This Is All So Stupid

I bought the bottle of pills below for $8.41.  This may seem like a mundane fact but sadly it is not.

Let's back up for a minute.  I have chronic heartburn.  I am able to manage it quite well by taking 150 mg of Ranitidine (aka Zantac) twice daily.  This not only helps to prevent discomfort from my condition but also reduces my chance of developing esophageal cancer.

I have had health insurance through Ohio State for almost eight years.  As far as these things go it is a good plan (as a rule it's good to receive insurance through an organization that administers their own plan, because it's literally in their interest to keep employees healthy).  I get free visits to my PCP, free therapy, and a reasonable maximum out-of-pocket.

Like most health insurance plans though, my coverage has gotten worse over the years.  The most salient degradation for me is that, as of a few years ago, the plan no longer covers Ranitidine.  This means that the prescription monthly refills that I had been getting for about $4 now cost more than $50.  As a result, I had to explore my options in the over-the-counter (OTC) market.  Most store brands run a little bit more than what I was paying through insurance, but after a little research I was able to find six-month supplies available on Amazon for a similar per-unit price.  What's peculiar is that this option consists of two packages of the CostCo store brand in a ziploc bag:

But now even this clever workaround isn't an option because of issues with the ingredients of OTC Ranitidine.  What began as a limited recall turned into a complete removal of the drug from the market.  And while I am appreciative that the FDA is looking into this, it seems like this whole thing is a large overreaction to a relatively minimal risk.  My guess is that most stores and suppliers are simply trying to prevent and/or minimize any lawsuits.

The saving grace is that the prescription versions of the drug are still widely available.  I hoped, perhaps foolishly, that my plan would now cover the medication as there is no other way to get it.  I checked the list of uncovered drugs and didn't see Ranitidine on the list (I did a CTRL-F and everything), so I thought I was in the clear.  I messaged my doctor and she sent the prescription off to the pharmacy.

And then I checked the pharmacy website before going in and it was still $50.  Bummer.

But my hope that I would pay a reasonable price was not lost.  Enter the prescription drug discounting startup GoodRx.  I had heard of them because The Tennis Channel* only has like nine ads in rotation and theirs is one of them.  The ad promises to save people money of prescription meds, which was most certainly something I was in the market for.  I went to the website and within a couple minutes had a coupon in my inbox for a 30-day supply for the aforementioned price of $8.41.  Problem solved.

*Owned by Sinclair Broadcast Group, which you might have heard of

But wait a minute.  Doesn't this all seem odd that a seemingly simple need took so many twists and turns to fulfill?  Procuring my drugs required direct interaction with my doctor, my pharmacist, my insurance and its associated pharmacy benefit manager (PBM, for short) Express Scripts, Amazon, and GoodRx.  And this list doesn't even include all the secondary parties that played a "vital" role in this process.  From just a standpoint of efficiency, this level of complication makes no sense.

And while it may seem that the last step in that process (GoodRx) saved the day, did it really?  Aside from the obvious artifice that props up their value proposition (a bottle of Ranitidine doesn't actually cost anywhere near $50), I'm not actually better off than I was before.  After all, I used to pay about $4 through both insurance and OTC and now even with their coupon I pay twice as much.  And this doesn't include the time I had to spend figuring all of this out.

Furthermore, I'm not even the person paying GoodRx for this service.  All I had to do was go to the website and print off the coupon.  They're making no money directly off of me.  I'm not the customer in my own healthcare transaction.  Their own website acknowledges as much:

Advertisements and referral fees, eh?  As someone who worked in digital advertising for three years, I will make an educated guess that the referral fees represent something like 99% of their revenue.  So how does that work?  If you want details, there's a lot of info out there, both hinged and unhinged.  The gist of all of it is that GoodRx acts as an intermediary between pharmacies and PBMs, and makes their money off of arbitrage.  Essentially they use the differing coupon rates to drive customers to the pharmacies where they can capture the largest percentage of the difference between price and cost.  Like most business success stories in the digital age they don't actually make anything or do anything novel.  They simply find money that isn't nailed down and let us have enough of it so we'll play along.

So who's behind this racket?  Well judging by their website it's a bunch of super-cool dudes who only want to make the world a better place:

Love too have more ways to spend less...its The American Dream.  Because all of this is clearly pablum, let's see if either of these guys like to put their money where their mouth is.

I am pleasantly surprised that I couldn't find any Trump donations from these guys (although there could obviously be dark money floating around somewhere).  That said, Hillary Clinton's explicit promise during her 2016 campaign was to keep the fundamentals of our current healthcare system (that enables companies like GoodRx to exist) in place.  With regards to prescription meds, small incremental improvements were all that was offered.  From here:

Clinton released her affordable healthcare and prescription drug platform on September 23, 2015. Under her plan, a patient could visit a doctor three times without it counting toward their annual deductible and families ineligible for Medicare could receive up to a $5,000 tax credit for out-of-pocket healthcare expenses. She also said that she would impose a $250 monthly cap on prescription drugs for patients with chronic or serious health conditions. Additionally, her plan would legalize prescription drug imports from Canada. "If the medicine you need costs less in Canada, you should be able to buy it from Canada — or any other country that meets our safety standards,” she said.

Tax credits!  Imports from Canada, the financial benefits of which will probably be captured by intermediaries!  And if you qualify (who knows what that process would be like), you get the privilege of paying only $3,000 a year for your meds!

Oh here's something else about Trevor Bezdek while we're here:

I get an illusory $40 discount on my pills and he gets a mansion.  Cool.

One thing I want to stress is that absolutely no one should pity me.  My condition is mild and I have both the wherewithal and the money to get my medication.  You should have no feelings towards my personal story other than a mild sense of exasperation.

But the other, more important thing I want to stress is that is all so, so, so stupid.  If a person with my good fortune has to go through all this just to buy pills how is any of this working for anyone?  And imagine if I didn't have any insurance at all.  Imagine if I didn't have the money to pay for my doctors and drugs.  Imagine if the pills cost more than $8.41 or even more than $50.  Imagine if I didn't have the time or ability to shop for the best deal.  Imagine if I needed different pills that don't have a couple good OTC equivalents.  Imagine if my condition were more serious, and I needed the pills to function and/or live.  Imagine how worse everything would be if just one, let alone many of these things was true.  And then remember that you don't actually have to imagine.

This is all so stupid.  It's time for it to end.