I recently had a patient whose blood sugar was well controlled until he lost his health insurance. He purchased his diabetes pills because they’re cheap, but he couldn’t afford the insulin. His diabetes had been well controlled. Now, almost a year later, his hemoglobin A1C was 14, or double what it should be. The HbA1C measures sugar control over the last three months.
The bee sting kit or EpiPen cost hike made the news in 2017. Suddenly it went from $25 to $300, or $600 for a two-pack kit. Less than one in 10 people have a severe reaction to a bee sting at some point during their lifetimes. But people can die without a speedy intervention.
Now, we’ve heard about the insulin price hike. Many people suffer and die from diabetes. In fact, diabetes was the seventh leading cause of death in the U.S. in 2015.
NPR did a great segment on diabetes medicine cost recently.The U.S. House of Representatives held a hearing in 2018. Senator Elizabeth Warren, now presidential candidate, introduced the Affordable Drug Manufacturing Act of 2018 along with Representative Jan Schakowsky (D-IL). The bill mandates the Department of Health and Human Services to produce or secure generic drugs where prices have spiked. Insulin is one of 15 drugs on the list.
Here are three take-home points:
1. There have not been any big innovations in insulin for the last ten years. But the price has skyrocketed. Part of the problem is that three companies control the global market. They have 96% of the business. And guess what, from 2010 to 2015, the price of Lantus (made by Sanofi) went up by 168%; the price of Levemir (made by Novo Nordisk) rose by 169%, and the price of Humulin R U-500 (made by Eli Lilly) soared by 325%. This is what happens when health care is for profit.
2. Acquiring your insulin is not just between the pharmacy and the diabetic patient. There are lots of hands collecting money. Pharmacy benefit managers negotiate with drug companies on behalf of insurers, such as employer plans and government programs like Medicaid and Medicare Part D. The PBMs are supposed to bargain for lower drug prices, but they also want to make a buck. They get “rebates” from drug manufacturers — payments based on sales or other criteria, which look a lot like kickbacks. The rebates are not publicly disclosed, but they are significant. Analysts estimate that those payments and other backroom deals amount to as much as 50% of the list price of insulin. This is what happens when health care is for profit.
3. From the doctor perspective, the prescribing efforts waste a lot of time and energy. The patient and I in a medication schedule that is working. Then the patient loses insurance, changes insurance (due to a job change or job loss) or the formulary changes (the insurer got a better deal). The patient and I are back to the drawing board. It eats time and resources. There are patient assistance programs (PAPs) which provide drug discount programs and cards (like GoodRx), but they require applications and most patients need help from clinic staff. More time away from just caring for the patient. U.S. health care creates a lot of administrative work for doctors and staff in the name of holding down costs.
The insulin hike is a big problem. About 30.3 million people have diabetes. Diabetes can often be managed through physical activity and diet, but for most people that is not enough. Medications and insulin are necessary to control blood sugar levels. People with diabetes are at increased risk of severe health events including premature death, vision loss, heart disease, stroke, kidney failure, and amputation of toes, feet, or legs. Preventing these saves money. Not providing affordable insulin wastes lots of health care dollars on treating unnecessary complications from the disease.
There are two kinds of diabetes: Type 1 diabetics are usually diagnosed as children and have to use insulin for life. Type 2 diabetics are generally adults. Now, 1 in 10 adults is living with diabetes. Many can be controlled with oral medications, but 14% use insulin. In 1994 about 5-6% of adults had diabetes, but now it is well over 10% due to the increase in obesity. Certain populations are more at risk.
- 7.4% of Non-Hispanic whites
- 8.0% of Asian Americans
- 12.1% of Hispanics
- 12.7% of Non-Hispanic Blacks
- 15.1% of American Indians and Alaska Natives
Eating healthy food and getting exercise helps. But many poor and working poor don’t live in neighborhoods that are safe for walking, have access to gyms or have stores that sell fresh fruits and vegetables. Healthy food isn’t cheap. Check out your local food pantry — not a lot of fruits and veggies there.
While single-payer health care would fix this, it’s a huge leap. Obamacare was a big step, but it didn’t rope in pharmaceutical companies. Our neighbors are doing a much better job.
Canada: Three-month supply of Lantus Solostar (3 ml), long-acting insulin administered once a day is ~ $447.00.
UK: ~$200 for a three-month supply.
India: $8 for a three-month supply.
For the U.S. is $1,160.39 for a three month supply. And recently Eli Lilly and Co. (one of the “Big Three” pharma companies) announced with some fanfare that it was manufacturing a generic version of its best-selling insulin brand, Humalog, which it would sell for half off — $137.35 versus about $275. However, in 2001 they were charging $35 for the same stuff, Kaiser Health News reports.
I hear an echo. This is what happens when health care is for profit. We need to do better.
Therese Zink is a family physician and can be reached at her self-titled site, ThereseZink.com.
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