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Re: [IP] Washington Post online Front Page today. High cost of Insulin



This is what the article said
"At age 15, I suddenly felt an unquenchable thirst and began urinating
frequently. I lost 20 pounds. I had developed Type 1 diabetes, an
autoimmune disease that destroyed my bodybs ability to produce
insulin. Without insulin, I would have eventually developed a
condition called diabetic ketoacidosis, which is lethal without (and
even sometimes with) treatment.

Years later, Ibm a practicing endocrinologist. I could never have
imagined back when I first started taking insulin that one day I would
have so many patients who could not afford the medication because of
skyrocketing prices. When the drug was discovered in 1921, the
original patent was sold to the University of Toronto for $1 so that
no one else could patent it and bsecure a profitable monopoly.b

Numerous improvements later, insulin is produced by a three-company
oligopoly. When the first of the newer insulin banalogs,b Humalog, hit
the market in 1996, it sold for $21 a vial. Today, vials of analog
insulins, including Humalog, sell for about $300 . Patients with Type
1 diabetes typically require two or three vials of insulin per month,
but patients who are more resistant to insulin, such as those with
Type 2 diabetes, may require six or more.

A recent paper in the Journal of the American Medical Association
found that insulin nearly tripled in cost from 2002 to 2013. A lawsuit
filed in January accuses pharmaceutical companies of price collusion
for allegedly raising insulin prices repeatedly and in lockstep to
match their competitors. Prices have gotten so bad that the American
Diabetes Association recently launched an online petition at
MakeInsulinAffordable.org, which has been signed by more than 250,000
people.

Because insulin is so expensive, some people take less than their
prescribed dose, causing higher blood sugars, which may lead to
preventable, very expensive complications such as kidney failure,
blindness, amputation, heart attacks or even death.

Unfortunately, the American Health Care Act (AHCA) passed by the House
last month would let states allow insurance companies to charge people
more for preexisting conditions such as diabetes, as would the version
under consideration in the Senate. This may leave more people unable
to afford insurance and make it even more difficult for patients with
already high premiums and deductibles to pay for insulin. while
current law protects patients with preexisting conditions better than
the AHCA would, too many people with diabetes are still going without
proper medical care. One of my patients, whom Ibll call bJoeb to
protect his identity, lost his insurance, then developed ketoacidosis,
a buildup of acid in his blood, because he couldnbt afford to pay $600
monthly for two vials of insulin. He didnbt die, but he required a
costly stay in an intensive-care unit.

Pressure on drugmakers has started to bring small changes. But theybre
not enough. In response to rising costs, Novo Nordisk will limit
future price increases to single-digit hikes per year. Eli Lilly will
provide insulin at up to 40 percent off for patients on
high-deductible plans. (The downside is that it may not count toward
their deductibles.)

Drug companies also offer savings cards that lower patientsb co-pays.
However, these cards steer patients toward newer, more expensive
insulins. And most cards may not help if the insulin a patient takes
isnbt on their insurance providerbs formulary. Plus, such programs may
save patients money, but the insurance companies donbt save anything,
so the costs are likely to be shifted back to patients through higher
premiums, deductibles or co-pays.

Endocrinologists like me spend far too much time deciding what
patients can afford instead of making sound medical decisions. I deal
with these issues nearly every day. Some doctors are uncomfortable
discussing costs with patients; many patients are embarrassed to admit
they canbt afford medication, and some wonbt acknowledge they arenbt
taking their full dosages. The physician may then increase the dose,
or with Type 2 diabetes may add another drug, when the real issue is
that the patient isnbt taking the right amount. Since it is so common
that patients cannot afford insulin, Ibve posted the American Diabetes
Association petition in each of my practicebs exam rooms, and if
patients donbt bring up cost as an issue, I will frequently point to
the petition as an icebreaker. I ask if they have difficulty affording
their insulin and medications, and I let them know they arenbt alone.

Like some other doctors, I have transitioned many patients with Type 2
diabetes onto older, less costly insulins. I try not to do that for
patients with Type 1 diabetes, because these older insulins cause more
dangerous low blood sugars. But sometimes I have no choice: Itbs
either cheaper insulin or no insulin.

Our system has additional issues that may heap more straw onto
patientsb already strained backs b such as insurersb bquantity
limits.b My patient bMikeb uses 40 units of insulin per day. A box of
five insulin pens contains 1,500 units and should last Mike 37 days.
Since that is more than a 30-day supply, his insurer charges him a
60-day co-pay. The cutoff depends on the policy: For some, a 31-day
supply will trigger a 60-day co-pay. Sometimes this problem manifests
itself in reverse: bMaryb needs three vials of insulin to last at
least one month. But three vials lasts her 33 days, so when she
refills her prescription for a month of insulin, she is dispensed only
two vials b a 22-day supply b for which her insurer charges a 30-day
co-pay. Sometimes patients are allowed bup tob a 90-day supply, so
they are dispensed five vials (which might work out to a 77-day
supply) instead of the six vials they were prescribed (a 92-day
supply). From the patientbs perspective, this bco-pay overchargingb or
bunder-dispensingb feels like getting one dozen golden eggs for the
price of two dozen.

Why do we pay so much more for insulin and other medications in the
United States than people do in the rest of the world? Many factors
drive prices up. Half a dozen companies may be involved with a drug
before it reaches the patient, and each may mark up the cost. Unlike
in many countries, there are no government-set limits on what
companies can charge. These include manufacturers, wholesalers,
pharmacies and pharmacy benefit managers (PBMs), which serve as the
middlemen between insurers and drugmakers. PBMs negotiate which drugs
are on an insurance companybs formulary; they can receive a brebateb
from pharmaceutical companies when drugs make it to formularies. These
brebatesb result in inflated list prices that the insurer never pays.
(In other countries with nationalized health care, therebs no such
middleman.) When people pay a co-pay, they donbt pay the list price,
either. The only people who do are patients who havenbt meet their
deductible, are in the Medicare bdonut holeb or are uninsured b and
these people are the hardest hit.

We also live in one of the only two countries in the world (New
Zealand is the other) that allow direct-to-consumer advertising for
prescription medications. Pharmaceutical companies spend billions on
advertising, and those expenses become juicy tax deductions. Finally,
while many countries with single-payer systems negotiate drug prices,
our Medicare system by law is barred from doing so.

All that complexity b and all the opportunities for profit b leaves
patients to be squeezed by the weight of the system when they go to
fill their prescriptions.

And it gets even worse. bTimb ran out of insulin for the first time in
his life last year because his insurance provider allowed him to pick
up only one vial at a time, and he didnbt realize hebd used it up
until it was too late. bBrian,b a Medicaid patient, requires six vials
of insulin per month, three vials each of short-acting and long-acting
varieties. Yet he, too, is not allowed to pick up more than one vial
of each at a time. Medicaid wonbt dispense a 90-day supply, because
many patients frequently change insurance, and many Medicaid providers
donbt want to give away a month or two of free insulin. Thatbs
understandable b insurers have a bottom line.

But properly managing diabetes requires a lot of work and can be a
tremendous burden. These sorts of limitations and frequent pharmacy
trips make it that much harder, and they magnify patientsb anxiety
about running out of insulin and getting seriously ill. Vials can fall
and shatter. Insulin exposed to high or low temperatures becomes
ineffective. Mail-order shipments may arrive late.

Anyone whobs taking insulin should always have at least two vials on
hand for emergency backup. Having only one vial is simply not safe b
it creates anxiety, and can mean preventable hospital admissions or
even death in some cases. It feels like driving on an eighth of a tank
of gasoline in the middle of nowhere.

My experience is limited to Minnesota, and I can find no published
peer-reviewed data on these practices. Internet forums discuss them
often, though, and I have spoken with academic endocrinologists from
both coasts who tell me my experience with patients is common in their
states as well.

All of these problems could be fixed. We should require pharmacies and
insurers to dispense a minimum 30-day supply and make sure patients
have a second vial on hand for emergencies. Letbs prorate co-pays for
patients who are dispensed more than a 30- or 90-day supply, rather
than rounding their co-pays up. Insurance companies could decide to do
this themselves, but since theybre unlikely to do so, it should be
legislated at the state or federal level. We should also eliminate
co-pay savings cards and require insurers to charge the lowest co-pay
for insulin to encourage good blood sugars and reduce
hospitalizations.

 If Congress were truly serious about addressing access to lifesaving
medication, it would overhaul the whole system and eliminate tax
write-offs for drug advertising to consumers (or better yet, eliminate
this advertising altogether), force more transparency into the
pharmaceutical market and PBM rebate system, investigate those rebates
and how and why PBMs and manufacturers raise prices, and allow
Medicare to negotiate drug prices.

Insulin is a necessity. Itbs time we return to the spirit of that
original $1 patent, put people before profits, and rein in these
greedy and unjust cost increases."
.
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