Insulin Wars: How insurance companies farm out dirty work to doctors patients

https://www.nytimes.com/2019/01/18/opinion/cost-insurance-diabetes-insulin.html

by yarapavan • 8 years ago

100 91 8 years ago

AlexandrB• 8 years ago

The reason seems pretty clear from contrasting these two passages:

The pricing is all the more infuriating when one considers that the discoverers of insulin sold the patent for $1 each to ensure that the medication would be affordable.
The bigger issue, however, is that companies tweak their formulations so they can get new patents, instead of working to create cheaper generic versions.

ddingus2• 8 years ago

There is a great living for someone to make a generic.

No need to make bazillions.

Crowd fund it.

Or, regulate.

Both would be just fine with me.

refurb14• 8 years ago

A generic already exists - Walmart insulin. Apparently it’s not that great.

ceejayoz3• 8 years ago

There are several reasons that insulin is so expensive. It is a biologic drug, meaning that it’s produced in living cells, which is a difficult manufacturing process.

Seems like this is a fairly minimal component. Per the chart at https://twitter.com/odavis_/status/930094350478045184, the price has gone up 10x in the last twenty years or so. It has presumably not gotten more difficult to manufacture.

tomalpha• 8 years ago

Insulin demand is apparently increasing at quite a rate[0]

It's plausible that that could contribute significantly to price increases. Not, to be clear, that I'm defending that or the actions described in the NYT article.

[0] https://uk.reuters.com/article/us-health-diabetes-insulin/mi...

ceejayoz3• 8 years ago

That article is talking about needing to increase production 20% over twelve years, which doesn't seem like a major obstacle. It also highlights pricing as the issue more than production capacity.

refurb14• 8 years ago

That’s list price. Interestingly, net prices have barely budged in the last decade. Up only single digit percentage.[1]

As the list price rose and rebates grew, Novo ended up paying more and more rebate money into the health insurance system. Employers used these extra payments to offset costs in any area, including hospital and physician payments. Health plans used them to reduce premiums and also offset other healthcare costs. PBMs retained a portion of these rebates as their profits.

[1]https://www.drugchannels.net/2016/12/novo-nordisk-sheds-new-...

ceejayoz3• 8 years ago

https://www.nytimes.com/2018/07/27/health/rebates-high-drug-...

Even as insurers’ drug spending has grown slowly, critics say the rebate game has served to inflate the list price of drugs, which consumers are increasingly responsible for paying. This is especially true for expensive specialty drugs, which treat serious conditions like cancer and multiple sclerosis — and whose prices have been skyrocketing.
As the cost of these products has gone up, insurers have raised deductibles and out-of-pocket contributions so that many of the sickest Americans must now pay thousands of dollars a year to cover their drug costs. These out-of-pocket costs are calculated using something close to the list price of a product, not the net price.

refurb14• 8 years ago

Interestingly, Walmart sells generic insulin. The same stuff used decades ago, for only $25 a vial.

However, the advances in insulin since then mean it’s a much more burdensome therapy.

https://insulinnation.com/treatment/why-walmart-insulins-are...

Eridrus• 8 years ago

So this implies that the articles blame on greedy drug manufacturers tweaking formulas to keep patent protection isn't really correct since they have made progress in actually improving the drug.

Not to say there is no greed here, but our policy has been that if you do the work of making a new drug, you get to charge whatever you want for an extended period of time.

This is the result of the policies we have chosen.

refurb14• 8 years ago

Correct. What we may view as a marginal tweak to create a new product, might mean better blood surgar control, fewer sticks and better health for diabetes patients.

tomohawk2• 8 years ago

This is exactly what you get when there is no transparency, and everything is driven by non-market forces. Why not create an actual market where all medications, medical services, tests, etc, have a known price and people can make decisions based on cost, quality, and other factors?

rhinoceraptor• 8 years ago

We could also fix the way medicine works so pre-diabetics are put on an appropriate, low carb diet so they don't end up with diabetes and all of the horrible complications in the first place.

Medicine as a whole will be looked back upon very poorly with how it handled diet, sleep, sunlight exposure, etc.

gumby2• 8 years ago

It's not like doctors and actuaries don't know this.

For reasons poorly understood (though there are many theories) most people have a difficult time changing whatever lifestyle was hurting them in the first place. People also have a poor model of how health care works (most people seem to think it's like getting your car fixed: go to "mechanic" and have problem fixed). Finally the educational level that needs to be addressed is quite low (e.g. the FDA requires that medical labeling assume a fifth grade eduction; since most people take two headache tablets, most are set at a level where two is not dangerous, etc).

Thus, for example, the ADA diet advice recommends you have a "small" amount of carbs ("have a smaller slice of cake, or have an orange instead") in the hope that at least they can reduce the severity of the symptoms. Too large a goal might lead to no compliance at all.

And the actuaries at the insurance companies have figured out the lifetime cost of putting someone on maintenance therapy vs more aggressive treatment that in most cases people won't follow.

A case in point: I was diagnosed with prediabetes and my endocrinologist would only prescribe mainline treatment without additional investigation. Legally she could order any test she wanted but not only would the insurance company bounce anything nonstandard (by their standards) but the hospital management would hassle her as well. I was lucky: I had the money and the education to find and work with a different doctor and found an underlying illness. Once treated, a bunch of symptoms (of which diabetes was just one) went away. The system is not set up to help people like me (though sadly it's not clear how it could even with infinite funding).

Gibbon13• 8 years ago

Kenneth Arrow showed in 1963 that markets can't work for Healthcare.

tomohawk2• 8 years ago

Well, the current heavily regulated cronyism isn't working, so what else you got?

refurb14• 8 years ago

Yet they seem to work fine for elective surgery like vision correction and cosmetic surgery.

harry8• 8 years ago

Well I'll provide the citation and personally disagree with that summary. Adults who give a fig can read it, it's short.

https://www.who.int/bulletin/volumes/82/2/PHCBP.pdf

Zimahl• 8 years ago

I can't read the article, it's behind a paywall. But from the comments I get that people don't truly understand that there isn't just one thing called 'insulin' that is universally the same. As the husband of a type-1 diabetic who has been on $25 Walmart generic insulin and $1000 name-brand insulin (we have insurance, obviously we don't pay that amount), I can tell you they are not the same. For my wife, she never has unexpected highs/lows on the more expensive insulin.

So, sure, non-generic insulin is probably more expensive than it should be. But there was serious research and development done to make these better insulins, and thankfully someone did because they can make life just that easier to manage for a type-1 diabetic.

refurb14• 8 years ago

This is a great point. They might all be insulin’s, but the “tweaking” the author refers to means real benefits to patients.

lozenge• 8 years ago

Try incognito mode. The article is about patients having to switch insulins every few months due to their insurance changing their minds on what's covered and what isn't.

LorenPechtel3• 8 years ago

I still think the approach I proposed years ago would be a big help: Turn the usual arguments on their head, prohibit all negotiation. Drug companies would be required to sell to all customers at the same price. This would end all cost-shifting, it's fair for all and forces the drug companies to actually compete on the end price.

This would end this sort of preferred drug shifting, it would end the game of state Medicaid often mandating the name brand rather than the generic because most of the money is federal and the state receives a big enough rebate that it's cheaper for them. Applied internationally (we don't have direct authority over foreign drug companies but we could make it a condition of importing them to the US that they follow our pricing rules) and the big subsidy to the UHC countries goes away.

jamroom3• 8 years ago

I agree 100%. The approach I like is what I call "lowest negotiated price". How it would work is that buyers (i.e. insurance companies) could still negotiate for a lower cost, but whatever that cost ends up being is the cost _everyone_ pays. This allows buyers to continue to try to get a better price if they can, while likely making sure the price that is agreed upon is fair to all.

newnewpdro• 8 years ago

That sounds like an interesting solution.

It makes me ponder a "highest negotiated salary for $position" approach to combat income inequality

refurb14• 8 years ago

There is evidence that this would actually increase prices across the board. How do we know? Such a system already exists.

The price that Medicaid plans pay is either 23% less than the average price paid or the “best price” (if lower).

When this was instituted, drug companies actually pulled back on their discounts to non-Medicaid accounts, so as to not trigger the “best price”.

conanbatt7• 8 years ago

Drug companies would be required to sell to all customers at the same price. This would end all cost-shifting, it's fair for all and forces the drug companies to actually compete on the end price.

Then you only sell the drugs that do profit, and stop making the ones that cost money. You cant make people do what they don't want to do, pharma is no exception.

The source of this problem is patent law, importation restrictions, etc. In short, competition.

slededit• 8 years ago

Then you only sell the drugs that do profit, and stop making the ones that cost money.

This is the situation we're in now. Just different people shoulder differing amounts of the cost. Equal pricing won't change the fundamental economics of drug research.

Data_Junkie• 8 years ago

You make people do what they don't want to do by passing laws. It is all on our cowardly, selfish, incompetent lawmakers.

refurb14• 8 years ago

You realize this could potentially increase prices right?

Every pricing decision undergoes a cost-benefit analysis. If I know that offering a small account a lower price means everyone gets that price, I’d be willing to lose all business to the smaller account because in the end I get more money.

A much better proposal would be no net pricing. The price that everyone pays is public knowledge.

LorenPechtel3• 8 years ago

As I said, it would end cost shifting. That would mean those paying the least would now pay more, but I'm not saying to preclude insurance or the like (I'm talking about the price the drug company sells it at, not who pays or the like), I don't see that it's going to be a problem.

test6554• 8 years ago

Perhaps they should just prohibit price and coverage changes mid-year. It's fine if prices change from year to year, but what's not fine is if the drugs that are covered are suddenly not covered after you enroll in a medical plan for that year. Prices should be locked in for the following year by summer of the previous year and in the fall of the previous year when people start shopping for insurance plans, insurers should be able to provide a list of medications that they will guarantee to be covered.

dreamcompiler2• 8 years ago

A better approach might be to prohibit insurance coverage for insulin altogether.

Part of the reason healthcare is expensive is that the entity paying for the product is not the customer of the product. When the customer pays, the customer becomes price-sensitive and markets work the way they're supposed to: Prices go down. Since insulin is inherently cheap, making everybody pay for it out of pocket would be both humanely reasonable and it would stabilize prices.

pkaye• 8 years ago

The bigger issue, however, is that companies tweak their formulations so they can get new patents, instead of working to create cheaper generic versions.

Wait don't the patents eventually expire on the old formulations?

SpikeDad• 8 years ago

Exactly. And that's why drug companies spend 100% of their advertising and promotional budget on the new patented drugs. It's well worth it if they can get doctors to switch prescriptions to the new medications with huge profits and no generic than continue to prescribe the in some cases identically effective old drugs that are now cheap and generic.

And it works. Not to be a big insurance company shill but they're often the last line of defense against your doctor trying to prescribe an identical, brand name product for the equivalent generic.

dhruvp• 8 years ago

This is a common problem in healthcare and I think it comes down to these issues:

1. Pharmaceuticals have natural monopolies on these drugs (due to regulation, market power, etc.).

2. The public and end consumers are largely unaware when these monopolies are exercising their power to increase costs. This is because there is no one price, you don't actually pay the actual price (if you're on insurance), and it's difficult to actually realize what the price of a drug is.

3. Many insurance companies don't have strong incentives to combat price increases. [1] As these prices increase, consumers become more and more reliant on insurance. [2] Insurance companies have targets for what percent of their expenses they are allowed to devote to administrative costs (buildings, salaries. etc). As the cost of drugs rises, they can increase salaries etc. while keeping the percent devoted to administrative costs constant. [3] Insurance companies are also largely monopolies. End consumers usually take whatever their employer gives them and in most states there are only a few providers. As such, they don't have much pressure to have more competitive plans.

4. Pharmaceuticals companies respond to demands to increase shareholder value by increasing drug prices. This is exactly what we'd expect them to do as per their incentives.

------

The solution to me is the following:

1. Allow the safe import of drugs from overseas to create a more competitive market (the US has strong regulations against importing drugs mainly due to safety concerns). See this(https://www.pbs.org/newshour/health/u-s-make-easier-import-p...).

2. Regulate pharmaceuticals and insurance companies as the monopolies they are, or dramatically lower the barriers to entry in the space.

3. Reduce the power of pharmaceutical companies to lobby and reinforce the regulations that help them preserve their monopolies. They have every incentive to lobby for protection and it's no surprise that healthcare industry has by far the biggest lobbying spend in the US - nearly double that of Oil & Gas (https://www.opensecrets.org/lobby/top.php?indexType=i&showYe...).

------

The book American Sickness(https://www.amazon.com/dp/B01IOHQ9LO/ref=dp-kindle-redirect?...) discusses just how far we are from any type of perfect competition in this industry and the resulting effects on consumers. I really enjoyed it and it's a great book if you're interested in the space.

aaavl2821• 8 years ago

It is hard to know where to direct my rage. Should I be furious at the drug manufacturers that refuse to develop generics? Should I be angry at the P.B.M.s and insurance companies that juggle prices and formularies to maximize profits, passing along huge co-payments if they don’t get a good enough deal? Should I be indignant at our elected officials who seem content to let our health care system be run by for-profit entities that will always put money before patients?
The answer is all of the above. But what’s most enraging is that drug manufacturers, P.B.M.s and insurance companies don’t have to pick up the pieces from the real-world consequences of their policies. That falls to the patients.

I think this is an important and balanced quote. Often in the public debate, drug pricing and access, which are two separate concepts, are conflated. A drug can be priced fairly but be inaccessible to patients because insurance companies and PBMs want to hold costs down. This often happens with drugs that treat lots of people. Because of the high volume, insurers will have massive expense for covering a drug, even at fair (i.e. Cost effective) prices. So they fight tooth and nail (often using the media as a weapon) to reduce price. Drug manufacturers won't lower price (often bc they will lose money if they do), so insurers deny

An example of this is CAR-T therapies. Cost effectiveness research shows that cost per QALY is within acceptable ranges but payers make it hard to get the drug. I think the same was true of the curative hep c drugs but don't recall the cost-benefit analyses. These drugs were incredibly effective and many people would benefit from them, so payers saw a huge potential expense and denied care until competitors emerged

In some cases though, pricing is the bigger issue. This often happens with established drugs where manufacturers increase prices, or drugs with limited competition.

Insulin is an example where both pricing and access are not great, i.e. PBMs / insurers and manufacturers are probably equally at fault

Drug pricing and access is a complex and highly competitive negotiation between manufacturers and payers and the media is a powerful weapon used in this negotiation. Lots of lobbying done as well. And there are many behind the scenes players with a stake in the debate (i.e. Hospitals wanting the public to blame drug companies for high healthcare costs). This seems like a balanced article to me, but take articles about healthcare with a healthy dose of skepticism

MrTonyD• 8 years ago

Maybe 20 years back I remember reading an article describing how many generics were intentionally ineffective - missing key ingredients - and secretly created by the drug manufacturer themselves in order to increase sales. It was a big article in the New York Times if I recall.

amriksohata2• 8 years ago

I always say this, but reading that makes me think thank God for the NHS in the UK. Health and education should never be a business. The pharmaceutical companies are so strong and greedy in the US they want people on their drugs, rather than look for preventing the problems. They often lambast and send confusing scientific studies out to ensure no alternative therapies succeed over their drugs.

ninjin• 8 years ago

As a Type 1 diabetic in the UK I feel inclined to agree and disagree. Yes, the drug price negotiation is great and keeps my insulin affordable. However, the NHS comes with its own ailments that we should admit.

For Type 1 diabetics in particular, technological support in the form of insulin pumps, continuous glucose metres, and closed-loop systems are only handed out readily to children, while in the US they are far more commonplace since they are covered by insurance. Personally, it took me 3 1/2 years of fighting to get my pump – something that I would have had in months if I would have remained in Japan. One week ago I finally got it and what a difference it makes in terms of control. However, a continuous glucose monitor is nowhere in sight and I frankly do not expect to get one within a decade. Perhaps a pseudo-continuous glucose monitor like the FreeStyle Libre if I am lucky. My diabetes team in London is great and pro technology, but I can only imagine those that are less well-informed on how to make the system (NHS) work or live out in the country. Do they receive the technology they need to manage this disease?

For those of us with Type 1 diabetes that seek technological support, do read up over at Insulin Pumpers UK [1]. Also, never feel ashamed to seek the technology that would help you live longer and less constrained by our illness.

[1] http://www.insulin-pumpers.org.uk/

amriksohata2• 8 years ago

Agreed lots of flaws, what I like is because it's state based it's in their interest to cut costs of medicine rather than try give as much medicine as they can to increase profits

maxerickson3• 8 years ago

In the US, dental and vision care are much more business-like than healthcare in general. Prices are reasonable and care is quite advanced. If there was no protection racket, dentistry would be even cheaper.

Which isn't to say that running them as businesses is necessarily the right idea, but the regulatory morass that is broader US healthcare probably doesn't teach us everything there is to know about healthcare as a business.

(people get angry when you do things like call a $200 filling "cheap", but it lasts for 15+ years and you get to keep the tooth. It's cheap!)

jorvi• 8 years ago

Even in most universal healthcare countries dentistry and vision are only covered for minors, because they’re seen as care that can be budgeted ahead of time (you know a tooth is sensitive waayy before you actually have it filled, so you can save up for the cost). Dentists and opticians are run like businesses.

And yes, $200 is still ridiculously expensive for a filling. Here in The Netherlands I’d pay ~$104 for a multi-sided composite filling (the most complicated filling you can get). For the cheapest (one-sided amalgam) I’d pay ~$25. Local anesthesia would be ~$8.

dotuser3• 8 years ago

I agree, the pharmaceutical companies in the US use dirty tactics to get their products to market. They put out these clinical trials claiming their product is superior or worse, are behind bogus claims of a cancer link to a drug - I was suspicious when my insurance stopped covering lantus and forced me to switch to levemir.

hirundo• 8 years ago

This pricing is, of course, hidden from most patients, except those without insurance, who have to pay full freight.

The rest of the story flows from this. The ordinary price mechanism is broken because the patient isn't the customer, and the customer is paramount to any business. As long as most patients don't care what it costs most of the time, it will stay broken.

HarryHirsch• 8 years ago

* As long as most patients don't care what it costs most of the time, it will stay broken*

Say what? With insulin it's "your money or your life".

talltimtom2• 7 years ago

As a patient, you don’t care if the drug costs 25$ with 20 covered by insurance or 2005$ with 2000$ covered by insurance. That is what he means. List price doesn’t matter to insured patients.

amgreg2• 8 years ago

Luckily I never had to take insulin, as I am not diabetic. I had a dog, however, who needed it. She was prescribed Humulin-N, which is not generic. The generic insulin would not be adequate for her, according to the vet.

When I got to the pharmacy, I was amazed to learn that it would cost us ~200 USD each time I needed a vial, which I would not be able to afford; I had pet insurance, but it wasn't any help.

I have family in Brazil. Identical medication is sold there for around 10 USD. By "identical" I mean exactly the same -- including brand name (Eli Lilly). Thus, every time a family member was coming to the USA, they'd bring me a few vials purchased from a local pharmacy that honored our US-issued prescription.

The price difference is shocking. I can only imagine the despair of many Americans who cannot afford the insulin they need and have no access to alternative markets such as I had.

dotuser3• 8 years ago

You can get novolin-n at Walmart for about $26 a vial without a prescription. I’m a type 1 diabetic and fallback to this when I’m unable to get a prescription.

amgreg2• 8 years ago

We ended up finding Novolin N at Walmart, before the Brazil solution, but our Dr. dissuaded us from switching.

You probably know this better than I, but the doctor advised us that Humulin N and Novolin N are not interchangeable; while they are the “same” insulin (NPH), the manufacturing process is different, affecting dosage.

In our pet’s case, the Dr. had conducted a series of exams to determine Humulin N dosages — which he advised us we would have needed to redo if we switched her to Novolin.

I think in humans it is easier to get blood readings, but in the dog’s case the Dr. needed to keep her in hospital to do a series of “curves;” this was expensive, so we did not want to redo.

tracker14• 8 years ago

While not for everyone, there's religious-like contention on all sides... but a ketogenic diet and fasting focus can help most people get off of insulin. It isn't easy and takes more effort for some than others.

I've been mostly off of insulin for well over a year, though I do keep a vial in the fridge for emergencies, I tend to have a spike once in a while.

Personally, I think it's about time for medical patents to all but be disbanded. The terms are too long, revision patents should not be allowed, and there should be dual-sourcing requirements for FDA approval. If there aren't two mfg's (cannon have a shared parent owner), you cannot sell the thing.

refurb14• 8 years ago

I’d argue you’d get far fewer advances in drugs with a system like that.

tracker14• 8 years ago

I'd argue most new drugs aren't "advances"

myrryr• 8 years ago

For type I diabetics, that option is off the table.

It isn't that they are resistant, it is they don't produce any at all.

It is insulin or death for them.

tracker14• 8 years ago

I understand that... but most diabetics (by a large margin) are type 2. Even for longer term type 2, with lower production (damaged beta cell production), it's necessary to monitor and have insulin on hand just in case.

... can help most people get off of insulin

rbobby• 8 years ago

Why is insulin not an over the counter medicine? Would having it OTC cause problems on the scale of alcohol? What's the "value add" of having a doctor renew an insulin prescription?

rhema• 8 years ago

Probably because its a serious drug that impacts metabolism in unsafe ways. I think it can also be abused as a component of extreme muscle building drugs.

syn0byte• 8 years ago

The number of unexplained but apparently natural heart attacks in middle aged people with disgruntled partners would sky rocket.

Weight trainers can and probably already do (ab)use insulin to maximize their gains by manipulating blood sugar levels during workouts.

self-diagnosed and self-medicated diabetics showing up at hospitals that have no indication of this and pump them full of glucose.

conanbatt7• 8 years ago

The number of unexplained but apparently natural heart attacks in middle aged people with disgruntled partners would sky rocket.

Are you saying that insulin has to be prescribed to prevent murder?

dreamcompiler2• 8 years ago

First because overdosing on insulin is fatal. That's not unique to insulin; overdosing on Tylenol is fatal too, but with insulin you don't get any warning: With a slight OD you'll feel your brain get foggy and you can chew some candy to fix the problem, but with a big OD you just pass out and die.

Second because the peculiarities of insurance often mean prescription drugs are cheaper to the patient than OTC drugs. Making insulin OTC might well make it more expensive.

maxerickson3• 8 years ago

I initially said "In many states it is available over the counter."

A better response is that several older, more difficult to manage versions are available over the counter.

nisa• 8 years ago

Not sure how possible such an idea is, but why not create a public utility that creates essential medication for the lowest possible price? In the end Medicare seems to pay already huge amounts of money for some medications and there must be know-how in the federal government or other public institutions on how to manufacture medications.

I'm not trolling. Like clean water, this is maybe an area were society should not tolerate market failure or cronyism.

UncleEntity• 8 years ago

...but why not create a public utility that creates essential medication for the lowest possible price?

One possible reason I can think of is then nobody would develop new essential medications because they know the government will just nationalize it after they spend the billions getting it approved through the FDA.

And everyone + dog would be calling their medication "essential" in order to get the benefits of governmental production.

talltimtom2• 7 years ago

Let’s say we do this, and you create a state funded company that creates cheap insulin, let’s say they can sell it for 25$ in Walmart. What then happens is that to sell that drug to the insurance companies they negotiate with the Phamacy Benefits Managers they will say to them:”We want a 66% rebate!!” They’ll say errr? At what price? The PBM will say:”we don’t care, insurance covers the price”. So that company ends up putting a list price at 74 but providing a 66% rebate to the PBM so they still get their profit... but then the next year the PBM comes back saying “well, we are going to need a bigger rebate because the competitors where willing to raise their prices even more and thus giving us bigger rebates”

You essentially have a party who’s getting every company to compete on who is willing to sell at the highest list price who’s driving negotiations against the producers who only stand to gain by higher prices.

The American system is rotten to the core.

en4bz• 8 years ago

For those wondering I found this on WebMD.

In 2000, the first long-acting synthetic insulin was approved by the U.S. Food and Drug Administration.

Looks like it will still be at least another year before a viable generic enters the market.

kgwgk• 8 years ago

It has been available for a couple of years already: https://investor.lilly.com/news-releases/news-release-detail...

More competion may be coming (or maybe not): https://www.fiercepharma.com/pharma/mylan-pressing-forward-l...

Insulin Wars: How insurance companies farm out dirty work to doctors patients

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