thelastpsychiatrist.com - A Solution To The Pharma Problem. Adnotated.

The problem so far is all arguments against Pharmaⁱ (prices too high; no interest in making meds people need; no interest in cures, only maintenance treatments, etc, etc) fail because they are ethical arguments.

The problem and solution require our reluctant acceptance that the problem is an economic one, and only economics will solve it.ⁱⁱ

Though I divide the solution into a "Doctor Side" and "Pharma Side," it is imperative that both solutions be executed simultaneously. Doing only one will absolutely fail.ⁱⁱⁱ

Doctor side: Pharma does not make meds for patients, it makes them for doctors -- they represent the demand. Read that again, that's Axiom #1.^iv

Doctors have no current incentive or pressure to consider the cost (effectiveness) of the meds.
But without the pressure, there is no incentive from Pharma to create products that are cost-worthy.^v If doctors don't have to consider cost, then Pharma can effectively get doctors to add on, say Nexium. It works, so why not? If doctors must explicitly consider cost, then not only can't Pharma successfully market Nexium, it will not even bother to create it. Pharma will work on something that's really worth the money.

Consider also that unlike other consumer products, price has no relationship to relative value. Nexium and Lipitor are the same price, but (arguably) Lipitor is more important.^vi

So doctors need to consider cost, which in turn will force Pharma to consider cost. So doctors -- not patients, President Bush -- must be given a healthcare budget, specifically a pharmacy budget. $20 per patient per day. Go.

That changes the market. If you do that, prices come down, especailly for "luxury goods" (e.g. Nexium.) And Pharma will create wonderful things (not that they haven't already.)^vii

Pharma SideAxiom #1 is: Pharma makes meds for doctors, not patients.

Corollary: They don't need to make a drug that is useful, or is awesome; only a drug that doctors will prescribe. Sometimes the two are the same, but that isn't by design.

Pharma gets no points, no credit, for creating drugs that work, only drugs that sell. No one I know has hugged a Lilly rep^viii, thanking them for having a drug that works, even if imperfectly. Their only thanks is the money.

The single problem from the Pharma side is the blockbuster drug model.^ix

The common criticism against the blockbuster model is that it entices other Pharma companies to invent "me too" drugs -- another SSRI, another statin, another Nexium.

But there is a much greater, critical, consequence of the blockbuster model: it makes doctors think that the mechanism of action of the blockbuster is the only, or most, important one -- it creates a paradigm that is hard to think outside of.^x In other words, the blockbuster model confuses science. It may be that lowering cholesterol is itself a red herring, and that the actual benefit is something else^xi -- consider Vytorin lowered cholesterol more than simvastatin alone, yet was not better at preventing intima thickening. But because cholesterol drugs -- nay, HMG co-A reductase inhibitors specifically -- are the big drugs, that's all doctors think about.

From 1980-1998, SSRI were all psychiatrists thought about. So obsessed were they with SSRIs that they tried to explain nearly all psychic phenomena by serotonin. Depakote was such a blockbuster that people couldn't even comprehend a "mood stabilizer" that wasn't an antiepileptic.

You can't get a novel mechanism passed an NIH grant reviewer; Pharma isn't interested either. How is it that 6 atypical drugs all have prominent serotonergic activity, but no one investigated glutamate? You have a working paradigm, you have stuff that is well established, it's hard to abandon it and try something new. Not when you operate on the blockbuster model.^xii

And meanwhile, Pharma loses out on new opportunities.^xiii) Pharma may have already invented a novel mechanism drug that reduces heart attack risk -- but not only does it have to bring it to market, it has to retrain doctors that they trained to be statin obsessed -- that cholesterol, after all, isn't everything. Strattera and Cymbalta -- both invented at the same time as Prozac -- languished in Lilly's basement because the world (of doctors) was not ready to hear about drugs that weren't "selective" or serotonergic.^xiv

But as long as doctors don't have to consider cost, blockbusters are the best way to make money. You want to make a drug that doctors will simply add on to everything -- and they will, if they're not paying.^xv

The Incentive Model: Broadly, there are three categories of people working from different incentives.

1. For Pharma researchers, the incentive is to get FDA approval for an indication.
2. For reps, it is to get market share. Many reps compete against other reps in their own company. (e.g. if they come up with a great sales pitch, or have an awesome speaker, etc, they don't want to share them with other territories.)
3. For managers, it is indirectly market share, more directly certain rep based metrics (reps made growth targets, reps conducted the right number of programs, all expense reports were done on time, etc.)
4. For the company itself, the current incentive is to create what doctors will prescribe.

It's obvious that the incentives are different, and none are actually in alignment with the company's goal of increased revenue.

1. Bringing a drug to market should not be incentivized, even from the basic profit perspective. Just because it gets an indication, doesn't mean it will generate any money. But since researchers are incentivized precisely on that, you see a lot of obvious "me-too" drugs and indications. The fix here is to incentivize researchers based on the future success of the drug, not the indication. Coupled with a pharmacy budget for doctors, the incentive will be to invent a drug of value -- whether in a disease that has few treatments; or a significantly better/safer alternative. While more difficult, it will be more profitable to the researcher than another SSRI (which doctors won't want to spend their budget on.)^xvi

2. Market share is also a bad metric, yet it's the one everyone uses. It does not matter at all that Seroquel has more market share than Zyprexa because they may not be used for the same things. It's not Coke vs. Pepsi. As an example, for Lilly, Zyprexa competes against Geodon, but not against Depakote -- because it doesn't share the same FDA indication -- even though in the treatment of bipolar, Depakote is a much bigger competitor than any antipsychotic. If Zyprexa wins all of Geodon's market share, it gains very little in real dollars. But convert all the Depakote to Zyprexa, and Lilly wins.

3. Managers. I am not really sure if there is any value to managers.^xvii I am not being glib or insulting, and I'm open to information. But my read is that Pharma could easily cut the number of managers in half, reducing expenses but also freeing reps to focus on selling. Or, it could use a mentor model where good or senior reps are paid extra to mentor newer reps.^xviii

4. Next, you have to incentivize Pharma to make valuable drugs; at least don't de-incentivize. There is a gigantic likelihood that any really useful drug will be commandeered by the NEJM's Marcia Angell and her band of merry socialists. Why would any company want to spend any money on a cure for HIV, when there is a real chance it will be stolen by the UN even before it gets approved? And we're supposed to accept that, because society "needs" it.^xix "Sanction of the victim" is what Ayn Rand called it (and I'm confident I just lost readers by invoking her name. Bite me.) So instead, you know what Glaxo's next big drug is? Treximet: Imitrex + naprosyn. Commandeer that, Dr. Angell.

The Research Model: The current model is completely broken. Allowing "thought leaders" to peer review grant proposals is as good an idea as allowing senior Senators to choose your next President.^xx Letting Pharma do it is like letting Coca-Cola decide your breakfast cereal.

I recognize that it can't be fixed all at once, so I propose an incremental solution.

Pharma puts money into a pot to fund independent research, no strings attached.^xxi

They can still fund their own stuff, of course, but we need a pool of non-taxpayer capital that private research can use. I recognize this is an expense for Pharma -- but not huge, NIMH budget is $1.5B -- but it earns considerable respect, and will likely lead to new ideas and directions -- and someone at Pharma will ultimately benefit.^xxii

The problem is who will manage this pot: putting it in the hands of "thought leaders" and academics is stupefyingly obviously a bad idea. You may as well let the Politburo decide. (Yeah, I said it.) Want to know what that would look like? The NIH.^xxiii

The solution is a "Digg" style voting of research projects.^xxiv Any doctor -- not just psychiatrist, because you need people with different mindsets to make good evaluations -- can vote up or down a research idea/protocol.^xxv If you want to get fancy, they can also vote up the amount the study gets (as opposed to simply approving an amount.) It's possible that allowing other scientists to also vote could be of benefit, but there are some problems with it that I haven't worked out.^xxvi

Again, Pharma and the NIH can continue the same biased, barely readable quasi-research they have always done, this is just another funding source.^xxvii

1. 
   

   "I think you're gonna find, when all this shit is over, I think you're gonna find yourself one smiling motherfucker. The thing is, Butch, right now you got ability. But painful as it may be, ability don't last. And your days are just about over. Now that's a hard motherfuckin' fact of life, but that's a fact of life your ass is gonna have to get realistic about. See, this business is filled to the brim with unrealistic motherfuckers. Motherfuckers who thought their ass would age like wine. If you mean it turns to vinegar, it does. If you mean it gets better with age, it don't. Besides, Butch, how many fights do you think you got in you anyhow? Two? Boxers don't have an Old Timers Place. You came close but you never made it. And if you were gonna make it, you would have made it before now." (holds out the envelope of cash to Butch, but just out of his reach) "You're mine, dig?"
   "It certainly appears so." (takes the envelope)
   "Night of the fight, you might feel a slight sting. That's pride fuckin' with you. Fuck pride! Pride only hurts, it never helps. You fight through that shit. 'Cause a year from now, when you kicking it in the Caribbean, you gonna say to yourself, Marcellus Wallace was right."
   "I got no problem with that, Mr. Wallace."
   "In the 5th, your ass goes down." (Butch nods silently) "Say it."
   "In the 5th, my ass goes down."

   Hey, remember back when the UStards still had the spunk to complain about the broken shards of their leftover scraps and shreds of industry scattered meaninglessly about ? Back when they'd protest perceived dysfunction rather than be overjoyously happy there's anything there at all, Argentina-like ? Well... those days are gone. Gone like the smoke, gone like that song, gone to be replaced with "nowadays".

   And that nowadays... o boy howdy, lemme tell ya. Nowadays, the same sad, broken, dysfunctional "Pharma" is proudly denoted as "Industria Americana", with no further epithets, to signal the disinclination to discussion. They sit around, watching each other with panic in their eye, a dozen grown adults on a "farm" (so says the shingle). They're gathered about a single, solitary, poxy hen. They watch it shed feather after feather, they watch each other watching for an egg that ain't ever gonna come, not no more, and as they're watching they dare not bring up "pustule" while the days go by and by. [↩]

2. This is what dead cultures say. It is literally homomorphic to "we are dead", when ethical arguments no longer prevail the elvis has left the building. It isn't a correct statement of fact, as it implicitly pretends itself to be. It isn't even incorrect. It's just a rattle, descriptive but contentless. It just happens to be called The Death Rattle, that's all. [↩]
3. "In the first phase, only trucks will change to driving on the left side..." [↩]
4. And the SOPS is not made for businessmen, it's made for lawyers. They "represent"... see the system yet ? [↩]
5. But it is also impossible to create the pressure in economic terms, because incomes are not comparable. Consider the "brilliant DA" in Fracture. He boasts a "97% conviction rate". Do you know how he got it ? Let's see how he got it.

   Have a seat.
   Thank you.

   William "no middle initial" Beachum. Wow, a 97% conviction rate. That's impressive.
   Thank you, sir.

   Course, you traded all your losing cases to other DDAs.
   Well, uh... I took on two or three cases for every one I gave away. They just couldn't handle their caseloads... and I don't like to lose.

   You won't always win working at Wooton Sims.
   Ahem. Working at Wooton Sims sort of is winning. Isn't it?

   Well, you'll need a middle initial.
   Sir?

   Well, those guys all play squash and have middle names.
   Ahh. Huh.

   They go in for their mother's maiden name a lot.
   Well, my mother doesn't have a maiden name.

   I think you belong here, William.
   Well, with all due respect, sir... I just didn't work this hard to stay where I belong.

   Yeah, well...I didn't think so. Well, you have your litigation experience... your chops... and your, uh, juicy private sector job. Pretty soon you'll be courtside at Laker games. Anything else the City of Los Angeles can
   do for ya?
   No, sir. I think that'll be all.

   Yeah.

   The incomes aren't comparable, see. Something comes in, a district attorney's office, or a doctor's office, or any other bureaucrat's. You know them, they're the scar tissue that forms once ethical arguments no longer prevail ; you gotta talk simple economics with them, generally about how you'll have their head. Something comes in, and now it's a "case". In a "file". An item, see, an entry in a ledger, part and parcel of the great socialist delusion, that "everything is the same thing".

   I say delusion, but they need it. It's unavoidable. They can't just give it up, it is fundamental to socialism because it is where the metaphisical problem with their system leaks if constrained under a particular rule set. This is the thing with essences, see ? They can never be pushed out of the world. And this is the thing with rulesets, see ? They can never be complete. It thus unyieldingly follows that any attempt to constrain reality by ruleset will produce some warts, like trying to squeeze a balloon in your hands, or stepping on the garden hose in cartoons. In the particular case of Roosevelt-socialism, the fundamental problem reforms as this particular delusion. It's inoperable.

   Those "cases" in those "files", those items, ledger entries that are nominally, by necessary representational fiat, "the same thing", are just as necessarily factually different. This contrast, incidentally, creates the premier tension of "modern society" (by which term we denote the last surviving socialism, for very good reasons). The smarter agents in the bureaucracy will trade themselves into supremacy ; the rest will grumble passively.

   So if, indeed, there were incentive for doctors to consider either the cost or the efficiency of medicine, that incentive would not result into what Ballas' inept societal model promises him ; they will result in some doctors, the better ones trading out leukemia to trade in apendicitis, and yes, they'd heal three apendectomies for every leukemia they trade out, and yes the grumbling Calibans will have "not been able to handle their caseload", being as they are the system-designated rug under which to hide the necessary dysfunction of an unfixably dysfunctional system. Would that be better medicine, where good doctors only treat things I can treat myself, and as soon as you get something actually dangerous you're up shit creek with Patel for a paddle ? (And fucking spare me the vomit about how "Indians can in principle make just as good doctors as anyone." In principle you can make just as good a slut as my sluts -- but do you ?!)

   PS. Don't you find it remarkable how much more than him I have to say on the actually interesting topics ?

   PPS. Did you get the "Spielen wir Liebe" reference implicit in that article title ? Oh, "which one", is it. Right. [↩]

6. Actually, Lipitor is more damaging. [↩]
7. This is possibly his lowest point. [↩]
8. But if the reps are... sorta-hot, why not ? What sort of company does this man keep ? [↩]
9. This isn't the problem "from the Pharma side". This is a fundamental, and unavoidable, problem of socialism : it can't finance itself. It has to draw the metaphysics into the monetary base somehow (no matter how!), because a confusion of causes with purposes results in the direct and strict impossibility of balancing the books. [↩]
10. For "doctors", which is to say, for pointedly non-thinkers. Who cares about them ? Oh, I guess people who want a dental bridge built as fits in their mouth, rather than as the doctor felt it should go ? I guess we're fucked, then. [↩]
11. What does the author want to believe ?

    That there is a benefit, yes ? Review note i, I guess. [↩]

12. It's unclear whether he's saying it's not hard to abandon paradigm and try something new when on the blackluster model, or something else. In any case, from my own experience (in a different field), the Hollywood model is relatively (when compared to the other approaches) rather promotive of alternative pathways. Certainly more likely to find something new than the faith-driven Afro-Indian imbecility, or the uppity-old-cunt-driven "farmer/artisan" system. In a word, I suspect he's dissing cars for being sluggish on the strength of his ignorance of wagon trains and lack of experience walking. [↩]
13. Not like they're going anywhere -- the steam engine the Greeks had but wouldn't apply waited patiently (eighteen centuries!!!) for the English to apply instead. This is a misrepresentation transparently constructed so as to protect Ballas' psyche from the actual opportunities that come with actual expiration windows ; it's a good thing "pharma loses out on new opportunities" because this way Ballas doesn't have to think about losing out by not having showed us his tits in time. (Yes, that was ongoing just about the time he phf'd. [↩]
14. Maybe the solution is simply to do away with the USG.FDA arm of nonsense, and simply let anyone prescribe anything ? No ?

    Why not. [↩]

15. Which provides one a fine heuristic in dealing with USG.bureaucrat "doctors", to go with the one we already have for dealing with USG.bureaucrat "lawyers" and the other one, for dealing with USG.bureaucrat "scientists" : never take any SWAG-drugs. If "everyone" is taking Lipitor, you don't take it, because "everyone" is just another name for organised and militant retards. It's a heuristic, which means it won't work perfectly -- but it's a good heuristic, which means it's guaranteed to statistically work better than the alternative. [↩]
16. The result will be that... no, seriously, guess. What will be the result ?

    "Researchers" still have to meet fixed periodic expenses, in the shape of rents, meals, weekly cocksuckers etcetera. They could of course self-insure, bridging the gap between certain present expense and uncertain future revenue out of their own, fat pockets. This will not happen, because, simply put, there's not enough slack in Inca lands to afford this kind of largesse, and should these "researchers" somehow have the fat pockets... why... they'd be dekulakized. Their owner, who isn't me and doesn't care, also has better uses and more pressing needs for that money.

    So no, they won't self-insure. They'll buy insurance, which means, quite specifically, they'll hire someone to pay them fixed amounts each day in exchange for whatever future upside. In other words... exactly what's happening now ; because what's happening now isn't happening because no special cuntlet of Ballas' caliber yet crawled out of cunt, to tell us all how his 5yo inventions would go. Because this is how it works, if you make a "rule" to stop them from being stupid, they create an indirection layer to get around the rule (while explaining why the rule should be repealed in the first place).

    That's the mechanism of rules, their lifecycle, you understand this, don't you ? Just as soon as the last horse fled the coop, "rules" are "created" to "cement public trust". To assure Joe Q Nobody that "no such thing could ever happen again". The rulepile is at this juncture entirely pointless, much like a reinforced door to an empty coop, and therefore everyone agrees it is both sound and needed.

    Then, as the various pressures mount (in direct relation to the rule's efficacity), more and more "dissenting" voices are heard, explaining how the rule is "outdated", as if that means anything, and that "we only need doors for empty coops! what point does a door to a full coop serve besides keeping things from going in", thus therefore the rules being "anti-business" and so following. Because paralogism is the true and universal substance of human "thought", and the simple observation that "the more ants you shove into a matchbox, the less likely for another ant to go in through a crack, and the more likely for an ant to go out of a crack, should you open it a crack" is entirely foreign to everyone. Somehow, magically, it's how "the wisdom of crowds" goes.

    So then the door's loosened, and the horses run off again, and there you have it, paroxistic behaviour as a fundamental human mode of existence. I expect you're plenty familiar with it, being exactly the way you've been training your asshole to give you up when we meet : right after you've fucked yourself in the ass, you come up with promises about how you won't do it again, and make up rules to ensure you won't, and so following. And they "work", too, in the limited sense that for as long as you're not fucking yourself in the ass, you're not fucking yourself in the ass ; but then... as the time comes for you to take it up there again... you do, don't you. When the time for it comes you do it again, and then make up some rules again, which are your companions for the downtime. You just don't remember them when it's time to take it up the ass again, that's all. Right ? When the time for them to be applied comes, the "rules" are just so much wet paper. At all other times they're cock-solid, though, of course, of course. Just not when they're about to be useful -- then, they're just in the way.

    This is how "society" works because it's how you work. And this is also why it's not society, and you aren't anybody. [↩]

17. Then again we knew all along he has no clue about how anything works. [↩]
18. Or it could fire all psychiatrists, and just let the rep managers stamp the "prescriptions". After all, when hiring astrologers, hire the cheapest. [↩]
19. Well, the niggers involved certainly do need it. [↩]
20. Yet judging by all the butthurt over Trump getting in, it'd seem that's precisely what the aspies wanted in the first place. They're certainly letting Apple pick their breakfast cereal, at that. [↩]
21. Keks.

    Why is this always the go-to of the aspie, "large pot of money, and it's all for me, free of anything" ? [↩]

22. I propose instead that everyone on Ballas' block puts up their daughters naked into a truck. It's not a big deal, their lives suck anyway ; it'll earn considerable respect and ultimately someone on Ballas' block will benefit.

    The only difference between his insanity and my insanity is that mine's actually happening, as in, right now. His never will. [↩]

23. Except everyone in socialism is "academics" aka the Gosplan. This is like proposing to pay the brothel janitor instead of the madam, "because it's more moral that way". What the cuck ?! [↩]
24. O yeah, totally. Idea of the year, this.

    By the way, whatever happened to digg ? Remember that thing, back in the day it was just as much a pretender to "this is everything" as retarddit was earlier this decade. What happened ? Did it buy Russia ? Or did it buy the barn, the same old barn all these glories've been buying like cockwork ? [↩]

25. And they will, because... what ? Someone might be wrong on the internet ? [↩]
26. Such as what, Perelman voting you all down to 0 ? For perfectly good reasons ? [↩]
27. Just another imaginary "funding source". Homeboy's ready with a gameplan.

    Then again... maybe medicine could just win the lottery ? [↩]