This week I 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 HgbA1C measures sugar control over the last three months.

The bee sting kit or epi-pen 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 ten 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 been hearing about the insulin price hike. Many people suffer and die from diabetes. In fact, diabetes was the seventh leading cause of death in the US in 2015. NPR did a great segment. The US House of Representatives held a hearing in 2018. Link to the report. Senator Elizabeth Warren, now presidential candidate Warren 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 fifteen drugs on the list.

Here are three take home points:

1. There have been no big innovations in Insulin for the last ten years. However, 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 (PBMs) negotiate with drug companies on behalf of insurers—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 back-room deals, amount to as much as 50% of the insulin list price. This is what happens when health care is for profit!                                                                 

3. From the doctor perspective, I spend a lot of time and energy on prescription changes due to factors beyond my control. The patient and I find 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 because the insurer negotiates a better deal. The patient and I are back to the drawing board. It eats time and resources. Sometimes prior authorizations are required to continue the medication that was working just fine. Sometimes it is calls to the pharmacy to figure out what medication is covered. Then 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, more physician and staff resources taken away from caring for the patient. Instead we are jumping through administrative hoops. US 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. Diabetics are at increased risk of serious 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 complications from the disease that can be prevented with routine health care and medications.

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, one in 10 adults are 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.(CDC data)

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 vegies 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: 3-month supply of Lantus Solostar (3 ml), long acting insulin administered once a day is ~ $447.00

UK: ~$200 for a 3 month supply.

For the US it costs $1,161 for a 3 month supply!!

I hear an echo.  This is what happens when health care is for profit. We need to do better!

Additional Resources:

CDC stats: https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html

NYT: https://www.nytimes.com/2016/02/21/opinion/sunday/break-up-the-insulin-racket.html

Family Medicine's recommendations for lowering drug prices: https://www.aafp.org/news/government-medicine/20180724hhsdrugsltr.html