manufacturer sell it for 90% off.
That ain't much of a negotiation!
It's certainly true that any government can at any time decide to reverse its decision to protect someones patent. That comes from the government after all. And Medicare is free (sort of, current legislation makes it hard not to cover drugs) to decide not to cover a drug if it doesn't like the price it gets. Same for Medicaid, etc.
But most manufacturers approach the situation as if they have something of value and we live in a rule of law society. Most efforts at negotiating with manufacturers focus on how lowering price could increase their profit margins via higher patient uptake, adherence, expanded indications, and PA/UM removal.
The government got pretty close to reaching a deal with the GLP manufacturers. I think they should have played less hardball to get it over the finish line, perhaps they will regret that and come back with a better offer next year when they see the uptake data on the bridge program.
It doesn't need to be the government that buys out a GLP-1 patent. A coalition of healthcare providers, for instance, could do it. The math might work - the savings in drug costs, extra customer wins and extra negotiating power more than covering the cost of the patent? Back of the envelope, Alitimume, which is introducing its GLP-1 variant, Pemvidutide, has a market cap of ~$550M. Similarly, it may be a very good deal for a firm like Hims & Hers, or Amazon (their start-up health line) to buy it.
The health benefits aren't there. If they were, every insurer would be covering them at $0 cost share.
The issue you run into is that GLP1s don't solve any acute health problems. Being overweight is a long term drag on health, but insurers don't really keep people on the books long term. You average length of someone on a health plan is just a few years, that's not enough time for losing thirty pounds to offset thousands a year in new drug cost.
So insurers will pay for blood thinners, because they prevent strokes and cardiac events in the very near term. But it's hard to get them excited about chronic conditions, especially if coverage will expose them to selection effects (people with a health problem choose their plan because they cover it).
I'm of the opinion that the long term health benefits are great for society, but the only way to realize that is for the government to subsidize the drugs and/or negotiate a better price (not through outright thuggery but through convincing the patent holders they can get a lot more volume at a lower price).
We just haven't gotten there yet. I know the people that have done the negotiations. As a patchwork Medicare is going to cover them for weight lose for eighteen months and then we will revisit.
(Disclosure: I am a patent attorney, although I am not in the pharma sector)
i. Could you clarify what you mean by abuse of the patent system?
ii. Buying off a patent (or group of patents) is probably the best option here, combined short-term with protecting compounders and turning a blind eye to grey. Two points to note:
-The government doesn't need to actually buy the whole US patent, and could instead buy something like a license that obligates Eli/Novo/whomever to ignore GLP-1 RA manufacture, offers for sale, sale, purchase, and use that happens entirely within the borders of the US but still allows them to assert the patent against export and import.
-Buying a license allows the government to pit Eli, Novo, and other potential entrants against one another as semaglutide, tirzepatide, retatrutide, and new 'tides are (imperfect) substitutes for one another.
Re: I. By abuses, I mean evergreening practices such as product-hopping, chiral switching, constructing patent thickets, etc. as well as practices like patenting biosimilars adversarially, which leads to less exploration of the indication space.
With the caveats that I don't practice in the pharma space (or chemicals at all) and I'm totally unfamiliar with any of the IP on the 'tides:
Most complaints about "evergreening" are problems from outside the patent system. For example, "product hopping," where a drug manufacturer releases a new drug (covered by a new patent) and withdraws the old drug (covered by an old patent). Patents are only enforceable for twenty years from date of filing; generic manufacturers can start cranking out and selling generic versions of the old drug the day the old patent expires. The problem is that we don't have a good way to quickly convert existing patients to drugs that might be less effective but are off-patent.
What I am more interested in is GLPs' impact on addiction in general. There seems to be growing evidence that GLPs reduce alcoholism and smoking. But a magic bullet for addiction in general would be the greatest anti crime measure in human history.
I really like the idea of (nationally) buying out a patent in this case (probably best done once there are enough alternatives that you can seriously negotiate with multiple companies). Then you can make the unit economics work out and let consumers capture the surplus without necessarily hindering new entrants.
Strong-arming lower drug prices in this case would work well in first order but really risks creating a dangerous precedent and lowering the amount of money spent on research (lest a drug is too successful and gets the same treatment).
Thee would be no need for strong-arming if the law were properly written and executed. But as it stands, companies spend billions to engage with intellectual property law in bad faith, to no discernable benefit to the public.
Both can be true though (IP law is terribly abused in many cases, but also we want drug makers to be able to predictably make money with good drugs). Optimally we would also make drug development & approval much cheaper so pharma wouldn't need to make quite as much money, but it seems the politics of this somehow don't work out well.
Frankly most Americans can afford the full, non-gray-market price and *should* be willing to prioritize truly life changing results for their health, appearance, social approval, and sense of self-esteem and well-being to cut other expenditures in their life to pay full price for these drugs. That many would not do so and prefer to stay fat while paying even more for the "everything sportsball" streaming package or whatever is of course their choice but also frankly their problem that does not by itself warrant special and extreme government intervention in the market. My own opinion is that I would derive considerable consumer surplus even at full retail price (and so should most people), and at grey market prices my surplus is simply incredible, akin to when my life was once saved by three dollars worth of antibiotics. Eli Lilly deserves every penny for everything they are doing to bring retatrutide to market, and it just doesn't seem unreasonable to me to conclude that most fat Americans are being both cowardly and cheap with regard to jumping on the glp1 wagon immediately (I can attest to several such cases within my own extended family who can definitely afford it and who could definitely benefit from losing a lot of weight but are being unreasonably hesitant and intransigent about it despite seeing real success story results in others they trust, and having been encouraged by those people with the enthusiasm of an ecstatic true believer sharing the gospel and even being offered free vials!)
Perhaps my personal experiences with quite a number of these miserly, overweight, stubborn mules has jaundiced my view, but my read of the problem of dismally slow adoption rates is that it is not principally a problem of them being "too expensive", but due to other psychological factors of people often having real, stumbling-block difficulty making rational economic decisions in their own interest when it comes to medical issues when they perceive something as not yet being completely socially normalized to such an extent that they're the weirdo for *not* doing it. Obviously econ-101 logic of supply and demand means lowering the price considerably will pick up some large margin of users on the fence and for whom a sharp pecuniary nudge would knock them off into adoption, but again, I don't think price is the real 'problem' here when compared to the more philosophical question of whether many people have a sufficiently mature view of "enlightened self interest" to adjust their consumption baskets to budget genuine miracle drugs into their lifestyles. This is one of those areas where the behavioral logic of "revealed preferences " does not apply being the subjects are not trained by the experience of trying. Sometimes you don't know what you've got til it's gone, and other times you don't know how highly you'll discover you value something til you get it (this is one of Hayek's arguments for the paternalistic establishment of an education curriculum, since the pre-educated are by their very nature often unable yet to assess or estimate the personal value of the things they have not yet learned, or to which they have not been exposed - imagine a picky child stubbornly refusing to try some new food item and then discovering he loves it after you nearly had to coerce it down his throat.)
I confess that this is obviously a kind of elitist and paternalistic / personal-preference-trumping attitude. Let me put it this way. If I had full legal control over an obese adult son who weighed 300 pounds and was spending thousands a year on digital entertainment but not taking a glp1 drug, I would feel fully reasonable and within my rights as a father who loves and cares and wants the best for him to force him to forgo his entertainment - however pleasurable - and use the money to pay full price for the drugs, which I would administer myself for some brief initial period if I had to. I know, "What a monster you are!" OK, sure, I'm "a monster". What makes me even more of a monster is that I regard such paternalistic action to be more legitimate than forcing Eli Lilly to give up what I regard as they well-deserved dividends from following current legal market incentives to achieve as quickly as possible a miraculous accomplishment which will benefit humanity tremendously for the rest of time!
I suspect a low friction and high trust route to getting GLP-1 RAs is the low-hanging fruit here. Right now there are three routes:
i. Go through a traditional doctor, who can be difficult to see and will usually be very hesitant to prescribe a GLP-1 RA for anything but serious obesity or overweight patents with follow-on problems like sleep apnea. High friction, high trust.
ii. Go through a telehealth company, which seem to all be at risk of closing and seem to mostly compound. Medium friction, medium trust.
iii. Grey. Low friction, low trust.
I think we should let people get GLP-1 RAs from pharmacists through a process similar to getting a flu or COVID shot. This would be low friction and high trust. Just screen people to make sure they don't have any health or drug conflicts and they have a BMI > maybe 23.
1) You can't get GLP1s if you're a type 1 diabetic. This is really stupid and so I just lie and say I'm not type 1, but many people don't like to lie.
2) The current coding usually requires a little more than BMI. Hypertension and such. Not insurmountable but not the same as standing on a scale.
3) You aren't supposed to take GLP1 anytime near a surgery. Again not rocket science but someone that isn't familiar with your health status isn't going to want to stick their neck out and get blamed for not catching it.
So one way we can measure this is to look at LIS (low income subsidy) members on Medicare. They pay amounts ranging between $0-$10 for GLPs a month depending on their plan.
My uptake rate for LIS is maybe 2x NLI, but both are still a minorities of the population either way.
And it's not clear to me that the 2x is price related. To get a prescription you need a Diabetes HCC. Those are way more common in the LIS population then the NLI population. It would not surprise me if the 2x difference is simply related to Diabetes being 3x more prevalent amongst the LIS.
You experience matches mine. Getting people to take these is an uphill battle because they consider medicine "unnatural" and they feel this is something morally wrong with losing weight through any means other than diet and exercise. I basically had to watch my wife guarantee she would lose X pounds by Y date and when she failed she went on them and realized that it's a miracle drug.
The other problem is that a lot of people like eating. It's pleasurable, it's called gluttony! You simply can't do that on GLP1s. And there is a significant portion of the population that would rather be fat then give up the joys of the table.
My guess is that we're on the edge of a positive feedback loop:
10 More people go on GLP-1 drugs.
20 GLP-1 drugs are more socially acceptable, people are more likely to know someone using them, and the population is thinner so heavy people stand out more.
One interesting observation I've had is that despite plenty of overlap there is still a massive psychological gender split in willingness to admit to using the drugs, let alone being evangelicals for them. Women seem to tend to prefer to keep it secret and let everyone else in their reference social group to conclude from silence that they did it via diet and exercise (even better if it's the latest fad in nutrition or fitness program).
Men on the other hand go full bro-code born-again apostles preaching the gospel and wanting to share to be seen as successful guys with valuable experience and tips and to convert as many other bros to become acolytes of the new glp1 true religion with the motivation of people trying to build up their subordinates in some pyramid scheme. OK, I am exaggerating. Slightly.
As all women get thin via GLP1s being thin will be less of a signal of desirable characteristics such as delayed gratification and self control. That's what women are really trying to signal with thinness. If the drug did it then *you* didn't.
With men being thin was never that much of positive signal. Skinny fat wasn't much better than fat. Being athletic was attractive. GLP can make it harder to build muscle, though there are ways to deal with it.
I think men see GLP1s as one tool in an arsenal of self improvement, and being able to use that tool well is a positive signal.
For women they just think they are cheating and it discredits the results.
As often for everyone, there are multiple motives at play, and this is clearly the case for both men and women trying not to look fat. Among other motives, the desire to inspire positive social judgment and avoid negative social judgments are felt intensely both at and below the conscious level. I think it is true that many women perceive accurately that admitting they need glp1 drugs to stay thin provokes people into lowering their assessment of a woman's value, quality, and character. Many women are still reluctant to admit they have had elective plastic surgery, even though in cases like breast augmentation or rhinoplasty they could at least get some sympathy of having the bad luck of being "born that way" (the equivalent of short men happily admitting they wear lifts in their shoes, i.e., something that rarely happens). Some of the reluctance to admit it is because it would reduce the instinctive assessment of "inherent genetic quality" and also it's a betrayal of the culturally promoted ideological message to which we are all supposed to pay lip service no matter how hypocritical and nonsensically unrealistic, which is that all body forms are equally beautiful and everyone should feel equal high pride in however they happen to have been born to look. But with weight loss it is worse because while they may be born with much higher disposition to be obese, they are not immutably obese and could, with sufficient exercise of self control, maintain low weight and a fit figure. Admitting use of the drugs is thus like confessing under torture that actually one neither has the inherent genetic high value quality to be "naturally passively slim" nor the kind of character or conscientiousness to be voluntarily slim, and would thus quickly plump right back up if they suddenly couldn't get or couldn't use the drugs, which they would have to continue using for the rest of their lives.
There are many obvious major difficulties standing in there way of trying to do any kind of rigorous accurate analysis of this question. My own impression is a gestalt derived from reading thousands of comments filtered through my own discernment based of my own understanding and experience of gender differences, cues and hints from the text, assessment of believability, correction for disproportionate selection effect of those willing to post online, etc. Not rigorous at all, but I nevertheless insist the pattern is pronounced and easily noticeable by those with good judgment and who can see things clearly.
If I'm right, one interesting consequence I should make explicit and which I was implying by responding that way to you comment is the the usual social-psychology drivers that are mechanisms of rapid and widespread adoption of new behaviors or technologies are going to be skewed and disrupted by such a gender split. Women get totally turned off by aggressively evangelical alpha gym-bro bro-code types who tend to take over discussion in open fora (this is why they often set up their own "just for women" version of a drug's subreddit) and instead their particular version of social contagion is to want to see lots of high status influencer women come out in publicly conspicuous ways on Instagram or whatever and promote their own success stories in a manner similar to how other beauty products, services, and practices are promoted and marketed.
You will see plenty of pretty models and actresses do that for the latest snake oil skin treatment or wrinkle cream and get millions of women to immediately fork over tons of money to try the new hotness. But, so far, you do *not* see things like Amy Schumer come out and say "this incredible transformation is 100% ozempic and it's the best thing ever so don't walk but run to your doctor and ... " One might speculate about financial incentive issues and difficulties with monetizing and capturing gains from additional sales, but still, there is just no real "Bob Dole saying Viagra gets him hard again" equivalent for women and glp1s.
My impression is that there are powerful psychological and cultural headwinds currently blowing hard against getting past the social tipping point of establishment a new social consensus that is not just accepting but encouraging of the use of the new drugs, and that these headwinds are in fact the root cause of slow adoption and much more important than the currently high price of the new drugs.
Speaking of gluttony, one irony is that even at high prices, these drugs can partially or even even entirely pay for themselves by cutting the desire for indulgent food is general and (now more expensive than ever) restaurant meals in particular. Most credit card statements break down spending by categories and many users report the reduction in these expenses (and some others like alcohol) is almost as shocking as the reduction in weight. This is yet another thing people don't realize and won't even accept until they directly experience it actually happening to them, and this additional source of substantial consumer surplus provides yet another reason to not push the pharma companies to give up their well-deserved profits. People who experienced the miracle personally will tell you how grateful they are - to the point of giving thanks on their knees - that they get to live in a time when these things exist and are readily available for a small fraction of their income.
I'm using gray-market retatrutide and probably saving somewhere between 2x to 10x the amount money on what I used to spend on junk food and alcohol vs the cost of drug! (I'm on a very low dose, as well.)
There are on reddit who say that as couples they are saving approx $1k a month by not going out nearly as much. I'm not at that point, but still in the "substantially pays for itself" category. That figure is not hard even for one meal our per week given how crazy expensive eating a nice big meal at even mid-tier places in major urban areas has become recently - my impression is that few things have been hit harder by post-covid inflation. I've been invited out to restaurants and find that even just a single appetizer is plenty satisfying, forget about a giant plate of pasta or steak and sides plus a dessert. Maybe I'll have one alcoholic drink and a coffee instead of 3+ beers / cocktails. After tax and tip one gets crazy sticker shock looking at other people's bills.
Something people don't realize is that you can easily just get them to give you a huge dose and then micro dose that for many months. I still haven't reached the minimum starter dose recommended and I have no appetite at all.
Retatrutide generates absolutely amazing before-afters. This is probably mostly because it's almost all grey market so the users tend to be more cosmetic-focused and are doing other things (e.g. TRT, lifting, tanning) in conjunction with the retatrutide.
All fine and dandy in theory. And yes big pamharma does rsther take the p155 re patent extensions and protections.
But... drug discovery is not free, and getting a product through trials to FDA acceptance is very expensive.
Until we have sorted out all our medical conditions and ailments, we are likely to want and need new drug therapies. And the research to discover and establish them. Oh dear.
If such changes were implemented, I suspect the US pharma industry might substantially decamp to switzerland or the UK or elsewhere. So... reinnin their excesses, but... don't overdo it.
Eliminate PBMs from the equation and branded drug prices fall.
About 25% of the way. It's big and I'd like to see it done, but it's still not enough!
Dude you don't know what you're talking about.
PBMs are the only entity trying to bring down drug costs. Every drug that the government forbids them from negotiating is expensive as shit.
When the government started negotiating drug prices in 2026 it literally did significantly worse than PBMs get on all the big drugs. Trump did better in 2027 but it's not a needle mover.
All of this boils down to, “we should steal value from the company that developed the patent by force, having already told them to invest billions developing a drug in exchange for the patent.”
That’s not a good take. If anyone should get rich on this it’s the people who make these drugs.
If you think that the health benefits are high then you can lobby congress to buy out the patent or subsidize the cost. These debates literally happen. I’ve been in them. People present studies and argue that congress should allocate more resources.
The hard part is simply that congress does not believe that the health benefits are worth subsidizing the cost. They believe this based on studies that show as much. I’m skeptical of these studies long term, but they have been convincing to congress. They don’t want to cough up the funds.
That is an incomprehensible misstatement of what I've written. It's directly contradicted in the post! What a comment.
I can only assume you don't understand anything about the drug market to not equate several of your suggestions with my summary.
"Basically, the idea is to lower the margins associated with the on-patent drug the government wants to buy by as much as possible."
This is literally in writing. The goal is to violate their patent to lower the price!
"Then, Congress could approach, say, Novo Nordisk with an offer that’s not just reasonable, but cheap given all the value low-cost GLP-1s would produce."
Congress already approached the manufacturers. It negotiated a price of $245 a month in exchange for expanding indications and $50 a month fixed copays. This was still a little high to make the medicare math pencil out for carriers post IRA reform (GLPs used to benefit a lot from dinging the CAT phase and passing on big rebates, but that went away, things like eliminating rebates make the math pencil even less).
I pushed for a lower price because the carriers still wouldn't want to carry it at $245. We suggested the government kick in some money to get the carriers to the point where $245 would pencil, but congress couldn't come up with the money. As is usual in the drug space each side doesn't want the other to "get a win" so the out of power party usually blocks things. Nobody wants to go to congress to pass legislation and deal with the filibuster. The studies out there just don't show enough savings to get a good enough CBO score to do it without legislation.
They passed coverage of weight loss indications through the next 18 months and will try again next year.
If you'd suggest that, then you're obviously daft given what you're replying to is direct evidence against your view.
The goal is obviously not to violate their patent. That's an egregious misreading of what I've said and it doesn't make any sense given the suggestion is to *buy their patent*.
Unless you think making an offer, or affirming the existing legal state of affairs, or using available tools for obtaining good prices is some sort of IP violation (it isn't), what you've said doesn't follow.
>Congress already approached
For something entirely different than what the post is about. Irrelevant comment.
You've said your negotiation goal is:
Give into whatever price I offer you or I will just shred your patent and let any knock off manufacturer sell it for 90% off.
That ain't much of a negotiation!
It's certainly true that any government can at any time decide to reverse its decision to protect someones patent. That comes from the government after all. And Medicare is free (sort of, current legislation makes it hard not to cover drugs) to decide not to cover a drug if it doesn't like the price it gets. Same for Medicaid, etc.
But most manufacturers approach the situation as if they have something of value and we live in a rule of law society. Most efforts at negotiating with manufacturers focus on how lowering price could increase their profit margins via higher patient uptake, adherence, expanded indications, and PA/UM removal.
The government got pretty close to reaching a deal with the GLP manufacturers. I think they should have played less hardball to get it over the finish line, perhaps they will regret that and come back with a better offer next year when they see the uptake data on the bridge program.
I didn't say that. Try not to put words into my mouth.
It doesn't need to be the government that buys out a GLP-1 patent. A coalition of healthcare providers, for instance, could do it. The math might work - the savings in drug costs, extra customer wins and extra negotiating power more than covering the cost of the patent? Back of the envelope, Alitimume, which is introducing its GLP-1 variant, Pemvidutide, has a market cap of ~$550M. Similarly, it may be a very good deal for a firm like Hims & Hers, or Amazon (their start-up health line) to buy it.
The health benefits aren't there. If they were, every insurer would be covering them at $0 cost share.
The issue you run into is that GLP1s don't solve any acute health problems. Being overweight is a long term drag on health, but insurers don't really keep people on the books long term. You average length of someone on a health plan is just a few years, that's not enough time for losing thirty pounds to offset thousands a year in new drug cost.
So insurers will pay for blood thinners, because they prevent strokes and cardiac events in the very near term. But it's hard to get them excited about chronic conditions, especially if coverage will expose them to selection effects (people with a health problem choose their plan because they cover it).
I'm of the opinion that the long term health benefits are great for society, but the only way to realize that is for the government to subsidize the drugs and/or negotiate a better price (not through outright thuggery but through convincing the patent holders they can get a lot more volume at a lower price).
We just haven't gotten there yet. I know the people that have done the negotiations. As a patchwork Medicare is going to cover them for weight lose for eighteen months and then we will revisit.
(Disclosure: I am a patent attorney, although I am not in the pharma sector)
i. Could you clarify what you mean by abuse of the patent system?
ii. Buying off a patent (or group of patents) is probably the best option here, combined short-term with protecting compounders and turning a blind eye to grey. Two points to note:
-The government doesn't need to actually buy the whole US patent, and could instead buy something like a license that obligates Eli/Novo/whomever to ignore GLP-1 RA manufacture, offers for sale, sale, purchase, and use that happens entirely within the borders of the US but still allows them to assert the patent against export and import.
-Buying a license allows the government to pit Eli, Novo, and other potential entrants against one another as semaglutide, tirzepatide, retatrutide, and new 'tides are (imperfect) substitutes for one another.
Agree re: II and beyond.
Re: I. By abuses, I mean evergreening practices such as product-hopping, chiral switching, constructing patent thickets, etc. as well as practices like patenting biosimilars adversarially, which leads to less exploration of the indication space.
With the caveats that I don't practice in the pharma space (or chemicals at all) and I'm totally unfamiliar with any of the IP on the 'tides:
Most complaints about "evergreening" are problems from outside the patent system. For example, "product hopping," where a drug manufacturer releases a new drug (covered by a new patent) and withdraws the old drug (covered by an old patent). Patents are only enforceable for twenty years from date of filing; generic manufacturers can start cranking out and selling generic versions of the old drug the day the old patent expires. The problem is that we don't have a good way to quickly convert existing patients to drugs that might be less effective but are off-patent.
What I am more interested in is GLPs' impact on addiction in general. There seems to be growing evidence that GLPs reduce alcoholism and smoking. But a magic bullet for addiction in general would be the greatest anti crime measure in human history.
I really like the idea of (nationally) buying out a patent in this case (probably best done once there are enough alternatives that you can seriously negotiate with multiple companies). Then you can make the unit economics work out and let consumers capture the surplus without necessarily hindering new entrants.
Strong-arming lower drug prices in this case would work well in first order but really risks creating a dangerous precedent and lowering the amount of money spent on research (lest a drug is too successful and gets the same treatment).
Thee would be no need for strong-arming if the law were properly written and executed. But as it stands, companies spend billions to engage with intellectual property law in bad faith, to no discernable benefit to the public.
Both can be true though (IP law is terribly abused in many cases, but also we want drug makers to be able to predictably make money with good drugs). Optimally we would also make drug development & approval much cheaper so pharma wouldn't need to make quite as much money, but it seems the politics of this somehow don't work out well.
Frankly most Americans can afford the full, non-gray-market price and *should* be willing to prioritize truly life changing results for their health, appearance, social approval, and sense of self-esteem and well-being to cut other expenditures in their life to pay full price for these drugs. That many would not do so and prefer to stay fat while paying even more for the "everything sportsball" streaming package or whatever is of course their choice but also frankly their problem that does not by itself warrant special and extreme government intervention in the market. My own opinion is that I would derive considerable consumer surplus even at full retail price (and so should most people), and at grey market prices my surplus is simply incredible, akin to when my life was once saved by three dollars worth of antibiotics. Eli Lilly deserves every penny for everything they are doing to bring retatrutide to market, and it just doesn't seem unreasonable to me to conclude that most fat Americans are being both cowardly and cheap with regard to jumping on the glp1 wagon immediately (I can attest to several such cases within my own extended family who can definitely afford it and who could definitely benefit from losing a lot of weight but are being unreasonably hesitant and intransigent about it despite seeing real success story results in others they trust, and having been encouraged by those people with the enthusiasm of an ecstatic true believer sharing the gospel and even being offered free vials!)
Perhaps my personal experiences with quite a number of these miserly, overweight, stubborn mules has jaundiced my view, but my read of the problem of dismally slow adoption rates is that it is not principally a problem of them being "too expensive", but due to other psychological factors of people often having real, stumbling-block difficulty making rational economic decisions in their own interest when it comes to medical issues when they perceive something as not yet being completely socially normalized to such an extent that they're the weirdo for *not* doing it. Obviously econ-101 logic of supply and demand means lowering the price considerably will pick up some large margin of users on the fence and for whom a sharp pecuniary nudge would knock them off into adoption, but again, I don't think price is the real 'problem' here when compared to the more philosophical question of whether many people have a sufficiently mature view of "enlightened self interest" to adjust their consumption baskets to budget genuine miracle drugs into their lifestyles. This is one of those areas where the behavioral logic of "revealed preferences " does not apply being the subjects are not trained by the experience of trying. Sometimes you don't know what you've got til it's gone, and other times you don't know how highly you'll discover you value something til you get it (this is one of Hayek's arguments for the paternalistic establishment of an education curriculum, since the pre-educated are by their very nature often unable yet to assess or estimate the personal value of the things they have not yet learned, or to which they have not been exposed - imagine a picky child stubbornly refusing to try some new food item and then discovering he loves it after you nearly had to coerce it down his throat.)
I confess that this is obviously a kind of elitist and paternalistic / personal-preference-trumping attitude. Let me put it this way. If I had full legal control over an obese adult son who weighed 300 pounds and was spending thousands a year on digital entertainment but not taking a glp1 drug, I would feel fully reasonable and within my rights as a father who loves and cares and wants the best for him to force him to forgo his entertainment - however pleasurable - and use the money to pay full price for the drugs, which I would administer myself for some brief initial period if I had to. I know, "What a monster you are!" OK, sure, I'm "a monster". What makes me even more of a monster is that I regard such paternalistic action to be more legitimate than forcing Eli Lilly to give up what I regard as they well-deserved dividends from following current legal market incentives to achieve as quickly as possible a miraculous accomplishment which will benefit humanity tremendously for the rest of time!
I suspect a low friction and high trust route to getting GLP-1 RAs is the low-hanging fruit here. Right now there are three routes:
i. Go through a traditional doctor, who can be difficult to see and will usually be very hesitant to prescribe a GLP-1 RA for anything but serious obesity or overweight patents with follow-on problems like sleep apnea. High friction, high trust.
ii. Go through a telehealth company, which seem to all be at risk of closing and seem to mostly compound. Medium friction, medium trust.
iii. Grey. Low friction, low trust.
I think we should let people get GLP-1 RAs from pharmacists through a process similar to getting a flu or COVID shot. This would be low friction and high trust. Just screen people to make sure they don't have any health or drug conflicts and they have a BMI > maybe 23.
Big hold ups in prescribing are:
1) You can't get GLP1s if you're a type 1 diabetic. This is really stupid and so I just lie and say I'm not type 1, but many people don't like to lie.
2) The current coding usually requires a little more than BMI. Hypertension and such. Not insurmountable but not the same as standing on a scale.
3) You aren't supposed to take GLP1 anytime near a surgery. Again not rocket science but someone that isn't familiar with your health status isn't going to want to stick their neck out and get blamed for not catching it.
So one way we can measure this is to look at LIS (low income subsidy) members on Medicare. They pay amounts ranging between $0-$10 for GLPs a month depending on their plan.
My uptake rate for LIS is maybe 2x NLI, but both are still a minorities of the population either way.
And it's not clear to me that the 2x is price related. To get a prescription you need a Diabetes HCC. Those are way more common in the LIS population then the NLI population. It would not surprise me if the 2x difference is simply related to Diabetes being 3x more prevalent amongst the LIS.
You experience matches mine. Getting people to take these is an uphill battle because they consider medicine "unnatural" and they feel this is something morally wrong with losing weight through any means other than diet and exercise. I basically had to watch my wife guarantee she would lose X pounds by Y date and when she failed she went on them and realized that it's a miracle drug.
The other problem is that a lot of people like eating. It's pleasurable, it's called gluttony! You simply can't do that on GLP1s. And there is a significant portion of the population that would rather be fat then give up the joys of the table.
My guess is that we're on the edge of a positive feedback loop:
10 More people go on GLP-1 drugs.
20 GLP-1 drugs are more socially acceptable, people are more likely to know someone using them, and the population is thinner so heavy people stand out more.
30 More people become willing to try GLP-1 drugs.
40 GOTO 10
One interesting observation I've had is that despite plenty of overlap there is still a massive psychological gender split in willingness to admit to using the drugs, let alone being evangelicals for them. Women seem to tend to prefer to keep it secret and let everyone else in their reference social group to conclude from silence that they did it via diet and exercise (even better if it's the latest fad in nutrition or fitness program).
Men on the other hand go full bro-code born-again apostles preaching the gospel and wanting to share to be seen as successful guys with valuable experience and tips and to convert as many other bros to become acolytes of the new glp1 true religion with the motivation of people trying to build up their subordinates in some pyramid scheme. OK, I am exaggerating. Slightly.
As all women get thin via GLP1s being thin will be less of a signal of desirable characteristics such as delayed gratification and self control. That's what women are really trying to signal with thinness. If the drug did it then *you* didn't.
With men being thin was never that much of positive signal. Skinny fat wasn't much better than fat. Being athletic was attractive. GLP can make it harder to build muscle, though there are ways to deal with it.
I think men see GLP1s as one tool in an arsenal of self improvement, and being able to use that tool well is a positive signal.
For women they just think they are cheating and it discredits the results.
What makes you think signalling personality traits is what women are really trying to do by being thin?
As often for everyone, there are multiple motives at play, and this is clearly the case for both men and women trying not to look fat. Among other motives, the desire to inspire positive social judgment and avoid negative social judgments are felt intensely both at and below the conscious level. I think it is true that many women perceive accurately that admitting they need glp1 drugs to stay thin provokes people into lowering their assessment of a woman's value, quality, and character. Many women are still reluctant to admit they have had elective plastic surgery, even though in cases like breast augmentation or rhinoplasty they could at least get some sympathy of having the bad luck of being "born that way" (the equivalent of short men happily admitting they wear lifts in their shoes, i.e., something that rarely happens). Some of the reluctance to admit it is because it would reduce the instinctive assessment of "inherent genetic quality" and also it's a betrayal of the culturally promoted ideological message to which we are all supposed to pay lip service no matter how hypocritical and nonsensically unrealistic, which is that all body forms are equally beautiful and everyone should feel equal high pride in however they happen to have been born to look. But with weight loss it is worse because while they may be born with much higher disposition to be obese, they are not immutably obese and could, with sufficient exercise of self control, maintain low weight and a fit figure. Admitting use of the drugs is thus like confessing under torture that actually one neither has the inherent genetic high value quality to be "naturally passively slim" nor the kind of character or conscientiousness to be voluntarily slim, and would thus quickly plump right back up if they suddenly couldn't get or couldn't use the drugs, which they would have to continue using for the rest of their lives.
I would be interested in some kind of analysis. Just anecdotally I agree, but I'm a man so I might be biased in the sample I have.
There are many obvious major difficulties standing in there way of trying to do any kind of rigorous accurate analysis of this question. My own impression is a gestalt derived from reading thousands of comments filtered through my own discernment based of my own understanding and experience of gender differences, cues and hints from the text, assessment of believability, correction for disproportionate selection effect of those willing to post online, etc. Not rigorous at all, but I nevertheless insist the pattern is pronounced and easily noticeable by those with good judgment and who can see things clearly.
If I'm right, one interesting consequence I should make explicit and which I was implying by responding that way to you comment is the the usual social-psychology drivers that are mechanisms of rapid and widespread adoption of new behaviors or technologies are going to be skewed and disrupted by such a gender split. Women get totally turned off by aggressively evangelical alpha gym-bro bro-code types who tend to take over discussion in open fora (this is why they often set up their own "just for women" version of a drug's subreddit) and instead their particular version of social contagion is to want to see lots of high status influencer women come out in publicly conspicuous ways on Instagram or whatever and promote their own success stories in a manner similar to how other beauty products, services, and practices are promoted and marketed.
You will see plenty of pretty models and actresses do that for the latest snake oil skin treatment or wrinkle cream and get millions of women to immediately fork over tons of money to try the new hotness. But, so far, you do *not* see things like Amy Schumer come out and say "this incredible transformation is 100% ozempic and it's the best thing ever so don't walk but run to your doctor and ... " One might speculate about financial incentive issues and difficulties with monetizing and capturing gains from additional sales, but still, there is just no real "Bob Dole saying Viagra gets him hard again" equivalent for women and glp1s.
My impression is that there are powerful psychological and cultural headwinds currently blowing hard against getting past the social tipping point of establishment a new social consensus that is not just accepting but encouraging of the use of the new drugs, and that these headwinds are in fact the root cause of slow adoption and much more important than the currently high price of the new drugs.
Speaking of gluttony, one irony is that even at high prices, these drugs can partially or even even entirely pay for themselves by cutting the desire for indulgent food is general and (now more expensive than ever) restaurant meals in particular. Most credit card statements break down spending by categories and many users report the reduction in these expenses (and some others like alcohol) is almost as shocking as the reduction in weight. This is yet another thing people don't realize and won't even accept until they directly experience it actually happening to them, and this additional source of substantial consumer surplus provides yet another reason to not push the pharma companies to give up their well-deserved profits. People who experienced the miracle personally will tell you how grateful they are - to the point of giving thanks on their knees - that they get to live in a time when these things exist and are readily available for a small fraction of their income.
I'm using gray-market retatrutide and probably saving somewhere between 2x to 10x the amount money on what I used to spend on junk food and alcohol vs the cost of drug! (I'm on a very low dose, as well.)
There are on reddit who say that as couples they are saving approx $1k a month by not going out nearly as much. I'm not at that point, but still in the "substantially pays for itself" category. That figure is not hard even for one meal our per week given how crazy expensive eating a nice big meal at even mid-tier places in major urban areas has become recently - my impression is that few things have been hit harder by post-covid inflation. I've been invited out to restaurants and find that even just a single appetizer is plenty satisfying, forget about a giant plate of pasta or steak and sides plus a dessert. Maybe I'll have one alcoholic drink and a coffee instead of 3+ beers / cocktails. After tax and tip one gets crazy sticker shock looking at other people's bills.
Something people don't realize is that you can easily just get them to give you a huge dose and then micro dose that for many months. I still haven't reached the minimum starter dose recommended and I have no appetite at all.
Retatrutide generates absolutely amazing before-afters. This is probably mostly because it's almost all grey market so the users tend to be more cosmetic-focused and are doing other things (e.g. TRT, lifting, tanning) in conjunction with the retatrutide.
All fine and dandy in theory. And yes big pamharma does rsther take the p155 re patent extensions and protections.
But... drug discovery is not free, and getting a product through trials to FDA acceptance is very expensive.
Until we have sorted out all our medical conditions and ailments, we are likely to want and need new drug therapies. And the research to discover and establish them. Oh dear.
If such changes were implemented, I suspect the US pharma industry might substantially decamp to switzerland or the UK or elsewhere. So... reinnin their excesses, but... don't overdo it.