Cell 2 Soul: The Humane Health Care Blog

The Insulin Cartel

by Kasia Lipskafeb, Feb. 20, 2016

NY Times Op-Ed Piece: Break Up the Insulin Racket

Excerpts:

by Gene Blasen

In the United States, just three pharmaceutical giants hold patents that allow them to manufacture insulin: Eli Lilly, Sanofi and Novo Nordisk. Put together, the “big three” made more than $12 billion in profits in 2014, with insulin accounting for a large portion.

What makes this so worrisome is that the big three have simultaneously hiked their prices. From 2010 to 2015, the price of Lantus (made by Sanofi) went up by 168 percent; the price of Levemir (made by Novo Nordisk) rose by 169 percent; and the price of Humulin R U-500 (made by Eli Lilly) soared by 325 percent.

Besides these pharmaceutical companies, [s]omething else is most likely contributing to the rising price of insulin: a very powerful and largely invisible group of middlemen, known as pharmacy benefit managers, or P.B.M.s.

The biggest P.B.M.s are out to make a buck. They get “rebates” from drug manufacturers — payments based on sales or other criteria, which look suspiciously similar to kickbacks. The rebates are not publicly disclosed, but they are sizable. Industry analysts estimate that those payments, and other back-room deals, amount to as much as 50 percent of the list price of insulin.

The three biggest P.B.M. — Express Scripts, CVS Health and OptumRx — bring in more than $200 billion a year in revenue. They control over 80 percent of the P.B.M. market.

In much of Europe, insulin costs about a sixth of what it does here. That’s because the governments play the role of pharmacy benefit managers. They negotiate with the manufacturer directly and have been very effective at driving down prices.

PhRMA and the P.B.M.s care making a killing while many patients have a hard time with co-pays for their insulin.

See Full NY Times article.

Steven Brill's Bitter Pill

There is a tsunami media blitz about Steven Brill's new book, America's Bitter Pill.  Is it because the book is really great or is it about marketing?  We will know in a few weeks.

Steven Brill has also recently published an important article in Time magazine on the same subject.  Both are called America’s Bitter Pill. 

See:  Zephyr Teachout’s book review of America’s Bitter Pill in the NY Times (1.9.15)
Time Magazine article:  you need to have a subscription to read it online
NPR interview with Teri Gross (35 minutes)
The Bill by Malcolm Gladwell (review of the Brill book). New Yorker January 12, 2015 (Full Text Online)  Gladwell, ever the contrarian, is less enamoured with Brill and his book than the others.

Excerpt from Terry Gross’ Interview of Steven Brill

“It's hard to understand why you get 36 different first-class envelopes with 36 different pieces of paper from the same insurance company on the same day. That tells you something about the efficiency of the health care industry right there. But then, as you open each envelope, they're as completely unintelligible to me as they are to you, as they are to everyone listening. But better yet, they're also as unintelligible, apparently, to the people who write them.

I got to do what is probably a reporter's dream ... which is I took one of those explanations of benefits, which said, "Amount billed: zero. Amount insurance company paid: zero." And the third column said, "Amount you owe: $154." So it makes no sense.

But here's what I got to do: I had scheduled, as part of the reporting for my book, an interview with the CEO of United Healthcare, the largest health insurance company in the United States — and my health insurance company, as it turns out. I went out to Minnesota to interview him and asked him all kinds of questions about what he thought the impact of the Obama health reform was likely to be. And at the end, I took that explanation of benefits out of my suit pocket and said, "I'm wondering if you could do me a favor, could you explain this to me?" ... "How can I owe $154 if nothing was billed?" He looks at it ... and looks up at me and says, "I could sit here all day and I couldn't explain that to you. I have no idea why they sent this to you."

Summation of NPR Interview:

GROSS: So we started our conversation by talking about your experiences as a patient and the bills that you got when you had open-heart surgery. So now being an expert on the history of Obamacare, on billing practices and on being a patient, if you could make one change what would it be?

BRILL: Well, it would be three.  You take the people who provide the kind of care that I saw firsthand in my own situation, and you put them in charge. You let them expand. You let major hospital systems expand, and you let them provide their own insurance. I'd rather buy my insurance from New York Presbyterian Hospital in New York or Yale New Haven because that's a brand I trust. And then you regulate them like crazy to make sure that they live up to their promises, and you control their profits. And at the same time, you regulate the cost of drugs, and you provide significant malpractice reform.

The NPR piece is a great interview and compliments the Time article.  The latter is not available online at this point.

There is a lot of important information in these resources.  If you are busy with many other things, start with Zephyr Teachout’s book review (online) and the Time magazine article that your local library will have.  I wonder, though, is this "a tale told by an idiot, full of sound and fury and signifying nothing?  Or is this "divinest sense?"

 

 

 

Pain Killers

In the U.S. today, drugs prescribed by doctors (myself included) kill more people than street drugs.  This sobering fact was brought home by a recent article in the NY Times (reported widely elsewhere,  too). 

     "In 2008, for the first time in nearly 30 years, more people died of poisoning than in car crashes. Poisoning is now the leading cause of injury death, and 90 percent of poisonings were caused by drugs. 
     Opioid painkillers like morphine, hydrocodone (sold as Vicodin and other brands) and oxycodone (Percocet and other brands) were involved in more than 40 percent of drug poisonings in 2008. These drugs were implicated in more poisoning deaths than heroin or cocaine.
     Opioid analgesics accounted for 14,800 of the 36,500 fatal drug poisonings in 2008.
     For full article see: Download Poisoning Kills

If you are a doctor, read this and weep.  If you are a patient, digest this.  If you are a family member of a patient, be vocal.

Marginal Notes: A Socratic dialog on health care reform (IV)

The philosopher Socrates seeks advice from Apothos the sorcerer for a potion or pill to dampen the discomfort in the wound on his foot and learns a bit about standards of practice in the pharmaceutical industry.  >>more

 

The fourth in a series of Socratic dialogs on health care reform.  Apropos of these discussions, interested readers may wish to peruse previous conversations with Aeschylus, Plato and Aesculapius.

 

 

Brian T. Maurer has practiced pediatrics as a Physician Assistant for thirty years.  His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."

 

 

Medicine's Murky Frontiers

Almost anything the investigative reporter Barry Meier writes is worth reading.  His book, Pain Killer, which we reviewed in Cell 2 Soul in 2005, is a brilliant expose of Oxycontin and the company that hawked it to an unsuspecting public.

Mr. Meier's recent articles in the NY Times about a new device which may prevent stroke in people less than 55 years old should be read by all since it gives insight into the medical device industry and the murkiness of science.  Reading between the lines, I'd suspect that Mr. Meier's next book may be about such devices as there are a number of them being used without sufficient proof at great financial, and sometimes human, cost.

A Device to Avert Stroke Lacks Proof that it Works

"Every year, experts estimate, about 80,000 seemingly healthy people in this country under the age of 55 have a stroke for no apparent reason. Some researchers have long suspected that one culprit is a cardiac defect that 40 percent of those people share — a tiny congenital opening between the upper chambers of their hearts

Based on that theory, doctors in recent years have implanted a small flexible seal in the hearts of thousands of stroke patients. The idea is that closing the hole will prevent future strokes by blocking a pathway for blood clots."

 

Full article.

In a companion piece, Mr. Meier reports on a lawsuit brougt by this device maker agains a British researcher who claimed online that the device is flawed.  Meier does a fine job of reporting the shades of gray. Also see: Device Maker Sues Doctor Who Called Its Product Flawed.