Pharma confidential (5)

Avui torno a parlar de preus confidencials dels medicaments perquè crec que aquest tema està sortint de mare. Veig a alguns una mica exaltats davant la possibilitat que hi hagi una resolució judicial definitiva a la transparència de preus, i tot això coincideix amb el lobby engreixant l'engranatge acadèmic que es deixa engreixar.

Publicar un presumpte article científic a una revista amb revisió no és cap garantia d'objectivitat ni imparcialitat, explicar els conflictes d'interès ajuda a comprendre perquè s'arriba a les conclusions. Si la revista no té cap política que mostri quin ha estat el finançament de l'article i els conflictes d'interès dels seus participants, aleshores ja hi ha motiu raonable per dubtar del seu contingut.

M'ha arribat un article que justifica l'opacitat de preus dels medicaments i ho fa amb uns arguments retorçats adhoc. Arriben a la conclusió de que la transparència dels medicaments seria inviable, després d'haver dissenyat una simulació específicament per arribar a aquesta conclusió, un applaus!!!,. Alhora explica que cauria una plaga bíblica que faria retardar l'accés als medicaments a aquells països que els fessin públics. 

Quan m'ho miro dues vegades veig que l'article té l'origen a una consultora, en un projecte pagat per una empresa farmacèutica. I ja hem arribat al final de l'afer. L'acadèmia pot arribar a la conclusió que el finançador vulgui o no, però si no s'expliciten els conflictes d'interès, hi ha motius sobrats per decantar les opinions. I dic opinions perquè una simulació, no té objectivitat, depèn de quines hipòtesis fas i la seva credibilitat, i les hipòtesis en aquest cas no són neutres. Són prefabricades per arribar a la conclusió que vol el finançador.

Em sap molt de greu per com queda tocada una determinada "acadèmia" i alguns economistes de la salut. Malauradament, aquest comentari d'avui quedarà en el sac de tants altres comentaris sobre la necessària objectivitat i imparcialitat de la ciència.

L'informe de l'OCDE en canvi, diu clarament:

There was substantial disagreement among the experts consulted on how greater transparency could impact the functioning of markets. Some were confident that greater price transparency could render significant benefits, namely stronger bargaining power for public payers in price negotiations with industry, greater public accountability and legitimacy of coverage decisions. Others saw greater price transparency as introducing new risks to the functioning of markets, for example, through price convergence, with the potential for higher prices and/or reduced patient access in countries with lesser ability to pay, unclear effects on differential pricing and parallel trade, and uncertain consequences for long term commercial decisions regarding both market participation and investment in R&D. Neither perspective is supported by the existing evidence, arguably suggesting a need for caution in moving the agenda forward.

Per tant, el pensament socràtic s'imposa, només sabem que no sabem res. 

Afegeixo, no ho veureu a l'article citat, la transparència de preus és un mecanisme per anul·lar l'impacte de la regulació mitjançant preus de referència, i alhora eliminar l'impacte de l'avaluació econòmica feta amb preus reals. Ses dues bísties a abatre en un mateix tret segons alguns.

 PS. Quan la política sanitària no la fas, te la fan. Avís per a navegants. Els jutges acabaran definint la política farmacèutica.

Literatura d'alta volada

Jordi Sàbat

Encongir o eliminar la malària

El Lancet avui mostra l'estat de situació de la malària i què cal fer: eliminació vs control. Explica avantatges i inconvenients. El resum del que hi ha:

In the past 150 years, roughly half of the countries in the world eliminated malaria. Nowadays, there are 99 endemic countries—67 are controlling malaria and 32 are pursuing an elimination strategy. This four-part Series presents evidence about the technical, operational, and financial dimensions of malaria elimination. The first paper in this Series reviews definitions of elimination and the state that precedes it: controlled low-endemic malaria. Feasibility assessments are described as a crucial step for a country transitioning from controlled low-endemic malaria to elimination. Characteristics of the 32 malaria-eliminating countries are presented, and contrasted with countries that pursued elimination in the past. Challenges and risks of elimination are presented, including Plasmodium vivax, resistance in the parasite and mosquito populations, and potential resurgence if investment and vigilance decrease. The benefits of elimination are outlined, specifically elimination as a regional and global public good. Priorities for the next decade are described.

Més d'una vegada he pensat que a l'hora d'establir prioritats a l'ajuda al desenvolupament, afrontar la malària hauria d'haver estat al capdamunt, al costat de la nutrició, aigua i clavagueram. Malauradament no ha estat així i el que ha fet el Global Fund amb en Richard Feachem va fer tot el que va poder fins que es va adonar que també la corrupció i el frau havien entrat a casa seva. Complicat. En Feachem fa una crida ara des del Lancet per a l'eliminació de la malària, tant de bo se l'escoltin.

PS. Sobre el NICE, actualització a Pharmexecutive

Global health impact labeling

 Global Health Impact. Extending Access to Essential Medicines

From the last chapter:

Beyond Global Health Impact Labeling, Licensing, and Investment: Advancing Public Health

The book began by making the case for a human right to health and to access essential medicines, in particular. It defended the right against recent critics. The second section explained the Global Health Impact initiatives. The final section made the case for consuming things with Global Health Impact and similar ethical labels and considered empirical evidence that can support such initiatives.
More precisely, the first chapter suggested that everyone should have an enforceable legal human right to health that includes a right to access essential medicines to treat diseases like malaria, tuberculosis (TB), and HIV/  AIDS because it protects individuals’ ability to live minimally good lives. It sketched an account of the minimally good life that has some advantages over the main alternative. It argued that a basic minimum of health supports,
and may even partly constitute, such lives. Moreover, it argued that the right (partly because it generates a derivative right to access essential medicines) protects this basic minimum. So, the first chapter concluded that everyone should have an enforceable legal human right to health.
The second chapter argued that the human right to health can help claimants, advocates, and duty bearers find ways to fulfill everyone’s claims. Even if this right cannot provide guidance for distributing scarce resources, the chapter argued that we should not reject it; the human right to health provides hope that can foster the virtue I call creative resolve. The right inspires a fundamental commitment to finding creative solutions to apparently
tragic dilemmas; it gives claimants, advocates, and duty bearers a response to apparent tragedy in motivating them to search for ways to avoid it.

The third chapter presented some creative new ways to use data on global health to address the access to medicines problem. It suggested utilizing information about medicines’ global health consequences to create incentives for positive change. More precisely, it claimed that having something like the Global Health Impact index provides a mechanism for incentivizing pharmaceutical companies and other organizations to extend access to essential drugs and technologies around the world. It opens the door to fruitful social activism including ethical labeling, fair licensing, lobbying insurance companies to include Global Health Impact products in their formularies, and so forth.

The fourth chapter made the moral case for supporting a Global Health Impact labeling initiative, in particular. It argued that (1) pharmaceutical companies violate rights and (2) do not do enough to address the access to medicines issue, so (3) if the initiative helps rectify these problems, people should generally purchase goods from Global Health Impact– certified companies. A similar argument might support many other ethical consumption initiatives as well.

The fifth chapter defended the new perspective on how consumers should think about their basic economic powers supporting the book’s argument for purchasing Global Health Impact– labeled goods. It defended positive change consumption: Under just institutions, people can consume what they want as long as they respect the institutions’ rules. Absent such institutions, significant moral constraints on consumption exist. Against recent critics, it argued that consumers can aim at democratic change but need not always do so.  emocratic constraints may prevent truly positive change; but, at the same time, democracy is important for bringing about such change. Although people can promote democracy, they can also promote other positive processes and outcomes.

This book’s final chapter considered how examining the prospects for Global Health Impact initiatives might expand traditional philosophical inquiry’s domain. It presented a proposal for testing consumers’ willingness to make decisions based on a Global Health Impact label. The basic idea is to put a Global Health Impact label on a few over- the- counter products and to collect data on changes in consumers’ willingness to purchase these products compared to otherwise similar products from sales.

Error

La imperfecció humana ens porta a cometre errors, ningú no és perfecte. Ara bé, quan un està avisat i persisteix, aleshores cal buscar-ne els motius. La introducció del copagament per recepta representa un impost pels malalts. És així, podeu mirar-ho per on vulgueu, al final és un impost que sorgeix fruit que algú ha anat al metge i li han prescrit un medicament. I per tant un pot estar o no d'acord amb més impostos, i si aquests han de ser els malalts qui els paguin, i si han de ser els malalts catalans, però el copagament acordat ahir és això.
El meu interès avui no és pas en aquesta qüestió fiscal, el que em preocupa especialment és que algú consideri que això modera el consum. És a dir, que algú pensi que una vegada un metge ha prescrit una recepta el que convé és no anar-la a cercar a la farmàcia. Promoure la ruptura de la relació de confiança metge-pacient mitjançant incentius als darrers em sembla que és el principal error que caldrà esmenar en el futur, un error que pot costar car. I si algú creu que els metges fan una prescripció inacurada, aleshores el que cal és actuar sobre ells i no sobre els pacients.

PS. En la mesura que la pressió fiscal ha pujat des d'ahir a Catalunya, algú convindria que calculés novament el cost-benefici de viure aquí i potser se'n durà una sorpresa. Potser per això ningú no ho calcula.

PS. I ara sabem també que els catalans i valencians rescatarem les autopistes de peatge madrilenyes amb els peatges de les nostres autopistes. Hi haurà un allargament de concessió que ja va caducar fa 20 anys!. Cada vegada que passis per la barrera del peatge recorda que els madrilenys et fan pagar per ells. Ja n'hi ha prou, ho torno a dir, no amb els meus diners.

PS. La carta del darrer adéu d'un broker de Goldman Sachs tal com s'ha publicat al NYT, una peça més per entendre el moment.

Why I Am Leaving Goldman Sachs

By GREG SMITH

Published: March 14, 2012, NEW YORK TIMES

TODAY is my last day at Goldman Sachs. After almost 12 years at the firm — first as a summer intern while at Stanford, then in New York for 10 years, and now in London — I believe I have worked here long enough to understand the trajectory of its culture, its people and its identity. And I can honestly say that the environment now is as toxic and destructive as I have ever seen it.

Share your thoughts.

To put the problem in the simplest terms, the interests of the client continue to be sidelined in the way the firm operates and thinks about making money. Goldman Sachs is one of the world’s largest and most important investment banks and it is too integral to global finance to continue to act this way. The firm has veered so far from the place I joined right out of college that I can no longer in good conscience say that I identify with what it stands for.

It might sound surprising to a skeptical public, but culture was always a vital part of Goldman Sachs’s success. It revolved around teamwork, integrity, a spirit of humility, and always doing right by our clients. The culture was the secret sauce that made this place great and allowed us to earn our clients’ trust for 143 years. It wasn’t just about making money; this alone will not sustain a firm for so long. It had something to do with pride and belief in the organization. I am sad to say that I look around today and see virtually no trace of the culture that made me love working for this firm for many years. I no longer have the pride, or the belief.

But this was not always the case. For more than a decade I recruited and mentored candidates through our grueling interview process. I was selected as one of 10 people (out of a firm of more than 30,000) to appear on our recruiting video, which is played on every college campus we visit around the world. In 2006 I managed the summer intern program in sales and trading in New York for the 80 college students who made the cut, out of the thousands who applied.

I knew it was time to leave when I realized I could no longer look students in the eye and tell them what a great place this was to work.

When the history books are written about Goldman Sachs, they may reflect that the current chief executive officer, Lloyd C. Blankfein, and the president, Gary D. Cohn, lost hold of the firm’s culture on their watch. I truly believe that this decline in the firm’s moral fiber represents the single most serious threat to its long-run survival.

Over the course of my career I have had the privilege of advising two of the largest hedge funds on the planet, five of the largest asset managers in the United States, and three of the most prominent sovereign wealth funds in the Middle East and Asia. My clients have a total asset base of more than a trillion dollars. I have always taken a lot of pride in advising my clients to do what I believe is right for them, even if it means less money for the firm. This view is becoming increasingly unpopular at Goldman Sachs. Another sign that it was time to leave.

How did we get here? The firm changed the way it thought about leadership. Leadership used to be about ideas, setting an example and doing the right thing. Today, if you make enough money for the firm (and are not currently an ax murderer) you will be promoted into a position of influence.

What are three quick ways to become a leader? a) Execute on the firm’s “axes,” which is Goldman-speak for persuading your clients to invest in the stocks or other products that we are trying to get rid of because they are not seen as having a lot of potential profit. b) “Hunt Elephants.” In English: get your clients — some of whom are sophisticated, and some of whom aren’t — to trade whatever will bring the biggest profit to Goldman. Call me old-fashioned, but I don’t like selling my clients a product that is wrong for them. c) Find yourself sitting in a seat where your job is to trade any illiquid, opaque product with a three-letter acronym.

Today, many of these leaders display a Goldman Sachs culture quotient of exactly zero percent. I attend derivatives sales meetings where not one single minute is spent asking questions about how we can help clients. It’s purely about how we can make the most possible money off of them. If you were an alien from Mars and sat in on one of these meetings, you would believe that a client’s success or progress was not part of the thought process at all.

It makes me ill how callously people talk about ripping their clients off. Over the last 12 months I have seen five different managing directors refer to their own clients as “muppets,” sometimes over internal e-mail. Even after the S.E.C., Fabulous Fab, Abacus, God’s work, Carl Levin, Vampire Squids? No humility? I mean, come on. Integrity? It is eroding. I don’t know of any illegal behavior, but will people push the envelope and pitch lucrative and complicated products to clients even if they are not the simplest investments or the ones most directly aligned with the client’s goals? Absolutely. Every day, in fact.

It astounds me how little senior management gets a basic truth: If clients don’t trust you they will eventually stop doing business with you. It doesn’t matter how smart you are.

These days, the most common question I get from junior analysts about derivatives is, “How much money did we make off the client?” It bothers me every time I hear it, because it is a clear reflection of what they are observing from their leaders about the way they should behave. Now project 10 years into the future: You don’t have to be a rocket scientist to figure out that the junior analyst sitting quietly in the corner of the room hearing about “muppets,” “ripping eyeballs out” and “getting paid” doesn’t exactly turn into a model citizen.

When I was a first-year analyst I didn’t know where the bathroom was, or how to tie my shoelaces. I was taught to be concerned with learning the ropes, finding out what a derivative was, understanding finance, getting to know our clients and what motivated them, learning how they defined success and what we could do to help them get there.

My proudest moments in life — getting a full scholarship to go from South Africa to Stanford University, being selected as a Rhodes Scholar national finalist, winning a bronze medal for table tennis at the Maccabiah Games in Israel, known as the Jewish Olympics — have all come through hard work, with no shortcuts. Goldman Sachs today has become too much about shortcuts and not enough about achievement. It just doesn’t feel right to me anymore.

I hope this can be a wake-up call to the board of directors. Make the client the focal point of your business again. Without clients you will not make money. In fact, you will not exist. Weed out the morally bankrupt people, no matter how much money they make for the firm. And get the culture right again, so people want to work here for the right reasons. People who care only about making money will not sustain this firm — or the trust of its clients — for very much longer.

Greg Smith is resigning today as a Goldman Sachs executive director and head of the firm’s United States equity derivatives business in Europe, the Middle East and Africa.

A version of this op-ed appeared in print on March 14, 2012, on page A27 of the New York edition with the headline: Why I Am Leaving Goldman Sachs.

Anticipating public concern over genome editing

Genome editing: an ethical review

The Nuffield Council has released a key document on ethical implications of genome editing. You'll notice that it is an open document, a work in progress because technology is evolving. If you want an excerpt check this short guide.

It should be remembered that most prospective technologies fail, and that some lead to undesirable consequences, a fact often obscured by ‘whig’ histories that reconstruct the history of successful technologies and their beneficial social consequences. Scientific discovery and technological innovation is important but not inevitable. Most important among the factors shaping technological development is human agency. It is human agency, in terms of decisions that are made about directions of research, funding and investment, the setting of legal limits and regulatory principles, the design of institutions and programmes, and the desire for or acceptance of different possible states of affairs, that will determine whether, and which, prospective technologies emerge and, ultimately,
their historical significance.

Nuffield council work is of interest, meanwhile, China is already testing CRISPR technology in humans, no ethical concerns...

Josep Segú - Barcelona

Pharmanòmica

 Pharmanomics. How Big Pharma Destroys Global Health

He enllestit la lectura d'aquest llibre, on el pitjor és el títol, mentre que el contingut és desigual. Ja he dit moltes vegades que tota generalització acaba en distorsió d'informació. Dir que big pharma destrueix la salut global és agosarat d'entrada. Hi ha de tot com per tot arreu

El capítol 1 va dedicat a escàndols de la indústria. Tema conegut i explicat suficientment a molts llibres que he mostrat en aquest blog. Si n'heu llegit algun, us podeu saltar el capítol. Que hi hagi escàndals no vol dir que tots siguin de tots i de la mateixa manera, hi ha nivells, és clar. El dels Sackler assoleix el nivell màxim d'escàndol de tots els temps.

El segon capítol parla de la financialització del sector. Tema familiar també pels que llegiu el blog. S'oblida del llibre "Capitalizing a cure" i en canvi fa un repàs a qüestions concretes de tres companyies, Pfizer, Gilead i Abbvie. Tot explicat i detallat, bé però curt.

El tercer va de la vacuna COVID amb una breu nota sobre Moderna i el programa COVAX. El quart entra en detalls de la pandèmia i com la monetitzen AstraZeneca, Pfizer, Moderna, per guardar. El capítol 6 va d'hospitals i no sé perquè. El setè de les llicències i acords TRIPS en temps de pandèmia, és una crònica d'un desgavell.

Acaba el vuitè capítol sobre què caldria fer, fonamentalment amb el monopoli que atorguen les patents. Es fa aquestes preguntes:

Why should the public contribute tax money to the development of most of the drugs we use while our citizens then cannot afford those same drugs? Why do we remain dependent on a pharmaceutical industry that has slashed investment in the actual production of medicines, therefore rendering ourselves unable to deal with epidemics that might become more frequent in future decades?

I de tot el que diu em quedo amb una referència a considerar en el futur. Duncan McCann proposa la creació d'una Propietat Intel·lectual Pública Comunitària amb unes regles. Trobareu l'informe aquí. En parlarem més endavant.

Segons l'interès de cadascú, al llibre apareixen algunes informacions útils, ara bé, d'altres són simplement refregits de dades aparegudes en altres llocs i sense massa ordre. Si jo hagués estat l'editor li hauria demanat revisar-lo en profunditat, però els de Verso són així.