$1,000 Hepatitis Pill Shows Why Fixing Health Costs Is So Hard - <AUTHOR> http://www.nytimes.com/2014/08/03/upshot/is-a-1000-pill-really-too-much.html <comment><USER2> Hepatitis C is a nasty disease that primarily affects people on the fringe of society. Many of these people don't have money, they don't have insurance, they often aren't good at sticking to complex drug regimens. And yet a bunch of pharma companies put in big money to develop a cure - not a treatment that makes it manageable, a cure. These drugs are a bargain and we should all be amazed and thrilled that this has happened.

<comment><USER3> And this is why most companies would rather treat a disease then cure it.

It has been so long since a disease has been cured that the current american system isn't designed to handle it.

I have to say the European state sponsored medicare looks way superior from this point of view.

They are not worried about the high upfront cost since every citizen is paying taxes for that.

Plus they can drive prices down since if the government buys from you you make a lot of money if it doesn't you have to sell it a lot cheaper for regular people to buy it with their own money.

It's not perfect it's open to manipulation however it's better that anything a dynamic corporate sector could offer.

<comment><USER4> > They are not worried about the high upfront cost since every citizen is > paying taxes for that.

Not only that, but that they can look very clearly at cost vs benefit. With a citizen, who is unlikely to move anywhere else, you can look at lifetime care costs and reduced earning ability (at least in the average case), and say outright that it is sensible to pay $100,000 to save many times that on a lifetime of ineffective care and reduced potential. You can also look at the public health impacts - treating one patient might reduce the risk of wider infection in society, which can also be placed in the cost-benefit analysis.

This is more difficult with American states (because people move between them much more- the payment comes from one state, but the benefit is spread out), and more difficult for insurers (because they are subject to much greater short term pressures, and can't look at wider benefits).

From the article:

"If it is cost-effective from a societal standpoint, it is not necessarily going to be cost-effective from a health plan standpoint," said Dan Mendelson, chief executive of Avalere Health, a health care consulting company.

<comment><USER5> > This is more difficult with American states (because people move between > them much more- the payment comes from one state, but the benefit is spread > out)

Simple: make it federal. Scale it up until you get controlled borders.

<comment><USER6> Because the American Federal System handles health care AND borders so well. _rolls eyes_

As a healthy Veteran, I can say I'm glad I haven't had to dip into my benefits...

<comment><USER5> > rolls eyes

Instead of rolling your eyes, work on a solution ;-)

</comment></comment></comment></comment></comment></comment><comment><USER7> This sentence worries me:

> The United States health insurance system works better for costs that are > spread out and predictable.

So the insurance companies want to reduce their tail-event risk. It's almost like they should buy some insurance. And they can do exactly that--it's called reinsurance.

The entire point of insurance from an individual's perspective should be to cover unexpected costs. Big costs, not small ones we can pay out of pocket. But it seems that over time, people have come to rely on their employer- sponsored plans to protect them from routine expenses like dental cleanings, eyeglasses, etc. That's not insurance--that's paying a premium to a middleman to manage your bills for you.

Insurance ought to be designed specifically for this sort of treatment: expensive, unexpected, and important.

<comment> vertex-four > that's paying a premium to a middleman to manage your bills for you.

The thing is, under the current system, it's not even that; it's some sort of complex mixture of insurance and collective bargaining. The "insurance" companies pay decidedly less than the rate you'd be asked to pay if you got any of these treatments, checkups, or whatever else, yourself. Therefore, it's only logical that you get your insurance company to pay for you.

I've run over this a few times in my head, and there doesn't really seem to be a feasible way to split up companies between "usual" and "unusual" treatments - collective bargaining groups vs insurance - in a fair way, and definitely not one that works out cheaper.

</comment></comment><comment><USER8> To all those pulling out pitchforks and torches, how do they think these drugs get discovered and more importantly, proved safe and efficacious for a given human disease?

Do they have any idea how much it actually costs? Sure, the Shylocks in "management" are greedy for their pound of flesh (and which industry does not have those?), but there is a genuine cost to finding these chemical/biologic agents. The days of Alexander Fleming and Jonas Salk are long gone. Just as the days of one-off genius chemists/physicists/mathematicians/explorers now exist only in history books.

Original research & discovery, that is not of mere _academic interest_ , that yields actual usable products, that people can put _inside_ their bodies, is a non-trivial investment of manpower and resources that carries excruciating risk. This ain't some app you can write in your jammies, that can be MVPd by Tuesday and pitched to VCs over next Sunday's brunch.

As to the public funding of such endeavors, that is a subject for another post(s), requiring a larger keyboard than the one on my smartphone :P

<comment><USER9> Have you looked at the pricing structure offered under insurance, vs the pricing structure offered for the uninsured? Guess who's paying the $1000/pill? Guess who's not?

If they needed to charge everyone on the order of $1000/pill to recoup expenses, that would be one thing. That's not the issue, since they are offering it to most people (who do have insurance) at dramatically lower prices.

I know HNers are in love with market segmentation, but isn't there an ethical problem with using price to segment a market for treatment for serious medical problems based on who has insurance and who doesn't?

It's been a while since the first thread on this, but I'll just quote from the sovaldi website:

 _We believe that cost should not be a barrier to receiving treatment. That's why the makers of SOVALDI offer a co-pay coupon. If you are eligible, you may pay no more than $5 per co-pay._

 _The SOVALDI co-pay coupon program will cover the out-of-pocket costs of your SOVALDI prescriptions after you pay the first $5 per prescription fill, up to a maximum of 20% of the catalog price of a 12-week regimen of SOVALDI. The coupon can be applied to up to 6 fills_

So, if your health insurance pharmacy coverage were 80/20, instead of paying your end (20%) out of pocket, you'd pay $5 per fill. So you're paying very close to $0 per pill, instead of $1000. Well, ignoring your deductable, which might be significant, but the obamacare max is $6350, so that's an order of magnitude cost decrease for the Sovaldi prescription even if you have no other out of pocket healthcare costs that year.

The only remaining, meaningful question is: _how much are insurance companies paying Gilead per pill_?

<comment><USER10> I've said it before and I'll say it again, one of the opportunities "Obamacare" missed out on was capping the level of discount insurance companies can get relative to the uninsured (both from hospitals but also from drug companies).

Right now the typical discount falls between 50% and 90% depending on the treatment and agreements made. If "Obamacare" had capped insurance discounting to something like 35-40% (which is still perfectly reasonable) we would have seen uninsured patient's costs drop between 10% and 60%.

As it stands Hospitals and drug companies know that insurance will negotiate a discount so they just increase the cost to compensate. Instead of something costing 3K with a 0% discount, it is 4.8K with a 60% "discount." If discounting were scrapped altogether it would be a huge "win" for almost everyone (e.g. reduced management overhead at hospitals, uninsured patients, et al).

The only party who wins by the current discounting culture is the insurance companies as it acts as a giant "lock in." Even if you're wealthy and can afford your own treatment insurance still makes sense as you'll get a huge discount not otherwise available.

<comment><USER11> To take it further, would it be so bad to have a rule that hospitals have stick to their own openly set rate cards (no discounts or rebates etc)? This way the playing field is significantly leveled for people and companies. Hospitals can openly compete with each other but not in behind the scene deals.

</comment></comment></comment></comment><comment><USER12> Just fired up a throwaway to comment here. I've been taking this medication over the past 3 months and finished about a week ago. A test a month ago showed I was already cured. This drug is good. Really really good. Side effects were minimal in my case and absolutely worth it.

I only skimmed the article but knew what it was about right away just from the headline. With healthcare, my copay per month was originally 200. My employer gutted my health insurance midway through treatment and my 2nd and 3rd months were quoted to me at a 2000 a month. I spoke with the specialized pharmacy and told them I couldn't afford that. They got me approved for a program that brought my cost of the Sovaldi down to 5 a month. The secondary medication (Ribasphere) to go with it was a little more expensive, but I forget how much.

Either way, I would have gladly paid the 2000 a month for this cure. Cost wasn't even a factor to me. If it came down to having to take out an 80K loan for it, I would have. My health is more important and the peace of mind knowing I've been cured is indescribable.

I'm open to questions since I've been dealing with this over the past 6 months.

<comment><USER13> Was the program that helped you with your co-payment run by Gilead? Seems like they will cover all co-pays over $5/month.

[http://www.gilead.com/responsibility/us-patient- access/suppo...](http://www.gilead.com/responsibility/us-patient- access/support%20path%20for%20sovaldi)

<comment><USER12> I'm pretty sure it was. I didn't have to apply directly. My specialty pharmacy handled it for me.

<comment><USER14> [cue jingle]

</comment></comment></comment></comment><comment><USER15> Classic case of value-based pricing rather than cost-based pricing. From that perspective they've priced it quite competitively.

But when their costs to manufacture are small and the process by which they develop drugs is so byzantine and opaque it's easy to see how people could get outraged.

I wonder how long before someone gets the bright idea to claim eminent domain on drug (or other) patents for the sake of medicare. Pay the drug company back R&D, maybe 2x R&D and then let people start making generics.

I'm not sure it's a good idea because it might well reduce investment in new drugs (developing drugs is like VC, you fail a lot and occasionally hit it out of the park) and that would be a bummer. But I could see it happening.

<comment><USER16> This ignored the fact that the company which develops a successful drug is also developing drugs which will fail. That costs money too, and the successes have to cover the failures.

That said... pharma companies are pretty greedy entities. I know a certain ex- pharma rep closely and she's no fan of her former employers. I can dislike the greed, but I can't blame a company for trying to make a profit.

<comment><USER17> > I can't blame a company for trying to make a profit.

10% is a profit. 50% is a profit. Heck even 100% is an understandable profit. You can and should blame them for screwing humanity over and above what is reasonable.

<comment><USER18> No. What screws humanity over is a system where nobody is incentivized to producing new drugs. If it is so effin' easy, you do it. Go ahead. Raise the hundreds of millions of dollars and promise your investors "you know, we're only going to make twice your money back". Its not that simple. I'd rather have the option and have it be expensive as hell than not having the option at all.

<comment><USER19> Research doesn't have to be funded by investors looking for a profit. Lots of medical research is funded by governments and non-profit organisations. For some diseases that is where the vast majority of funding research comes from.

</comment></comment></comment></comment></comment><comment><USER20> If you treat rather than cure, in the case of a transmitted disease such as Hep-C, eventually you have no remaining market share since the disease is in essence eradicated.

In this light it makes sense that Sovaldi costs so much. Gilead needs to get back their research costs and make as much profit as possible while there is a market for their product. A lot of these profits are going back into their research costs for HIV; this is the next disease they are trying to cure.

Even with a genetic non transmittable disease, such as Type 1 diabetes (which I have), there is less profit to be made with a cure and so there is a need to charge more for the product.

Right now I have to pay monthly for 2 forms of insulin, needles, testing supplies, hormones, pain killers. Due to the long term circulatory, liver, and kidney problems that come with this I can look forward to increased costs from additional medications and treatments over time (think blood thinners, ace inhibitors, dialysis). On top of this there is all of the cost for recurring labs and other medical testing that I have to go through on average about once every 3 months.

So yeah; give me one big expensive cure and a healthier future to look forward to and I will take that any day over "managed treatment" and control programs that will still lead to poor life conditions for me in the long run.

<comment><USER21> Exactly. These guys have essentially cured a major _viral_ disease. If they are wallowing in cash because of it, that's fine with me. Even if my premiums go up 2%. If the public sector is not going to do the work, there needs to be incentive for private corporations to lay out the millions required to advance medicine. We can't have near-zero public funding and then get all pissy when miracle cures are expensive.

And this is very close to "miracle cure". I had Hep C when I was younger (blood transfusion) and I went on interferon and ribavirin, which was 6 months of daily (maybe twice daily, can't remember) shots. And I was told that there was still a very good chance that I would never be "cleared". And sure this is $1000 a pill, but that six months of shots was not cheap either. Probably at least half.

<comment><USER22> Congrats to them to for curing a major disease but some bits of the economics seem a bit odd - initial research cost about $14m paid partly by tax payers. Gilead spends "tens of millions" to put it through trials and then it gets sold, partly back to the same tax payers, for about $84k * 3 million = ~ $200bn.

( [http://www.bostonglobe.com/business/2014/05/31/costly-new- he...](http://www.bostonglobe.com/business/2014/05/31/costly-new-hepatitis- treatments-curing-patients-but-straining-health-care-system- finances/SmBE9NoUESxjfgphfqvXKL/story.html) )

<comment><USER20> Did you read that whole article, or just skim it?

The piece where I am assuming you got your numbers from...

"Federal grants and Pharmasset's research outlays on Sovaldi totaled more than $14 million, but Gilead spent tens of millions more to shepherd the drug through clinical trials."

That is only a tiny fraction of the cost invested by Gilead on this drug. If you read the whole article you would see that Gilead took a big risk and paid $11B to purchase Pharmasset before this drug had been approved so they could bring it to market. Their total cost is well over that by now.

Now add to this the fact that when a pharmaceutical company makes a new "wonder drug", the other big pharma companies get right to work on make workable variants so they can get a piece of that pie.

Take a look at GILD on Yahoo Finance sometime and you will notice they are remarkably flat lately despite great profit margins, P/E, etc... This is because investors are worried long term. A variant product could destroy the profitability; now add to that the government wants to get involved and start regulating the prices on this thing. PFFH

</comment></comment></comment></comment><comment><USER23> Just to throw something out there, maybe for important cures to diseases, the government should just pay a one time purchase of the patent and make it public domain (or something like that). I imagine the price of the patent would be extremely high, but it might be a simpler way of dealing with things than regulating the price. And given the direct and indirect costs of regulation (such as lobbying, counter-lobbying, etc.), it might be worthwhile.

<comment><USER13> You have a point. Pharmasset (where the drug was discovered) was bought by Gilead for $11B a couple years ago. The gov't could have been a bidder, purchased the company and sold the drug at cost. It certainly would have ended up much less expensive for them.

<comment><USER24> Well, any company could have done that. That's investing. The question is what effects it will have on the market if the government starts acting as an investor.

I'm sure the government's investment department would be visited by a lot of lobbyists, for example.

<comment><USER25> The government (via the FDA) approves drugs for use. The government being able to approve drugs and own drug companies (while still competing with the private sector) seems like a conflict of interest.

</comment></comment></comment></comment><comment><USER26> Did anyone else notice the last two paragraphs which basically said "oh by the way, competition is already here, so this is not a long term issue, and costs will rapidly decrease.". Which basically defeated the entire hand wringing nature of the article!

<comment><USER13> I'll be honest with you, the price of these drugs is not going to come down with competition. Rarely do drug companies ever compete on price. Usually, the only time you do is if you have an inferior drug.

If Medicaid/Medicare were smart, they'd put out a tender when the competition arrives. Go to both companies and say "We're will to buy enough drug to treat 1 million HCV patients, what can you do for us."

</comment></comment><comment><USER14> Available on NHS, though.

[http://www.ukmi.nhs.uk/applications/ndo/record_view_open.asp...](http://www.ukmi.nhs.uk/applications/ndo/record_view_open.asp?newDrugID=5502)

[http://www.pharmatimes.com/article/14-04-16/NHS_England_to_f...](http://www.pharmatimes.com/article/14-04-16/NHS_England_to_fund_hepatitis_C_drug_Sovaldi.aspx)

<comment><USER13> I think the reason why Gilead's drug is causing such an uproar is because it _is_ worth the money, yet governments are tired of healthcare costs always going up.

A short summary of the issue: In the past HCV had terrible treatments. You would have to take interferon (makes you feel like you have the flu) for 8-12 months. Plenty of patients took their chances on their disease not getting worse. Even if you stuck it out, the cure rate was maybe 50%. The total cost of therapy? Around $80K (for most patients, others were much more expensive).

Gilead comes out with a wonder drug Solvaldi (it truly is revolutionary). You still have to take interferon, but only for 12 weeks. If you do tough it out, there is a 90% chance you're cured. The price? A little more than than the $80K of the previous treatments.

Honestly, if you think about it, for a little more money, society is get a _much_ greater benefit. So what's the big deal?

Well, because this drug works so well and has much better side effects, all those HCV patients who before said "I'll wait and see if HCV gets worse" are now saying "cure me!". There are millions of HCV patients in the US, so if we tried to treat them all right now, it would bankrupt the system.

I can tell you exactly what will happen with Sovaldi and the newer drugs being launched later this year: governments and insurance companies will say "no, unless you are very sick, you're not getting this drug". It will still cost the same to cure everyone, but it'll just take longer.

Now, if you were Gilead, what would you do? Especially if competitors were coming? I know what I'd do, I'd go to Medicaid and Medicare and say "lets make a deal, I'll give you 50%, 60%, 70% off if you agree to let everyone get treated this year". The gov't would have to pay out a lot in one year, but they'd be getting a deal and Gilead would get their return.

<comment><USER27> Just a little correction: you don't have to take interferon with Sovaldi. A lot of doctors are off label prescribing both Sovaldi and Olysio together. Olysio was actually approved to treat HCV a few weeks prior to Sovaldi but wasn't quite as effective in trials. The bulk of the revenue Olysio is generating (which is still quite a lot) is coming from doctors prescribing it alongside Sovaldi. The cost for both together is about $150k but the cure rate goes up a little bit and there are virtually no side effects because the patient no longer has to take interferon.

<comment><USER13> You are correct! I think Sovaldi's label has with and without interferon, but standard treatment often includes it.

Later this fall Gilead and Abbvie will be launching all oral combinations, so interferon will pretty much be gone by end of 2014.

</comment></comment></comment></comment><comment><USER28> This article seems to single out an odd outlier. Sure there are super expensive drugs like these but on average major components of health care is not drugs but hospital and doctor's fees. My 1 hour visit to emergency room costs $2500 in which single injection was administered that was under $100. Rest of the charges were simply for "services" provided by hospital. I once calculated average hourly charge for doctors using other examples I was aware of and it came out to around $1000 for every hour per doctor spends with you plus $100 for each nurse for each hour they have to attend you. Price component for drugs on average is negligible in most ordinary treatments.

The problem with US health care is invisible for-profit conglomerates that controls and owns major health care facilities across the country. There ridiculous charges works because consumers don't care because they don't pay out of pocket majority of expense in lot of cases. So all these conglomerates have to do is to make sure laws allow them to charge 3X-4X fees like above to have amazing margins.

One way to solve this issue in US is to promote non-profits to operate health care facilities. This can be done by government subsidies and grants in the same way they are provided to universities and research community. There are 200 major cities in US. If we want to build 2 great non-profit hospitals in each cities, it would cost 2 X 200 X 0.5 = $200 billion even at the higher end. If we spread this out to 5 years, it's less than $50 billion per year - drop in the bucket for current health care bugets. These hospitals can then charge 2X-3X _lower_ amounts to drive the price down. Without introducing non- profit competition to for-profit organization we are in same situation where operating systems are controlled by one commercial company and there are no open source alternatives resulting in redicluously high prices and stagnated innovation.

</comment><comment><USER29> I have what some would consider strong opinions on health care.

\- First, all medical and pharmaceutical companies should be non-profit. Health care is a basic human right, not a privilege reserved for those who can cough up the sick prices for treatment.

\- The government should run all medical schools so doctors graduate without debt. You serve for 10 years as payment for the schooling. After this, you are free to pursue other goals.

\- Pharmaceutical companies should hold no patents, no trademarks. Companies should be merged so their collective brain trust can solve the world's medical woes. Non-profit company results. R&D payed for by taxpayer money.

I severely dislike for-profit business in general, but more so when medicine is concerned. Human beings always should trump profits. Always. Doctors should become doctors to solve problems, not enrich themselves.

Sadly, I have several medical conditions which need repair, but even with insurance, I cannot afford the co-pays, upfront deductible costs, and other sick for-profit BS I would need to meet in order for my insurance to kick in at 100%. I have seriously toyed with moving overseas simply for tax-payed health care.

I'm in IT (non-profit), make OK money, but I refuse to enrich the for-profit system. I simply do without, because it's sick when your insurance costs equal 1/3 of your paycheck.

</comment><comment><USER30> Socializing research for major diseases seams like a no-brainer to me since the end goal is so well-defined. It's not a question of "do you want the budget hepatitis vaccine or the deluxe hepatitis vaccine?", it's simply one vaccine. The demand is also well-defined: people will spend virtually anything to live a healthy life.

The polio vaccine was funded by federal money, which it allowed it to be reproduced freely.

<comment><USER31> Other than 'some people might not be so wealthy' I haven't heard any good arguments against a given country moving all pharma research over to a government agency. (Most arguments are emotional / political / historical / naively optimistic about the current situation.)

<comment><USER30> Also: information sharing. If private companies are competing for a hepatitis cure they're not sharing their advancements, which could inhibit the speed of discovery. That sounds like a public health issue to me.

</comment></comment></comment><comment><USER32> Drug Costs and High Prices - Here We Go Again:

[https://news.ycombinator.com/item?id=8129695](https://news.ycombinator.com/item?id=8129695)

</comment><comment><USER33> If this debate interests you and you want to learn more about it, you should get in touch with me. Check my profile for my email address; [http://contextmatters.com](http://contextmatters.com) is the company I work for and here was a post our analysts wrote about Sovaldi: [http://www.contextmatters.com/sticker-shock-in-drug- pricing-...](http://www.contextmatters.com/sticker-shock-in-drug-pricing-are- we-missing-the-bigger-picture/)

We're systematically collecting data on this exact conundrum - how much is a treatment that was, until recently, infinitely expensive worth? there's a whole lot of room for smart people to make a difference.

</comment><comment><USER34> I believe around 1/3 to 1/2 of all medical R&D in the US is paid for by the government; if we had an actual program in place to ensure the government kept a financial interest in these things (instead of just giving it away), we could choose to either lower prices or recoup funds, or some mixture of both.

This is nothing new; the railroads were built with massive federal subsidies and guarantees (making Ayn Rand's hard-on for railroads hilariously misguided). Especially the trans-contitental railroad which was seen as a massive risk and almost entirely funded by US federal government loan guarantees. The US Interstate highway system and the internet were funded initially by the government as well.

<comment><USER35> It is about a third. The US government is effective at funding early research but quite poor at funding development, and they ignore some valuable areas of research for reason of political optics. Development tends to be where almost all the expense is incurred. In practice, there is a hand-off between government and industry in the transition from research to development because it plays to their respective strengths. Most of the research done by the government, like all such early research, turns out to be medically worthless during development.

Looking at it like a startup, the expected annual return on biomedical R&D if you have a huge portfolio is something like 10% even with the unrecovered government investment. In other words, better than investing in an S&P index fund and worse than broadly investing in early stage tech. Without the early government investing at a loss, it might not even be worth the money of the private sector to follow on for the development compared to other things they could be investing their money in.

</comment></comment><comment><USER36> It seems to me that in certain industries profit motive doesn't mesh with the public good. Isn't there a need for a publicly funded pharmaceutical agency that develops drugs for the public good in an open source manner?

<comment><USER13> Where would the money come from?

Right now the NIH's budget is $30.1B. US pharmaceutical companies invest $48.5B in 2012. Note, that's only R&D expenditure, not all the capital costs (e.g. Pfizer spent $1B for a manufacturing unit in Ireland; the drug failed due to safety).

<comment><USER31> > Where would the money come from?

Same place it does now - the end user. But the money would cover research, development, trials, data mining, treatment, etc. It would not be used to mislead medical practitioners, patients, or government officials.

> Right now the NIH's budget is $30.1B. US pharmaceutical companies invest > $48.5B in 2012. Note, that's only R&D expenditure, not all the capital costs > ...

US-centric may not be the best way to come at a discussion about health costs (no disrespect - just it's not typical in the world stage, and you'd be hard pressed to find someone that considers it best practice).

How does that R&D component stack up against the industry's Sales and Marketing budget? (Hint - less than admirably.)

<comment><USER13> I think the US is a good example since _most_ pharmaceutical R&D is done in the US. Also, the NIH has a pretty beefy budget. For other countries, the cost of running their on pharma companies would be _much_ more burdensome.

To answer your first point, you're saying that the cost of R&D would still be born by the end-user (patient). What's the benefit then if it's not saving money?

If you think a gov't run company would not pull some of the same stuff the private ones do, I'd have you take a look at some of the corruption that goes on at public companies. A gov't run company might not be for-profit, but someone there has budgets and revenue numbers to meet. The motive to cut corners doesn't disappear when it's run by the gov't.

And why shouldn't a pharma company have a sales and marketing budget? Do you think your doctor has time to sit down and analyze all of the clinical trial data? Getting in front of a doctor and touting the benefits of your drug sounds like a good thing to me. Sure, some sales reps use slimy tactics, but overall educating physicians doesn't sound like a bad thing.

<comment><USER37> If it was not 'for-profit' and public. It could be shared more freely. Meaning you'd ideally have a global effort towards drug R&D. This would easily dwarf any number the current US pharmaceuticals invest, or the NIH budget. Advances would be shared and make the cost of an advance cheaper.

Also if it were open (globally) countries could be the checks and balances for each other.

And no, pharma don't need marketing. Marketing is always used to trick people into buying things, or to create brand awareness, it's never about the good of the recipient. Dr's could simply have a database where they look up drugs and supporting material (i.e pull information rather than push marketing).

<comment><USER38> Marketing is solely about tricking people into buying things? What about informing people of goods and services they might want but didn't know about?

<comment><USER39> > What about informing people of goods and services they might want but didn't > know about?

If marketing didn't exist, this need could easily be fulfilled by organizations acting on behalf of the buyers. Consumer buying guides and professional industry-specific journalists publishing reviews are examples.

<comment><USER38> Yeah, and we can replace capitalism with a more efficient centrally-planned economy. In theory.

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER40> > But in America's health care financing system, people tend to change > commercial insurance whenever they change jobs, lose Medicaid coverage when > financial circumstances change, or leave the commercial market altogether > when they become eligible for Medicare at age 65. That means one company > will be stuck footing the big bill, and another will probably reap the > benefits of a healthy liver 20 years later.

>"If it is cost-effective from a societal standpoint, it is not necessarily going to be cost-effective from a health plan standpoint,"

/sigh. Can we have a public option for health insurance already, please?

We have a pharma company not playing by the normal, "gentlemen's rules of the game" that backload costs. Instead, they've got a great cure and are going with the "fuck you, pay me" model. Which, fine, more power to them. I really have no trouble with it. However, unfortunately, it doesn't play well with our current racket of employer-based health insurance.

<comment><USER41> > Which, fine, more power to them.

Really? We as a society have the knowledge necessary to cure a person's illness and yet they go untreated.

In the absence of IP legal protection, this would be a non-issue.

<comment><USER42> The more you turn medical research into a noble endeavor with no chance of making money, the more you're going to drive brilliant people to Wall Street and Silicon Valley companies instead.

The company that developed this sold to Gilead for $11 billion (less than a WhatsApp) after 13 years. Why would Gilead even buy the company if they could copy the drug for free? And why spend 13 years building this company with no hope for an exit? Especially when drug development is incredibly risky. For every success like this, there are many companies that fold with nothing to show after burning eight or nine figures of capital.

<comment><USER43> Pharmasset lost a total of $325mm during those 13 years before their exit. Then Gilead spent an additional two years and an undisclosed sum bringing it to market.

</comment></comment></comment></comment><comment><USER44> This kind of thing is becoming increasingly common. The latest "wonder drug" for cystic fibrosis costs some crazy amount (like $300,000 annually) and I believe it works for about 5% of people with CF -- though, in this case, testing can determine beforehand if it will work for you because it basically works for people with specific alleles. Here is one of many articles on the topic: [http://www.independent.ie/lifestyle/health/cf-wonder-drug- ka...](http://www.independent.ie/lifestyle/health/cf-wonder-drug-kalydeco- sanctioned-after-deal-on-price-29026121.html)

Part of the problem is the mental models behind our concept of "health care." Everyone who is looking for a new drug (and I don't just mean researchers -- it is a broad cultural phenomenon and patients are equally guilty) or miracle cure tends to have their blinders on with regards to more effective but less splashy treatment modalities.

</comment><comment><USER45> I find it insane that the US created this monster of a health insurance system, forcing people to purchase their health insurance through their employer.

So far, this looks a major PITA for employees, because (correct me if I got this wrong) a new job with a new insurance policy meant that all (chronic) diseases you may have had in the past would not be covered by your new policy.

Now this time there is also a problem that affects the insurance companies - they might not profit from the cured liver (a cured client is a cheaper client), but they'll have to pay for the cure.

Seriously: NOBODY wants to switch insurance every five years. Why not get rid of this stupid requirement and allow people to shop for health insurance on a free market? Your health and your insurance is nobody's business, especially not your employer's.

<comment><USER46> I think that employer based health insurance is the real problem of the US system. It sets up all incentives the wrong way.

</comment></comment><comment><USER47> Something smells here... The drug is taken in a short period of time, and cures the disease, thus killing the existing business model of selling treatment for a very prolonged period of time. Since this means lost revenue from the old treatment, the new drug, the cure, gets priced high enough to somewhat compensate? or, (economics - as exact as spitting into the wind) priced just high enough to still be cheaper than the old, long term option, regardless of costs of development (which are presumably lower)?

<comment><USER48> because tinfoil hats aside, these companies are in it to make money by saving the lives of people. Living people buy other products these companies sell to maintain their lifestyles. one eventuality is having drugs that you want to take because they extend the youthful and productive period of you life.

plus all these new cures and treatments further along their knowledge and ability which means the process continues and eventually they can chip away at the big problems in medicine.

and lets be honest, there are people working their both in the labs and the executive level who want to feel they did good and some want the recognition.

this story [https://news.ycombinator.com/item?id=8131808](https://news.ycombinator.com/item?id=8131808) gives me hope that nothing is beyond their eventual reach

</comment></comment><comment><USER49> Disregarding the price issue, one of my main takeaways from this is that it is another issue that completely wouldn't exist if we had a single payer system.

They said that the cost of treatment isn't really that out of line with other treatments insurance covers. The issue is that the payment is completely front loaded. Because of this, combined with the frequent changes of insurance in the U.S., you end up with one insurance company footing a giant bill for a customer who may end up switching providers in a year.

</comment><comment><USER50> The problem with completely free health care is that there's no incentive to be healthy. In other words if you smoke etc it has no negative impact to you financially. So there has to be some kind of balances to check for things like this. This drug is a very bad example but a lot of the arguments are for free health care and research, and this is one of the big issues with that...

<comment><USER51> Just out of curiosity, how old are you? I'm not trying to be confrontational -- I'm genuinely curious, because you sound like someone who hasn't had anything worse than a flu so far.

Here's an incentive to be healthy: medicine is not magic. It's not like I can opt to do all sorts of unhealthy stuff and just keep paying a certain sum to live a completely normal life.

For example, you mention smoking. I smoked for 5 years, one pack a day on the average. After a while, I was coughing my self to sleep at night. There's no pill or treatment that will fix that magically and allow you to keep smoking. Only quitting made it go away.

</comment></comment><comment> steve-howard Apologies in advance for the off topic, but what the hell is with that web site? I double-click a term on the page to highlight it for a search and it changes the font size. I move my mouse to the left because that's where I put my tabs and a menu pops out. They're trying to be clever but it's just incredibly frustrating.

</comment><comment> guard-of-terra 3.1 million ill?

I guess that US should just buy a billion pills with huge discount and then distribute those as they please.

</comment><comment><USER52> It is almost like using artificial IP rights to prop up supermassive R&D and then letting the company charge whatever they want for "their idea" is not the most sane business model.

<comment><USER13> They certainly don't "charge what they want". There are multiple examples (particularly in the EU) where the government says "no, we're not going to pay for that".

If you have a better idea on how to reward pharmaceutical R&D, I'm all ears.

</comment></comment><comment><USER53> I think it is things like this that get some people wondering about the prices.

US: 3.2 million people with Hepatitis C. Price $1000/pill.

Egypt: 12 million people with Hepatitis C. Price $10/pill.

<comment><USER13> This is what I don't get.

Drug companies get shit on when they charge a high price in developing countries. When they create a program that offers drugs at prices that are much more affordable, they get shit on as well.

I see the difference in price as a good thing.

<comment><USER54> They also get shit on for creating treatments for diseases that you have to pay for for the rest of your life.

Then they come up with a cure that you only need to take for a short time, works for most patients and has few side effects, and they get shit on again.

Best to keep coming up with $xxx/year therapies that you have to take for the rest of your life and only benefit a few percent of people that take them. (Statins for primary prevention, I'm looking at you).

</comment></comment></comment><comment><USER55> I was kind of hoping for an article that did an actual analysis of why the pill was priced at $1,000. R&D, Regulatory Risk, Cost of manufacture that sort of thing.

I was disappointed.

</comment><comment><USER56> I often wonder if people even read the articles. Yes this drug expensive upfront. Why is it expensive? Unknown. Does its development process justify its expense? Unknown. Is this drug a potential cure versus a lifetime of (more expensive) maintenance treatment? Likely. Are there competitors coming to market soon (as someone else mentioned)? Most likely

Edit: Larger costs spread over the long term are more palatable than lesser costs compressed into a shorter term. Humans are bad at estimating scale.

</comment><comment><USER57> The cycle of greed keeps healthcare prices high.

<comment><USER58> "The cycle of greed" also created a drug to cure a chronic disease, keep that in mind.

<comment><USER36> The cycle of greed wasn't needed to develop the polio vaccine. This was publicly funded, historically more advances in medicine are made by people interested in science and the public good rather than corporate profit.

<comment><USER59> The polio vaccine was fairly easy to discover. Give someone a weakened or dead version of the polio virus, and they develop antibodies, and they don't get sick when exposed to the full virus.

We are past the age when one guy running a small lab can just decide to cure something. It's going to take lots of money and lots of researchers and lots of false leads to find each new thing, and even after that there are going to be lots and lots of tests.

</comment></comment></comment></comment><comment><USER60> Drug companies don't want us well, they want us as a life-long customer.

<comment><USER61> How is that relevant to an article about a short course of treatment that cures people of a life long disease?

</comment></comment><comment><USER62> No, it's not hard at all. You imprison the people making it cost that much for corruption.

They are entitled to profit if you want to argue for that, they are not entitled to destroying society.

$80,000 for hepatits cure is only the start if you let them get away with this.

<comment><USER13> Wait a second! The older therapies, which people happily paid $80K for (but only cured 50%) of the people were OK, but now this company creates a drug that cures 90%+ and it's corruption? I don't understand.

<comment><USER63> And if this is such a good idea, why shouldn't it have been done earlier? That would save us another tiresome discussion, for this drug would have never been developed.</comment></comment></comment>


Piracy raid: German police search homes - <AUTHOR> http://www.bbc.com/news/technology-29914753 <comment><USER2> You know for being "so upset about America's spying" on her, Merkel sure seems willing to want to fight America's war on piracy of American content.</comment>


George Saunders: what writers really do when they write - <AUTHOR> https://www.theguardian.com/books/2017/mar/04/what-writers-really-do-when-they-write <comment><USER2> It's interesting where he talks about having an imaginary meter on your forehead and moving the needle to (P)ositive or (N)egative. He explains this with a nice example:

> When I write, "Bob was an asshole," and then, feeling this perhaps somewhat > lacking in specificity, revise it to read, "Bob snapped impatiently at the > barista," then ask myself, seeking yet more specificity, why Bob might have > done that, and revise to, "Bob snapped impatiently at the young barista, who > reminded him of his dead wife," and then pause and add, "who he missed so > much, especially now, at Christmas," – I didn't make that series of changes > because I wanted the story to be more compassionate. I did it because I > wanted it to be less lame.

Chuck Palahniuk (author of Fight Club) suggests a similar exercise for writers [1].

> From this point forward – at least for the next half year – you may not use > "thought" verbs.

> You can't write: Kenny wondered if Monica didn't like him going out at > night…"

> Instead, you'll have to Un-pack that to something like: "The mornings after > Kenny had stayed out, beyond the last bus, until he'd had to bum a ride or > pay for a cab and got home to find Monica faking sleep, faking because she > never slept that quiet, those mornings, she'd only put her own cup of coffee > in the microwave. Never his."

Writing "Bob was an asshole" or "Kenny wondered if Monica didn't like him going out at night." is lazy writing and stops us from exploring the characters and getting to know them.

In the same post, Chuck says: "Thinking is abstract. Knowing and believing are intangible. Your story will always be stronger if you just show the physical actions and details of your characters and allow your reader to do the thinking and knowing. And loving and hating."

[1] [https://litreactor.com/essays/chuck-palahniuk/nuts-and- bolts...](https://litreactor.com/essays/chuck-palahniuk/nuts-and- bolts-%E2%80%9Cthought%E2%80%9D-verbs)

</comment><comment><USER3> This made me smile:

>Another reason you're crying: you've just realised that Tolstoy thought well of you – he believed that his own notions about life here on earth would be discernible to you, and would move you.

>Tolstoy imagined you generously, you rose to the occasion.

It reminds me of a line from intro of Björk's "Biophilia" app [0]:

      "Sound, harnessed by human beings, delivered with generosity and emotion, is what we call music."

It's one of the best definitions of music I've ever heard.

0: [https://www.youtube.com/watch?v=o8AELvVUFLw](https://www.youtube.com/watch?v=o8AELvVUFLw)

<comment><USER4> > "Music, when combined with a pleasurable idea, is poetry; music, without the > idea, is simply music; the idea, without the music, is prose, from its very > definitiveness." [1]

I like it more when we combine music and ideas ...

[1] [http://www.goodreads.com/quotes/473592-music-when- combined-w...](http://www.goodreads.com/quotes/473592-music-when-combined- with-a-pleasurable-idea-is-poetry-music)

</comment></comment><comment><USER5> In its own way this is quite a profound piece on writing.

I like the basic idea that you needn't know the goal of a piece of writing when you set out, but you learn to edit it.

Some people are going to try to connect that with the way startups iterate. Perhaps that is right, and iterating is a form of editing, but this doesn't illuminate the insight. The actual examples he gives serve to make the idea clearer.

</comment><comment><USER6> Cross-referencing a pair of HN discussions about writing:

 _How to Self-Publish a Novel in 2017_ [https://news.ycombinator.com/item?id=13743908](https://news.ycombinator.com/item?id=13743908) (Last week -- more about the tooling but some discussion of the writing process.)

 _How to Write a Novel_ [https://news.ycombinator.com/item?id=12208269](https://news.ycombinator.com/item?id=12208269) (~8 months ago)

</comment><comment><USER7> He's an amazing writer. Here's one of his short stories: [http://www.newyorker.com/magazine/2012/10/15/the-semplica- gi...](http://www.newyorker.com/magazine/2012/10/15/the-semplica-girl-diaries)

</comment><comment><USER8> tl;dr: it's like juggling, apparently. Also, this is actually a promotion piece for his new book.

<comment><USER9> for what it's worth this is the best, most resonant, description of the process that i've ever read (the whole article, not just the juggling bit)

and personally, i needed to be reminded that it's hard for other people too, that it doesn't just come out fully-formed as conventional wisdom might have you believing it should.</comment></comment>


Talkspace threatened to sue a security researcher over bug report - <AUTHOR> https://techcrunch.com/2020/03/09/talkspace-cease-desist/ <comment><USER2> Why do shitty companies behave shittily I wonder. Also I used talkspace. Really awful service.</comment>


Ask HN: What's the most useful skill you ever learned? - <AUTHOR> <comment><USER2> This is a very meta response, but the best skill I've ever learned is how to learn. Barbara Oakley's _Learning How To Learn_ class [0] was immensely helpful for understanding how brains work and how I could learn efficiently.

I made it through college with a combination of cramming and bad sleep habits, but focusing on spaced repetition, the diffuse/active modes, and sleep has made classes I've taken since feel like easy mode.

[0]: [https://www.coursera.org/learn/learning-how-to- learn](https://www.coursera.org/learn/learning-how-to-learn)

<comment><USER3> I did not care for that course. The production value was horrendous 2 years ago when I tried to take it. But this answer is 100% accurate

<comment><USER2> Ha, I know what you mean! I found the information extremely valuable, but I do agree that the production value leaves a lot to be desired. I'm not sure if you've read her book _A Mind For Numbers_ , but it has largely the same information (without nearly as many clipart zombies).

<comment><USER4> In a similar vein, one of the biggest lessons I've learned is that it's hard for people to get to the message if they can't get past the presentation.

And that a killer presentation can even get you trust from people that you shouldn't even be getting, bypassing what may otherwise have been great difficulty to earn their trust.

</comment></comment></comment></comment><comment><USER5> Active listening. I'm amazed at how much better discussions go when this simple tool is used. Conflicts big and small melt away. Understanding, trust, and confidence are built. And even if not everyone agrees at the end, they at least feel heard, which is such an overlooked and underrated need.

<comment><USER6> What resource did you learn this from?

<comment><USER7> One way I found helpful is to repeat or paraphrase what the other person had said in the conversation. At first I was surprised by how difficult this was. Then I realized it's because I was just hearing the words but not processing them. This also signifies to the other person that you are understanding and engaging in the conversation.

<comment><USER8> That's basically it. I find that it serves three functions: one is making the other person feel heard, two is making sure I actually understand what they're saying (misunderstandings are more common than I think!), and three is forcing me to put my own response on hold. That last bit is huge. I had no idea how reactive I was in conversation, and what a detriment it is to communication.

</comment></comment></comment></comment><comment><USER9> Sticking to commitments. That means showing up on time, delivering on what you promise. Also related is not making promises you can't keep.

<comment><USER10> I believe this one should be of high priority on the list of things that one should learn.

</comment></comment><comment><USER11> Touch typing. Took a course at Sawyer Business College during my psychiatry rotation in my 3rd year of med school.

</comment><comment><USER12> Transcendental meditation, and making it a daily habit. Changed my life.

</comment><comment><USER13> programming. and on more life broad approach the big 4's: "not my fucking problem" & "could not care less" & "don't give a shit" & "piss off, i'm busy'. These 4's made wonders to my health and family, now everybody leaves me alone with their stupidity and only approach me for serious stuff. I don't have time for crap or smalltalk, for that I already have my family.

</comment><comment><USER14> Public speaking

</comment><comment><USER15> To worry less.

</comment><comment><USER16> Reading. The second one is writing.

<comment><USER17> IDK, eating has served me quite well ;)

I think developing a love for reading is really important. I'm not a big reader, but I can usually finish 20+ books a year, half of which are beneficial beyond enjoyment.

</comment></comment><comment><USER18> Questioning first principles.

</comment><comment><USER19> Writing blog posts every week!

</comment><comment><USER20> Programming.</comment>


The Creative Apocalypse That Wasn't - <AUTHOR> http://www.nytimes.com/2015/08/23/magazine/the-creative-apocalypse-that-wasnt.html <comment><USER2> Good article. I think the voices that cried the loudest about this were people at the top of the food chain -- they are the ones getting cut out. In the music industry, what happened were bands just started self-producing albums once it became feasible to do so with a consumer PC. The bands ended up making more (which wasn't hard because record companies had been screwing them over for years) and suddenly had a publicity outlet other than radio. Most bands were more than happy to give their music away for free because they had been doing it for years anyway.

And I think we're starting to see the beginning of the "content crash" hitting TV as well. With the rise of cord cutting, the big TV networks are going to have a hard time justifying the prices they charge to cable providers. Cable video prices will have to come down significantly -- millennials are not willing to pay $30/mo AND have to watch ads when they can pay $8/mo for ad- free content from Netflix. People may be willing to spend $30/mo on video, but they're going to want that content to not be laden with ads.

<comment><USER3> Netflix has set the price for large quantity of video content way too low. They have successfully exploited the media industries price discrimination to get a ton of content for absurdly low prices. But now netflix is killing off the media companies it free rode on.

Normally I'd say that the price would move to account for it, but netflix has been pretty unable to move their prices without a huge amount of rage from consumers. I think it's similar to how the 99 cent app set the market psychology on mobile apps, Netflix's 8 dollars a month has sort of screwed the video on demand market.

I also believe Netflix knows this. That is why they are getting into original programming. But that is so much more expensive than buying second run tv shows. Especially since they created the binge watch trend.

Netflix spends a 150 million on a season of House of Cards and I watch it in a day and a half. Look at what HBO produces for 15 a month. It's high quality, but it's not a ton of a content.

I'm guessing that in 10 years netflix will have tiers and packages. You'll be able to buy an AMC package and a comedy central package, etc.

Re:30 a month

Cable pays about 30-50 dollar a month to channels for content depending on area and whats in a package. A pretty big chunk of that is sports. I bet you could buy all non sports from the channels for like 25 bucks a customer a month.

But typically channels get half their revenue from advertising.

I'm guessing 30/month is way to low. 50/month maybe?

<comment><USER2> It's not about what revenue level will sustain the existing players in the market; it's about what price consumers will be willing to accept. I don't think consumers will be willing to spend $30/mo on a single video service in 5 years. Maybe across multiple services, but the whole concept of channels is going away in favor of individual shows. The networks don't have the power anymore; the shows do.

I also bet that rather than go through Netflix, AMC et al will sell subscriptions directly to consumers. The value add from Netflix isn't that big; you could set up a very similar service on AWS and Akamai with very little investment since they already own the content rights. Much of the appeal of Netflix is in the simplicity; and I don't see them throwing that away (or consumers accepting it).

<comment><USER4> Having spent the last 8 years building a Netflix competitor, I think you overestimate the commoditization of VoD tech. You need a lot more than AWS + Akamai. The costs of those are too high for the types of margins a Netflix- like service has. Also, you need apps everywhere, and those apps have to be _good_. Even though it's getting a lot easier every day, it's still way outside the reach of any individual show, they're just not structurally set up to build and manage the tech side. HBO can do it because they are just barely big enough, but individual shows will never jump that canyon.

What's going to happen is not that shows replaces channels, but that _services_ become the new channels. Instead of having a few cable companies monopolizing the last mile, building and running all the distribution tech, and charging an arm and a leg for access, the new model is that there are no gatekeepers on distribution. But that is not to say distribution is a commodity or easy, in fact doing good distribution ala Netflix that cuts across devices, geography, and a long tail of content will become an essential value-add and it will be more competitive than it's ever been.

<comment><USER2> Having also spent the last decade or so building a similar service, the tech side is commoditized by at least a half dozen companies. The ingest workflow is still somewhat manual, and there's a lot of QA that has to go in to your metadata, but the tech side (transcoding, CDN delivery, etc) are commoditized -- especially if you're a network that already owns the rights to your content.

This is all headed towards a world where the big ISPs run CDN nodes and all the channels buy delivery from them not because they force them to, but because the big ISPs can run their CDNs with a lower cost base (they already have the interconnects and disk space is cheap). The gatekeepers will still exist because they own a market control point -- you didn't think it was going to be that easy, did you?

Apps are an issue, but they're not that cumbersome to create, even cross- platform. I was able to hack together a prototype iOS app that played back video from a CMS attached to a CDN reasonably well in about 4 hours -- and I'm not even a professional developer. For the long tail, there are always services like YouTube and Vimeo -- they're a better fit than a custom app anyway because you get access to a larger audience.

<comment><USER4> Your response is orthogonal to my main point—which is that services will be the new channels, and they will have much more power than they did under the cable regime.

The mega-services at Netflix/Hulu scale will definitely by CDN capacity direct from ISPs, but that in no way means that these ISPs are gatekeepers with anything near the power that is crumbling from the grasp of the cable companies today. That would only be the case if the ISPs defeat net neutrality and become as evil as possible about restricting outside content to reach their users, and frankly if they twirl their mustache that hard consumers will revolt and regulation will come down on them like a ton of bricks.

</comment></comment></comment></comment></comment></comment><comment><USER5> > As a society, what we most want to ensure is that the artists can prosper — > not the record labels or studios or publishing conglomerates, but the > writers, musicians, directors and actors themselves.

I'd think that as a society what we most want to ensure is that _art_ prospers. If that means prospering artists, great. But the goal for society is not wealthy artists but a wealth of art.

<comment><USER6> There is already more art than can be consumed in a lifetime. I think at this point, some people really do buy art to support high status artists.

</comment></comment><comment><USER7> I'd like to know more about how ticketmaster has affected the world of live music. Its such a bizarre market of scalping and reselling. You have entire companies now dedicated to the act of scalping, like stubhub, where the artist doesn't see a dime of the transactions. The article points out that the revenue generated by ticket sales is greater than it once was, but it still hasn't eclipsed the amount once made from album sales. I have to wonder if the "ticket industry" has something to do with that, but of course its like comparing apples to oranges.

<comment><USER8> Well, the artist sees some of the original ticket sold. And places like StubHub may increase the total number of tickets sold (or may not, I have no actual data).

> The article points out that the revenue generated by ticket sales is greater > than it once was, but it still hasn't eclipsed the amount once made from > album sales.

That's revenue, though. How much did the _artist_ see from album sales? In most cases, not much, given the way the game was rigged to favor the labels. The artists saw a much bigger slice of the ticket sales.

</comment></comment><comment><USER9> I'd like to see more discussion, numbers and focus on the 'margin' \- those people who are on the edge of being able to work full time on their art/music/whatever. That's where gains or losses will be, not with bands that can sell out stadiums.

</comment><comment><USER10> A well researched article, I love it when people write/speak and have the data to back up their positions.

As far as $30 a month goes for content, my Comcast bill sans internet is about $45 (I split the taxes in 1/2). I'm about to cut the TV part out, I can get all the shows we watch other ways for about $25 a month.

I also pay for some of the online content, I have enough value for the NY Times that I pay to get past their paywall (I'm trading down Starbucks $$$ coffee for a better information flow)

Another poster asked about Ticketmaster / Stubhub / etc. I've given up on major venue's, I can't afford the $100+ seats to be next to a drunk yelling "California!!" (Yes, looking at you G131 at the last Brian Wilson concert) We will go to smaller places where the ticket price isn't so bad.

One of the points in the article that's very true for me is that I have a big music library of new music that's not from the traditional mainstream publishers. I'm always picking up new stuff that I get leads on. (Which reminds me there was someone here that said they had a new album out and I got it, so that direct to consumer model works).

Things change due to technology. Buggy whips are mostly gone at this point and there isn't anyone lobbying congress about bringing them back.

</comment><comment><USER11> Interesting read, but there's one fairly major shift the author missed: the transition away from long-form printed books into bite-sized, often free/ad- supported online content.

In the charge-by-the-piece print publishing world, the economics don't work for anything smaller than a hundred pages or so, which means you need to get a single author to write a lot (= a book) or compile together a bunch of stuff from different authors (= magazines, anthologies, etc). We take this as granted, but a hundred years ago smaller works were still common: Marx's _Communist Manifesto_ was a 30-page pamphlet.

In the online world, this is no longer a concern. Much of my print reading has been replaced by following blogs, many of them on "serious" topics, where even the longest post is rarely longer than a single book chapter. And whereas it was previously quite difficult for an unknown to get accepted into a magazine, much less a book, it's now an everyday occurrence for an aggregator like HN to pick up a piece and get tens of thousands of readers for it. This parallels what we're seeing in music and film: the barrier to entry has been drastically lowered, but the effort/skill/luck needed to make money off it has gone up to compensate.

</comment><comment><USER12> I think the same trends are playing out with game development. As development and distribution have gotten easier the winners are winning more. It reminds me a bit of Sam Altman's "Upside Risk":

      > It's common to make more money from your single best angel investment than all the rest put together.

Applies to games as well as start ups.

<comment><USER13> Book publishers and movie studios have been operating off of this model for decades. Probably others as well.

</comment></comment><comment><USER14> Nothing will ever be more bewildering than the people who get all sanctimonious that some rando can no longer get rich turning his blues scale riff into a 7 year marketing cicada.

People who actually care about music and can do something unique with it are currently taking advantage of the internet's costless promotional channels, getting famous, and making a perfectly good living off of youtube views if nothing else.

The real issue is that these promotional channels exist and the entrenched players don't control them, so they can't fabricate a superstar out of regurgitated shitmusic anymore. Cry me a river, mainstream media. Cry me a river, narcissistic "band" who aspires to be millionaires.

<comment><USER15> > People who actually care about music and can do something unique with it are > currently taking advantage of the internet's costless promotional channels, > getting famous, and making a perfectly good living off of youtube views if > nothing else.

Hogwash. Every heard of Mike Keneally? Exactly. He fits your description to a T.

Except that you _have_ heard of him. He plays for this guy: [http://www.satriani.com/splash/](http://www.satriani.com/splash/)

Oh, and he happens to play guitar in this band: [https://en.wikipedia.org/wiki/Dethklok](https://en.wikipedia.org/wiki/Dethklok)

Now, if _that_ guy can't make it work, I doubt anybody can.

<comment><USER16> It would be far more informative if you could tell us why he isn't making it work? Is he not making a living playing music?

Regardless, music is the ultimate free market. Regardless of how talented you are, if you don't make something that people will vote with their money to see, you won't make any money. This hasn't changed for 50 years and has absolutely nothing to do with the fall of record sales. 30 years ago talented musicians were still being ignored because their genre wasn't fashionable.

Do you really doubt that anyone can make it work as a professional musician? Really? Because I don't work anywhere near the music industry and I know a handful of professional musicians. Sure, there's far more people who play instruments and can't make it work professionally, but that's always been the case.

</comment></comment></comment><comment><USER17> Worth noting article is by Steven Johnson, author most recently of How We Got to Now. Bonus points for Walter Benjamin reference in the lead.

<comment><USER18> How We Got to Now is excellent! Quick and fascinating read. Especailly loved the story about Ada Lovelace at the end - waaay ahead of her times.

<comment><USER19> Was my favorite part as well. Surprisingly fun read.

</comment></comment></comment><comment><USER20> Someone said in the comments that "the voices that cried the loudest about this were people at the top of the food chain".

In reality I think those were just the voices that were heard more. Because obviously being at the top of the food chain gives them more visibility. Plenty of small-scale artists cried too, but nobody heard them or cared for.

Regardless of what people NOT in the music business will say, the thing, from all I've been able to gather, goes like this:

1) Album sales ―which before mp3s used to be a decent way for a small scale independent artist to make a living (shifting even 50.000 units was enough to live on as an independent artist in the eighties and early nineties)― have dried up.

Top acts sell this myth in their interviews that if you weren't in the charts, or you barely made spot number 46 for example you might as well not exist. That, in IT terms, is like saying that 37 Signals is not a "real company" and only Google and Facebook are. Just because they were used to limos and champagne release parties doesn't mean the thousands of artists outside top-100 didn't make a living and create their art.

So, yeah, there WAS a huge, booming scene outside the "Billboard Top 100" (not to mention the UK and regional European scenes, and obviously elsewhere in the developed world), and those musicians could make a decent living too.

Mp3 and streaming have killed that for the most part (the "decent living", not the scene part).

1.2) A small aside regarding this:

You'll hear musicians tell horror stories about how the company took all their profits, and even charged them for recording costs, held their advance etc (e.g. the classic rant by Steve Albini). That was something that mostly happened to first-time stars and star-struck kids.

Musicians with some experience in the game, independent lower-volume selling acts etc, could always go to an independent label, have better contracts and a personal experience, etc. And of course those independent musicians also didn't need 1.5 year in the studio to make an album, blowing most of their time (and advance money) on hookers and coke.

2) In the early days of mp3 (and still today) you heard people saying "piracy hasn't harmed album sales, I buy more music now, since I can hear more stuff before I decide what to buy" etc.

Those people were either outliers or telling BS — the declining numbers of both CD and digital sales all this time disprove their claims.

3) There's another suggestion often heard to "make money from playing live".

First, for smaller bands (that weren't the Rolling Stones or the Grateful Dead), live shows were a loss leader for album sales — and it's not much better now. In fact, in most of the world, people — when adjusted for growing up — go to fewer live shows that they used to.

Second, while this might work for some, it's a very american thing to assume that musicians exist to "play live". In Europe there were lots of electronic musicians (not DJ/EDM style) having decent album sales that never cared for playing live.

There's also the issue that a musician with 30.000 fans buying their albums around the world, might not have the required number of fans in any single town (apart from his hometown or some mega-city like NY) to hold concerts. And with the 30.000 fans becoming 2.000 people still buying his CD (and 28.000 just downloading it of somewhere) the artist is now screwed.

Then there's the inane "sell merchandise" "solution", as if a musician is just some merchant, and if one thing (selling music) doesn't work, he'll just pivot to selling some other stuff.

Not to mention that all those ideas are based on very US-centric perception, where all music that matters contains guitars and plays live, and all musicians are selling to 13 to 25 year old kids (because those are the primarily buyers of BS band merchandise — not 40 or 50 year old jazz, blues, electronica etc fans).

4) Streaming just made all of this worse.

5) I'm not saying we can go back in time. Or that we have some duty to provide musicians with a living if their business model doesn't work.

I'm Just stating this, to recap: independent musicians that used to do well income-wise in the album days, are fucked up in the digital/streaming/piracy days.

That doesn't stop them making music (especially since you can now create something from your home studio that used to take thousands upon thousands in studio time and you can release on your own on the internet), but it does stop them making a career in music, in the way musicians in the 70s, 80s and 90s used to.

<comment><USER21> I don't think the problem is piracy. I think the "problem" stems from the huge amount of good quality cheap content we have available.

I have around 1 hour of free time each weekday to spend on entertainment.

I have so many cheap sources of content, costing well under $1/hr, vying for my time. All available on demand.

Content decays very slowly. A good show from the 90's is still worth watching today. Good music from the 80's and 90's is still worth listening to today.

I just spent the last 3 months of my small amount of free time re-watching Friends. For the 2 months before that it was playing dota and watching starcraft2 videos on youtube.

<comment><USER20> That's part of it -- music today competes with YouTube, the internet, games, social media, mobile, tv series, 100+ channels, etc. Most teenagers -- the de facto pop music consumers -- don't care for music the way teenagers in decades without all these did, when a new album was a window to another world.

But music sales have started declining even before all those become prevalent -- youtube, social media, mobile, all either began or become popular circa 2005. In 1997-2005, it was mostly the "free" downloads that did music sales in.

Now it's a combination of these and of all the other stuff competing for people's attention and winning it.</comment></comment></comment>


New Study Adds to Skepticism Among Experts That North Korea Was Behind Sony Hack - <AUTHOR> http://bits.blogs.nytimes.com/2014/12/24/new-study-adds-to-skepticism-among-security-experts-that-north-korea-was-behind-sony-hack/?ref=technology&_r=0 <comment><USER3> Sony just had a major layoff,pointing to a possible insider.[1] Many Koreans work for Sony and they may have had a personal gripe with NK."Guardians of Peace" comes from a quote used by former President Richard Nixon describing South Korea.[2] In this debate[3], the security expert on the side of the FBI keeps rehashing the old it's the same IP address debate. But I don't buy it. Those are open proxies.

Combine that with the fact that North Korea has a terrible education system and an entimated 1 in 10,000 people have access to the Internet in North Korea. This is not the kind of environment that fosters elite super hackers. I don't think NK did it.

[1] [http://www.polygon.com/2014/9/18/6377971/sony-financial- resu...](http://www.polygon.com/2014/9/18/6377971/sony-financial-results- mobile-2014)

[2] [http://www.thedailybeast.com/articles/2014/12/20/sony- hacker...](http://www.thedailybeast.com/articles/2014/12/20/sony-hackers- guardians-of-peace-troll-fbi-fbi-is-the-best-in-the-world.html)

[3] [https://www.youtube.com/watch?v=vNCpHM4BBJQ](https://www.youtube.com/watch?v=vNCpHM4BBJQ)

<comment><USER4> > Combine that with the fact that North Korea has a terrible education system > and an entimated 1 in 10,000 people have access to the Internet in North > Korea. This is not the kind of environment that fosters elite super hackers. > I don't think NK did it.

Business Insider spoke to a defector about the DPRK's cyberwarface program[1]. Even if they can't develop hackers organically, they can build a small cadre by selecting some people who might be talented, hiring outside experts to train them and giving their trainee hackers certain privileges. An analogy might be that in the US, we build our olympic teams organically - <USER2> choose what they want to do based on personal interest and it's a good environment in which to grow as an athlete. North Korea has a terrible environment to develop athletes organically, but they can hire outside experts to train a small cadre of their own people. They win a few gold medals every summer Olympics.

[http://www.businessinsider.com/north-korean-defector-jang- se...](http://www.businessinsider.com/north-korean-defector-jang-se-yul- trained-with-hackers-2014-12)

<comment><USER5> The only problem being that no outside expert with the right skillset would _ever_ travel to North Korea, and them doing so would be highly suspect.

Even if NK wanted to build such a team, the reality of nation-states is that you can't make up for the complete failure of your society with _just_ money alone. The degree to which the Soviet Union turned out to be behind the US during the Cold War speaks to that - and NK is _a lot_ worse off then the Soviet Union.

<comment><USER6> You can build the skillset without having anybody teach you in person.

NK is a lot worse than the Soviet but NK still managed to develop nukes and cobble together a midrange ballistic missile, something no teenage hackers in a basement can manage. You shouldn't underestimate NK. Just the fact they have survived as long as it has shows it means something.

<comment><USER7> The Copenhagen Suborbitals are a group of "teenage hackers in a basement" who have cobbled together a midrange ballistic missile, although without any intention of using it as a weapon. The main thing preventing other teenage hackers from doing this is violence — either the police come and arrest you, or your neighbors steal your things, or your neighbors get pissed off about the amount of nitrogen oxides you're wafting over their house and coerce you to stop.

<comment><USER6> True. But the focus is NK is capable of putting up ballistic missiles and naturally they are capable of cobbling some malware tools to hack into sony. Especially into sony.

</comment></comment></comment></comment></comment></comment><comment><USER8> Potentially interestingly, a guy from Norse security figures:

>data is pointing towards a woman who calls herself "Lena" [...] someone who worked at Sony in Los Angeles for ten years until leaving the company this past May.

So we may actually get a proper answer as to who did it. Maybe.

[http://www.cbsnews.com/news/did-the-fbi-get-it-wrong-on- nort...](http://www.cbsnews.com/news/did-the-fbi-get-it-wrong-on-north-korea/)

<comment><USER9> > It's worth noting that the original demand of the hackers was for money from > Sony in exchange for not releasing embarrassing information. There was no > mention of the movie "The Interview"

That alone really pokes a hole in the official narrative.

<comment><USER10> This isn't really true.

[http://regmedia.co.uk/2014/12/08/sony_hack.jpg](http://regmedia.co.uk/2014/12/08/sony_hack.jpg)

[http://cdn.arstechnica.net/wp- content/uploads/2014/11/sonypi...](http://cdn.arstechnica.net/wp- content/uploads/2014/11/sonypictureshack-640x1136.jpg)

These are the two original defaces on Sony's computer systems. Neither mention money, just vague "obey our demands or we will expose all your data". The first one explicitly mentions a "great effort to peace of the world", in line with the name "Guardians of Peace".

Why would a disgruntled insider make something up about world peace if they just wanted money?

Not saying that means it's necessarily North Korea, but I'm pretty sure the actors either had The Interview as a real motive, or used the movie as a pretext, from day 1.

<comment><USER11> > Why would a disgruntled insider make something up about world peace if they > just wanted money?

Why would someone extorting a company attempt to be deceptive? We're really asking that question?

<comment><USER10> I'm not disputing that, really. I'm disputing this:

>It's worth noting that the original demand of the hackers was for money from Sony in exchange for not releasing embarrassing information. There was no mention of the movie "The Interview"

It very well could be an extortionist, but I think they clearly intended to give the impression that it was allegedly about The Interview, first subtly then explicitly. No public message, or leaked private message, was ever released that showed the hackers asking for money. It is possible they sent a private demand for money to Sony which has yet to be released, but that would just be speculation.

Their group name, constant requests to "preserve world peace", releasing all sorts of movies and scripts except anything relating to The Interview, and then explicitly calling The Interview a "movie of terrorism" seems to show that they intended to use the movie as a bargaining chip from day 1.

</comment></comment></comment></comment></comment><comment><USER12> I doubt anyone seriously believes NK could have manufactured the malware that was used.

...but it's plausible they may have paid other people to do it; or at least seed funded some third party (eg. russian hackers).

To be fair to the NSA; they're not retards.

Evil... maybe. But stupid? I don't think so.

If they (via the FBI) say it was NK, they probably have _something_ to back that up (eg. intercepted communications or money trail that leads back to the NK).

Interesting point drops out of it though; I'd say it's pretty obvious the NK were never _in control_ of the data or malware. If they paid for it, are they still to blame? Or are the people who actually did the hack to blame...?

<comment><USER6> I doubt many 'hackers' manufacture the malware themselves these days. Many buy/copy from others.

And we keep saying NK doesn't have enough capable human talent but they developed nukes and launched a mid range ballistic missile. Surely they can lock up some men in a building and teach how to run malwares?

IF NK paid for it, they are responsible still.

</comment></comment><comment><USER13> > Post-Watergate, post-Snowden

The only times the state has been caught lying!

</comment><comment><USER14> So is the US government lying, or incompetent?

<comment><USER15> I'll go with lying. Blaming NK serves their political agenda for now. It's still not outside the bounds of reason to believe Sony Pictures did it themselves.

<comment><USER4> It really doesn't make any sense to me that blaming North Korea serves a political agenda for the administration. They have a limited time left in office and they're trying to use it to accomplish something in foreign policy (so far, Cuba, a climate deal with China). This is particularly important since the President's domestic influence will be limited. This business with North Korea seems like a distraction. It's not serious enough that it's going to change anything in the relationship between the US and the DPRK. The DPRK is so unpredictable that starting a beef with them unnecessarily seems like a terrible idea. It's another item on the agenda with China, and I'm sure that there are a lot of other things that we would rather be discussing with the Chinese.

<comment><USER16> Whether NK is behind this hack or not, you cannot deny that the president's statement is a show of force. It is a clear message to any country that plans to use 'cyberwarfare' against the United States - we will retaliate proportionally.

<comment><USER17> The clear message the USA appears to be broadcasting by reacting swiftly on what appears to be very dubious information is that it is now providing the facility for trolls to SWAT entire countries, rather than just someone who had pissed them off on Counterstrike. I do not think this makes the world safer.

<comment><USER16> Agreed. I find this aspect worrying and underreported.

</comment></comment></comment></comment></comment></comment><comment><USER18> Here's an idea for the government:

Detonate a nuclear device somewhere isolated where you already detonate nuclear stuff for fun. However, this time say that it wasn't planned at all.

Proceed to fabricate a story where the nuclear warheads were connected to the internet but with extremely high security measures. Why? Because, who knows, maybe the president is someday in the middle of a world crisis and the only way to launch nuclear retaliation is through some internet channel. Then proceed to say that North Korea and his world-class elite terrorist hackers (with the help of some insider scapegoat that you can take from jail) managed to HACK (it is important that you use this term) into the system and launch the nuclear device; fortunately they were programmed to strike on desolated terrain, god bless us all :'). Clearly, this is a direct attack towards american ground and it's people; without a doubt, a formal declaration of war. #KIMISBAD, #STOPNK2015, etc... ensues. Invade the country then, with the public's approval. And finally accomplish your goal: a military base in the outskirts of China.

<comment><USER19> Not to mention the higher approval ratings for NSA et al.</comment></comment>


Are you looking for a co-founder? But why do you expect a stranger to take risks with his/her career, make personal sacrifices, and be passionate about *your* idea before funding? - <AUTHOR>

<comment><USER2> First of all ideas change but people don't. Finding a cofounder is more a meeting of minds and interests - the ideas one has and are passionate about can be modified accordingly.

Every entrepreneur isn't short of ideas - but every entrepreneur in his/her social circle is a maverick of one sort or another. SO if the local concentration of mavericks isn't high it makes things difficult. Finding a cofounder is pretty hard and only something that can be done by finding someone you agree with - then trying out the relationship over a project.

I met my cofounder accidently - last year i had an idea and approached a couple of people cold and just tried doing a project. One of the guys i met i seemed to work with amazingly well. We sparked ideas, started creating other side projects, had complementary skills, believed in beautiful design and how simple ideas could really impact the world and above all we had the same positive attitude and stamina to make things happen (we both have great stamina and a get things done attitude). Our ideas have changed from the original one. A year later we've worked on so many things - but most importantly we can depend on eachother to make things happen.

Bottom line, cofounders pop up in unexpected places. Be open, talk to people you know, friends, their friends - see if anyone sparks. Its a hard road until then - but trial people out - get them involved in your project. Hidden mavericks do exist in local environments and passion is infectious.

<comment><AUTHOR> Change every occurence of 'cofounder' in your para to 'spouse'. What do you see? :)

</comment></comment><comment><USER3> First important question is ---Do you really need a cofounder?---

I am founding this company http://www.onista.com (A Social Marketplace) and so far I am doing it all by myself. Didn't have any issues yet and I am very well on the course to launch it in Summer. It is true that it is taking me little longer time than what I could have done with one cofounder.

But again, why should I expect a stranger to take risks with his/her career, make sacrifices and be passionate about my idea. After launching http://www.onista.com if people like it, then I am sure I will get cofounders.

<comment><USER4> The problem is that it would be difficult to get funding initially if you have no cofounder. So this means you will need to get lots of users all by yourself and maybe then some funding will come your way. But even that doesn't always happen.

<comment><USER3> Well, It is true that Funding will most likely follow towards companies those have 2 or more founders. But there are great success stories around single Founder. Look at Amazon, Del.icio.us, EBay.

I agree, having confounder helps a lot, but if one can't find it then that should not stop you from doing what you want to do.

<comment><AUTHOR> True

</comment></comment></comment></comment><comment><USER5> Big part of the puzzle is to build value in your potential cofounder's eyes from your past ________ experiences. It is a two way street: your cofounder should need you as much as you need him. -Zaid

<comment><AUTHOR> dicey dance, I suppose. But I disagree. you are essentially talking of "everyone loves a winner..."

<comment><USER5> I'm talking from personal experiences of my own so there is no point of disagreement;)

That said, you're right: people love "winners." The trick is you don't have to have sold a big startup to make a reputation. Even before my startup went live, I started getting emails from people across the campus about their ideas and working with them. That's when I realized a lot of attracting folks to work with you is about PR - backed by a real plan and intelligence.

</comment></comment></comment><comment><AUTHOR> I am looking for a co-founder and this is exactly the struggle I have had. I wonder if most entrepreneurs who werent blessed with the right networks, aura and people skills also face this hurdle. \- Anil AT juwo DOT com

</comment><comment><USER6> Because it's a good idea?

Not that you should start a company with a stranger, though; I would not recommend that.

<comment><AUTHOR> Many people to whom I have demo'ed, have said that I have a good idea. I also have an almost beta, prototype. I have approached 16 potential cofounders since May 2006, but they didnt want to take risks with their career, had families to support, had their own career track to pursue and frankly, wondered how it would make money.</comment></comment>


Show HN: Value and money redefined on blockchain to fix ad-blocking - <AUTHOR> https://thank-u.org/press/ycombinator <comment><USER2> This seems to be a very promising approach to get content authors payed without ads. I read your white paper earlier at [https://thank-u.org/download/thank-u-white- paper.pdf](https://thank-u.org/download/thank-u-white-paper.pdf) but wasn't aware that thank-u is already live. It's really time to let the money flow the way it makes sense!

<comment><AUTHOR> Thanks leromi! I was trying to solve my personal problem here, as usual: my favorite site once asked me to whitelist them in ad blocker. I did so as I wish them to be there tomorrow. After struggling for a few days, I couldn't help reverting the change, feeling guilty. But thank-u works perfectly for me to fix it. I wonder if it will be accepted to solve torrent problems and copyright in general.

<comment><USER2> Thank-u for tackling the problem! Same here every once in a while and started looking for solutions. I recognized that others also used blockchain to target similar problems. Do you have any information how thank-u compares to Flattr+, Blendle or others?

<comment><AUTHOR> In short, we are not profit oriented and can implement the true 0% commission. Others, like the ones you mentioned, suggest improving the current model, replacing intermediaries with a cheaper one. I believe, it is not radical enough to be generally accepted. The platform should be decentralized, owned by the community. Please see a more detailed comparison table here - [https://thank-u.org/about/#why-thank-u](https://thank-u.org/about/#why- thank-u)

<comment><USER2> Hi vadim! Very impressive feature matrix! I'll definitely give it a try! thank-u :)</comment></comment></comment></comment></comment>


Unchecked exceptions can be strictly more powerful than call/cc - <AUTHOR> http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.19.694&rep=rep1&type=pdf

<comment><USER2> ...in the context of statically-typed purely-functional lambda calculi without recursion.</comment>