November 9, 2018

Pay Attention to the Man Behind the Curtain on Drug Prices

I'm enough of a nerd that I'm a fan of the blog Drug Channels.  It is written by Adam J. Fein, Ph.D. and consistently brings smart analysis to the drug marketplace. By smart, I mean pealing back the layers of the onion and getting to the root causes of market distortions, like spiraling list prices while manufacturers face stagnant net revenue.

I found this recent piece a particularly good example of why I like it. Drug Prices After the Midterms: Five Crucial Implications of Pharmacy Benefit Design

Going beyond complaining about drug prices, Fien seeks to explain some of what is going on behind the curtain in the mostly invisible drug middle market. This is where the big companies that manage drug benefits (not make medicine or dispense it) do their thing.  The whole post is a good read but here are a few highlights.

This quote should send chills down the spine (bold text added):

Coinsurance amounts are typically based on the negotiated rate between a pharmacy and payer. These amounts typically approximate a drug’s undiscounted, pre-rebate list price. Though patients pay the list price, their employer can still collect a rebate that is not reflected in that pharmacy pricing. For some high-list/high-rebate drugs, the patient’s out-of-pocket costs can even exceed the net cost of the drug to the employer.  
That’s right: Employers can actually profit from certain drugs. Plan sponsors can hoard rebates rather than share the savings with the employees whose prescriptions generated the rebate funds.

Who is likely getting screwed over in these cases?
Employers and their PBMs typically place therapies for such chronic, complex illnesses as cancer, rheumatoid arthritis, multiple sclerosis, and HIV on the fourth and specialty tiers of benefit plans.

So IMHO, PBM reform that applies rebates at the point of sale seems like a really good place to start the conversaton on drug price reform. If anyone is serious about it. 

November 8, 2018

OmniPod & Samsung Working Together

OmniPod announced they are working with Samsung to control the Pod with select Galaxy phones.* It is an announcement of working to that end not an approval, yet. But that is good news none the less.

The announcement says they will be using Samsung security at hardware and operating system levels. Sounds positive. I'm no expert.

No word on other phones.

For the announcement details see:

From the release:
*Capabilities will be limited to select Samsung Galaxy smartphone models. Information on exact model availability will be shared at a later date.

November 2, 2018

Omnipod Announces Tidepool Loop Agreement

This very cool news from the Omnipod earnings call:

“As a first step in our support of interoperability, we are pleased to share that Insulet is the first pump partner for Tidepool’s Loop Program. For those who aren’t familiar, Tidepool is a non-profit organization that is working to get an open source, iOS-based Looped app and algorithm, approved by the FDA. Together, we are developing an interoperable, automated insulin delivery system that allows Omnipod DASH to be controlled by the Tidepool Loop algorithm from an iPhone. This partnership is additive to our internal Omnipod Horizon program and offers a potentially faster avenue to market, an automated insulin delivery system with iPhone control for our Podders, and a terrific way for us to support the DIY diabetes community.” (About 23 minutes into earnings call starts getting more interesting for PWD aka less businessy at about 20:00)

At first blush, it seemed to me that the Bluetooth Omnipod DASH offered little more than an evolutionary step for the Pod, particularly without smartphone control. Nicer new controller but still something extra to carry.

Well, now revolutionary is more accurate. They announced the path to phone control and interoperability aka multiple Automated Insulin Deliver algorithms.


(listen to) the earnings call

October 29, 2018

Patients, Data, Care, Research

Patients, our health information, and better care are in my email this morning. 

I was very much pleased to get an email from a specialist's office. It not only invited me to use their patient portal to manage my relationship with the office, they actually set up an account and gave me a one time use password. 


This is opposed to the deal at my primary doctor. I had a portal account there. It was great. I could see all the reports and letters other specialists sent about treatment.  For example, once I read the details of a specialist visit before we had the conversation that was written up. That was a little too proactive. I fired that doctor later in the day when we had our appointment.

My primary doctor's practice got bought up by a rapidly growing hospital system. My portal was closed pending a change to the new system's patient experience. Closed, not converted. Way to go Jefferson - quality care. And  - I have to go into the office to apply to join the new portal.

Also in my email today, Faster Cures aka the Milken Institute, sent a link announcing "new initiatives to engage the private sector, strengthen global partnerships and harness the power of data to save lives." Their stated priorities are:

  • Advance policies that break down regulatory and other barriers to getting scientific advances to patients more quickly;
  • Identify incentives to increase private sector investments in biomedical R&D;
  • Build global communities that expand capacity to treat disease;
  • Put patients – and their health data – at the center of biomedical research and analysis.
They go on to say: 
"Groundbreaking cures require access to, and analysis of vast amounts of health data. Researchers face obstacles to collecting these data because medical providers often fail to share information with patients, or because patients distrust a system that does not explain how the data will be used or ensure its privacy and security."  - (Emphasis added) 

The press release goes on to announce the new board of very impressive medical providers  - doctors, insurers, business people. One has a Nobel. That is impressive! 

While all of the very impressive people are at times patients - none is at the table with a portfolio explicitly representing patients. So who is gonna, "Put patients – and their health data – at the center of biomedical research and analysis?" Ya know - so that patients trust the system. 

Feels like the - I need to come into the office and apply - idea. Patient access as an afterthought. Maybe while we are there, you can address the distrust the system part too. Ideally in something other than an impressive if unreadable terms and conditions page.  

In fairness, I think the Milken Institute is doing good stuff. I just think it would be better if they could figure out how to do what they say is a priority - Putting patients at the center or at least in a seat at the table. 


October 25, 2018

PBM Without Rebates (aka Kickback?)

Pharmacy Benefits Manager Express Scripts has announced a program with 18 large employers where rebates are passed back to the employer, in total. The Blog Drug Channels says;
You should pay close attention to this b.i.g. news. It is structured so that Express Scripts will not profit from the flow of funds from a brand-name manufacturer to a plan sponsor. What’s more, the PBM’s compensation will be fully delinked from drug list prices.
Drug Channels sees this as a "PBM compensation approach could be an important step in our industry’s journey toward a world without rebates."

I hope so. I am not convinced. No rebates and lower prices make more sense to me. In the meantime is this a move to no rebates or a move to the employer getting all the money.

Rebate bucks are not clearly linked to the people and conditions that generate them. So chronic health issues can become a source of subsidizing healthcare at large employers that are not seen as connected. For example, insulin rebates flow to employers, even if the plan doesn't cover the insulin and the PWD pays full price. So the process transfers deductibles from people with diabetes to other employees in the system. I am sure the argument would be that all plan member face similar deductibles.

Drug Channels asks:
Will the funds be used primarily to offset total plan costs for the employer and premiums for everyone? Or, will the money offset the out-of-pocket costs incurred by the patients whose prescription activity generates the rebates and fees?
No rebates and lower drug prices are the best ideas. It seems to me that like rebates at the point of sale would be a better step in a move to a no rebate system for equitable reduction of rebate distortions. But any step to eliminating rebates is a step in the right direction IMHO.

Buried in here is something else to be concerned about. The PBM will get paid for managing care with a better spend. From Express Scripts press release:
Pay-for-performance for clinical and administrative plan management that improves patient and plan outcomes. Express Scripts will demonstrate, definitively, that it does not just buy better, but manages trend and spend better. Express Scripts' ability to deliver clinical and financial outcomes is directly tied to its compensation. Pay-for-performance means Express Scripts will take on more risk from clients, and be rewarded only when it delivers on agreed-to commitments. 
Is spend better, better care? Is it patient-focused care? It could be. It could also be more treat to failure restrictions. I have little confidence in middlemen working for patient-focused health-care. It didn't work for HMOs and PMB history isn't good. I could be wrong.

Stay tuned.


October 18, 2018

Of Adam, Appendixes, CGM, then AID in Hospitals

My friend Adam Brown just went through the maze of navigating blood glucose and a hospital stay. You can read about it in his post titled: My Appendix Ruptured: Scary Lessons Learned About Diabetes in the Hospital

Years ago my son had his appendix out. Like Adam, we were not willing to let the hospital manage his diabetes. Institutionally, they didn't like that idea. After all, had white coats. We prevailed. In the end, they were impressed. I came away convinced that PWD and their caregivers are WAY BETTER at insulin management than hospitals.

So did Adam.

I am in no way suggesting that hospitals, nurses, anesthesiologists, or surgeons don't know their stuff. They certainly know their stuff. I'm just saying that nothing like your diabetes is their stuff.

I wrote about our appendicitis adventure a post called, Poke a Finger on the Invisible Hand. I learned some lessons. While back then I prattled on about meter accuracy. I was fighting the current battle not the next.

Adam came away with a deep conviction that CGM is desperately needed for inpatient care. I agree with Adam. That is a battle to be won.

I think we need to go one step further. Adam spoke of needing to turn loop off for surgery.

Our experience was clinicians at the hospital were loquacious about insulin and had no real plan to administer it other than assuring us they had a sliding scale. That they couldn't answer what rates were in that scale gave us no comfort.

CGM is critical to better care. Full stop.

That includes those hopefully few times PWD are inpatient and under the knife.

I have seen academic presentations on the importance of managing post-op BG for non-PWDs. In fact, I spent a day in lofty, scholarly presentations on the matter. (I have had such adventures - you wouldn't believe.) Seems surgery is a shock to the system and high BG are a risk for complications, particularly infection. Not the kinda highs PWDs routinely see, by the way.

Bugs like sugar. Who'da guessed?

CGM isn't enough. The staff does not have the time or experience to manage diabetes' insulin needs even with CGM data. 

I think Automated Insulin Delivery is desperately needed in hospitals. OK, You are right to say, "Hey! Wait there isn't really automated insulin delivery other than DIY solutions in the wild."


But as systems come online, somebody needs to look at them for use in hospitals for T1s. Then T2 and finally for everyone who has had surgery and is a glucose risk.

Adam pointed out the horrifically inflated cost of finger sticks in his stay. He reports his appendix burst creating the need for infection care. But imagine the savings in those cases where infection could be minimized with automated BG control. Automating insulin could be a cost-effective driver of better post-operative care for some, maybe many.

In the meantime, better is better. If Adam Brown, possibly the most empowered patient in T1 history (or at least second to Kelly) cannot keep his automated insulin delivery system on in the hospital the rest of us are destined for trouble.

September 28, 2018

Is Your Work Getting Rebate Bucks from Your Chronic Condition

I have ranted about PGM rebates a lot. One big question is who gets the money? It may be the company you work for.

Quick Rebate Refresher.
When people with insurance get a drug at the pharmacy there is a lot of money changing hands behind the scenes. Your insurance policy doesn't pay the retail price. They get a rebate. It can be a big chunk of the price. They often get that rebate even if you haven't met the deductible and you pay the full retail. Some of that flows back to your insurance to 'help hold down the cost of coverage." A recent article suggests that most of it flow back. 

So you may have a high deductible to hold down the cost of coverage, and they get huge chunks of what you paid for medicine before meeting that deductible to help hold down the cost of coverage too. Double whammy or reverse insurance.

As Drug Channels Explained
Put another way, the PBMI data demonstrate that employers operate their pharmacy benefits like reverse insurance. Employees and their dependents taking medicines for chronic, complex illnesses generate the majority of manufacturer rebate payments. These funds are used primarily to offset total plan costs for the employer, not to offset the costs incurred by the patients whose prescription activity generates those rebates.
Paying rebates at the point of sale would put the rebate and the usage together so that patients benefit from the rebates paid on the drugs they use. Or the whole system could just be eliminated as the kickbacks they look like.

August 30, 2018

The Type 2 Medical Device that makes the Biggest Difference for Me - a Bicycle.

Two wheels, pedals, and spandex.  I know that the last thought is not a pretty image. - Sorry.

Biking helps with blood sugars (unless I have a massive Reese Cup craving after a long ride.) Time on the bike helps transfer weight from my gut to my leg muscles and maybe also shed a few pounds off.  I find a calm, meditative state when I ride. Particularly in a group ride where I don't need to think about navigation. Some folks get that in yoga, for me it kicks in around mile three of a long spin.

But even though I love biking, at times, I just don't want to go out. Last week I had 100 miles in five days. This week - zero. It is too hot, I told myself. The sofa is too comfy, whatever. It is super easy to swap being active for the shadow of being active.

I need some help keep at it. Peer pressure can be that nudge. I find knowing that my friends are out running or biking makes me feel I should 'keep up.', an activity tracking site helps me stay motivated.

I was invited to Stava years ago by a friend (thanks Adam) who is much younger, more fit than I am, and thinks about motivation more than I do (follow that link.) I was afraid Strava would put me in competition with him. That is something that I couldn't win. So it took me a while to join.

Turns out, we didn't complete we just gave each other 'attaboys. Who doesn't like a pat on the back?

Being part of a real-world group helps too. I don't socialize a lot on rides (see meditative above), but there is a comradery to groups, an implicit I'll show up and ride with you if you show up to ride with me. I have had rides where my ability/will to keep going broke. I hit the wall. Friends slowed down and helped me back. I have paid that forward for others.

Today Strava and real-world are colliding. I passed on riding on Tuesday. It was crazy hot. But there, on Strava, I see my friends showed up to ride anyway. That is enough to guilt me into a ride in the crazy hot tonight.

Thankfully, I have friends that help pull me back when I feel an excuse to not exercise. My type 2 device doesn't make a difference if I don't use it.

August 2, 2018

Call Lilly for Help with Insulin

The market for medicine in the United States is nuts. It is not always easy for patients to find the options that may help.

Navigating the process for Lilly insulin users is now easier with a newly opened helpline. They say:
Starting August 1, a new dedicated helpline called the Lilly Diabetes Solution Center will assist people who need help paying for their insulin – such as those with lower incomes, the uninsured, and people in the deductible phase of their high deductible insurance plans, Eli Lilly and Company (NYSE: LLY) announced today. A customized suite of solutions for all Lilly insulins, including for Humalog® (insulin lispro), will be used by helpline operators to find answers that best fit the personal circumstances of patients.*
Nothing in diabetes is perfect. Hopefully, this is one step towards better form many.  Better is Better.

*More at

April 24, 2018

Drug Prices Should Piss People Off, Maybe Not For The Obvious Reason

Drugs are expensive. Like death and taxes, drug list price increases seem inevitable. There is lots of room for justifiable ire.

I think maybe that anger gets aimed at the wrong target. We all feel we understand prices. We go to the store, see an amount for a product on the shelf and choose to buy or not. If the price goes up, we pay more. Sometimes we fill out a form and get a rebate that limits that price increase. But rebates typically are a pain in the ass, and most folks don't factor them in.

But the list price of drugs on the shelf is misleading. In part because few see it. For most, we make a copay and don't know what the actual price our insurance policy paid for the meds.

HUGE rebates are happening, and nobody sees it. How huge? More than $150 billion. Yeah with a "B." So the drug prices keep going up but so do the rebates to the invisible parts of the drug payment system.

In some cases the rebates more than equal the price increases. What that means is that the drug company nets less income even while they raise the price. Where does the money go? Rebates.

Remember back when nobody bought a car without a rebate? It is like that - on steroids. Plans do not buy drugs without rebates.

Those rebates may get back to the insurance plan and in theory, reduce premiums. But that is not true in all cases, and there is no way to know.

So be pissed that $150 billion in drug rebates seems to sift through the cracks of insurance coverage and we the insured patients may or may not get the benefit of that sifting.

What can be done?

Maybe the first thing to do is to start to understand that rebates exist and be pissed that $150 billion is getting shuffled around with nothing approaching transparency. Our anger at drug prices should be focused on this rebate scheme.

What is a good policy solution? Applying rebates at the point of sale for all plan members, whether or not they have met their deductible.

For the uninsured require the average rebate that drug pays insurers to be applied to the uninsured too.

Want to learn more?
This post at Drug Channels.