AltHealth: Prescription Price Gouging

It is becoming an ever more prevalent litany: “The pharmacy won’t fill my prescription; they say the one that you gave me is wrong.” What is frustrating is that yesterday, the prescription might have been filled. Today, the insurance company no longer covers that brand. This Game of Groans is hitting those with diabetes hard, for insulin, their drug of need, has become one of the most lucrative pawns on a very checkered board.

Between 2002 and 2013, prices tripled for some insulins. Ten years ago, the cost was about $24 a vial. Today’s versions can run from $250 to $300 a vial, and patients may need anywhere from two to four vials a month. It’s a life-threatening problem for people with Type 1 or Type 2 diabetes. The skyrocketing prices have forced those on limited incomes to practice self-rationing, with sometimes disastrous results. Disorientation, coma and collapse are common with poorly controlled blood sugar levels, and there is a very real long-term risk of blindness, amputation, heart attack and stroke. In a country where more than 30 million citizens have diabetes and an additional 84 million have prediabetes, the fact that this drug is nearly unaffordable borders on criminal. How did the pharmaceutical companies come to hold patients hostage?

According to the World Health Organization, the patents to manufacture insulin are held by only four companies: Eli Lilly, Sanofi, and Novo Nordisk and Pfizer. They have been guarding those patents for more than 90 years. How? Given a normal shelf life, patents run out. However, it is possible to extend the life of a patent by making incremental “improvements” to the drug formula, causing prescriptions to change with frequency. This strategy has been of great concern to doctors, many of whom are forced to spend an enormous amount of time chasing prescriptions that their patients are able to fill. Pharmaceutical reps manipulate doctors, convincing them to use the newer and more expensive products – the endocrinologists who prescribe them receive the highest per capita amount of money from the pharmaceutical industry. Currently, there is only one affordable, older version available, the result of a corporate partnership between Walmart and Novo Nordisk, and it reaches a very limited market. Walmart has the exclusive rights to sell the ReliOn brand of insulins at a reduced rate of about $24 a vial. ReliOn is unavailable at all other pharmacies. Why?

For an answer, we need only follow the money to a group of middlemen, called Pharmacy Benefit Managers. Their job is to negotiate with drug companies on behalf of employer plans and government programs like Medicaid and Medicare Part D. In theory their goal is to reduce prices, but in truth, they get “rebates” (the new PC term for kickbacks) from drug manufacturers based on sales. How much? The rebates are kept secret, but industry analysts estimate that these deals can amount to as much as 50% of the list price of insulin. Newer versions have higher costs with higher rebates, so these get the biggest push in sales.

An article in The New York Times in January 2019 by Yale School of Medicine endocrinologist Kasai Lipski laid it on the line: “To make insulin affordable, we need more competition. Nothing would do this faster than a ‘generic’ form of insulin.” Yet the pharmaceutical companies have blocked every effort to open the market to generic versions of their drugs. Fortunately, one company’s patent expired recently, which could allow other companies to begin developing new generic forms.

The practice of drug switching is not limited to insulin. According to my friend Dr. H, this game of musical chairs happens with disturbing frequency. This can force a doctor to prescribe a medicine they are not familiar with, which increases mistakes in equivalent dosing. It wastes an enormous amount of doctors’ time, and the switches can cause confusion for the patients – more than a few times it has resulted in the patient not taking or getting the medicine. This is happening with cheap generic drugs too; it doesn’t cost the insurance company anything to deny the drug and make the doctor and the patient do all the educational and transactional work. If doctors had a union to represent them, this abuse of time wouldn’t be tolerated.

Some of the more frequent switching involves asthma inhalers, sleep apnea devices, insulin test strips and glucometers, Prilosec meds and testosterone replacements. Obamacare insurance plans flatly refuse to pay for the testosterone gels, forcing patients to take IM shots every 10 days for the rest of their lives. High cholesterol pills are switched often, and every change puts a patient at increasing the risk for a very serious myalgia reaction. The insurance companies seem to be  insulated against any repercussion from denying medications.

One thing is certain – the pricing for many drugs is pumped up for reasons that have nothing to do with medical considerations. It’s about the money. When people can’t live without your product, you can jack up the prices and they will still pay; the consequences of a boycott could be deadly. Why does congress allow the price gouging to continue? It is a question well worth asking.