{"id":4931,"date":"2016-05-01T08:24:12","date_gmt":"2016-05-01T12:24:12","guid":{"rendered":"http:\/\/www.khpi.org\/blog\/?p=4931"},"modified":"2016-05-02T09:44:43","modified_gmt":"2016-05-02T13:44:43","slug":"soaring-insulin-prices-highlight-broken-pharmaceutical-policy","status":"publish","type":"post","link":"http:\/\/www.khpi.org\/blog\/soaring-insulin-prices-highlight-broken-pharmaceutical-policy\/","title":{"rendered":"Soaring Insulin Prices Highlight Broken Pharmaceutical Policy."},"content":{"rendered":"
Just business\u2013 or greed?\u00a0 You be the judge.\"ky-medicaid-insulins-2015-treemap-lg\"<\/a><\/h6>\n

Discovered and patented almost 100 years ago, insulin is a critical drug for the treatment of both childhood Type I and adult onset Type II diabetes mellitus.\u00a0 Diabetes is a costly disease for our society in more ways than one.\u00a0 In 2015, the cost to the Kentucky Medicaid program for insulin alone annualizes to\u00a0$101.8 million.\u00a0 Insulin consumed 9.1% of Kentucky Medicaid’s entire non-hospital drug expense while making up only 1.1% of all prescriptions.\u00a0 In 2013, the last year in which Medicare Part-D drug utilization data are available to me, insulin consumed 7.3% of total Medicare reimbursement for drugs in Kentucky costing a total of $141.8 million.\u00a0 In both federal programs, insulin consumed a larger portion of the drug budgets in Kentucky than nationally.\u00a0 A review of several reasons why insulin has become so expensive illustrates what is very wrong with our national drug policy.<\/p>\n

It has been a long time since I prescribed drugs for general medical problems.\u00a0 As a result, when I was exploring the prescription of opioids<\/a> in the Medicare and Medicaid programs, I found myself having to look up the names of many of the most commonly prescribed or the most expensive drugs.\u00a0 One of these was Lantus, a brand of insulin which by itself was the single most expensive drug for the Kentucky Medicaid program in 2015 ($51.2 M), exceeding even the combined annualized cost of the two notoriously expensive drugs (Harvoni and Sovaldi) that are used to treat hepatitis-C ($45.4 M). \u00a0This was frankly a surprise.\u00a0 I admit that in my former life as a house officer when I last prescribed insulin, I did not pay much attention to the price of drugs.\u00a0 We used insulin extracted from the pancreas of cows and pigs which I assumed at the time was relatively inexpensive.\u00a0 I became aware that with recombinant DNA technology that actual human insulin could be made by bacteria or yeast.\u00a0 That seemed like a wonderful advance and it was my understanding that the cost was the same or less than insulin obtained from animals.\u00a0 Even if that had been true once, it is decidedly not so now.<\/p>\n

Brought to our attention.<\/strong>
\nMy theory about the medical literature<\/a> is that things jump out at you only when you are primed to receive them.\u00a0 So it was with insulin.\u00a0 I began to notice articles in general medical forums with titles such as: “What’s behind skyrocketing insulin prices<\/a>?,”\u00a0 or “Diabetic cost doubles<\/a> as insulin use increases,” or even, “Break up the insulin racket<\/a>.”\u00a0 My reflexive indignation about how drugs are marketed and priced was accordingly sparked and I returned to the Medicare and Medicaid drug databases for a closer look.<\/p>\n

Where I looked and for what.
\n<\/strong>The Centers for Medicare and Medicaid Services (CMS) provides in their public-use databases specific utilization and cost information about some 19 different insulins in 8 different branded families. (See useful table<\/a> here from Diabetes Forecast.) Human insulins include Humuin and Novolin.\u00a0 The insulin analogs incude Apidra, Humalog, Lantus, Levemir, Novolog, and Toujeo.\u00a0 Insulins can vary within a brand by things like concentration, packaging, rapidity or duration of action, mixes of different insulins, or method of administration. \u00a0I learned that my old friends, beef or pork insulin, are no longer available in the USA. \u00a0The two federal programs use different definitions and categories of information and therefore cannot be combined. The programs serve very different populations but cover one third or more of Americans.\u00a0 The most recent data available to me are from 2013 for Medicare, and from the first three quarters of 2015 for Medicaid. Nonetheless, the observations I will offer below apply to both programs, and by inference, to non-governmental health insurers.<\/p>\n

Prices of individual named insulins.
\n<\/strong>Because total cost and the number of prescriptions or claims are provided, the cost of an individual prescription can be calculated.\u00a0 These vary widely ranging from $104 to $566 for each Medicare claim and from $95 to $655 for each Medicaid prescription. (See Tables below.) \u00a0In general, the original human insulins are considerably less expensive then the newer insulin analogs which are slightly modified to alter the onset and duration of action. The older “human” insulins are the closest we have to a “generic” insulin, at least in price. \u00a0The most expensive insulins by far were mixtures of short and long-acting insulin in the same solution.\u00a0 In a very recent short paper in the New England Journal of Medicine that sparked a series of responses in both the professional and lay press,\u00a0 the estimated (yearly?) spending for insulin abstracted from patient surveys showed that between 2002 to 2013, the average spending per patient tripled from $235 to $736. \u00a0In contrast to the rising prices for insulin, the prices for older oral hypoglycemic drugs went down.\u00a0 The authors concluded that their findings “suggest a need to reassess the effectiveness and cost-effectiveness of alternative anti-hyperglycemic therapies.”<\/p>\n

\"ky-medicaid-insulins-2015-table\"<\/a><\/p>\n

\"KY-medicare-data<\/a><\/p>\n

Medicare & Medicaid Compared.\"ky-medicare-insulins-2013-treemap-lg\"<\/a>
\n<\/strong>I have posted an extensive interactive set of graphics for both Kentucky Medicaid<\/a> and Medicare<\/a> for the reader to explore and sort as desired. (The Medicaid data visualization is also embedded below.) In both programs, insulin as a group was more expensive than any other single drug. The various insulin types were\u00a0prescribed in the same relative frequency in both programs.\u00a0\u00a0To my surprise, the cost per prescription for most of the same insulins was considerably higher in Kentucky’s Medicaid program than in Medicare! \u00a0In Medicaid, the Cost per Unit of insulin correlated well<\/a> with Cost per Prescription. Within the\u00a0Medicaid program, the per-prescription price was higher in managed care<\/a> than in fee-for-service (FFS) Medicaid.\u00a0 The big caveats here are\u00a0that I do not know the quantity of insulin dispensed in a single prescription in either program, what constitutes a “unit” of insulin, or if there is a difference in the amount of insulin per-prescription in Medicaid FFS vs managed care.<\/p>\n