4 minute read
PRESIDENT’S MESSAGE
Rising Drug Costs in the US
The American Dream is a set of ideals in which equality and freedom lend to opportunity for prosperity and success. The definition of success differs per individual.
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A patient of mine used to say, “Having medical insurance is my American Dream.”
She just wanted a job that would give her kids and herself financial safety and health care.
Health care for all is a dream for many. But even with health care, are treatments affordable?
I have a 49-year-old patient with out-of-control diabetes who just underwent a partial foot amputation. For years she’s been non-compliant with her medication. She is riddled with side effects from high blood sugar – protein in her urine, retinopathy, and vascular disease. Insulin was too expensive for her. She had insurance but would not refill her insulin because of the cost. She already struggles to afford food, clothes, and school needs for her children. Despite the fact that insulin has been discovered one hundred years ago, it could not help her to save her foot and end organs because of the cost.
The average US manufacturer price per standard unit across all insulins is about $100, compared to $7 in Australia, $12 in Canada, and $7.50 in the UK.
Xarelto is $16 per tablet in the US, but only around $1 in Turkey.
Symbicort is $334 but is only $25 or less in other countries.
PRITI GAGNEJA, MD, PRESIDENT
Humira’s prices went up. For many, the co-pay used to be $800 per month, but now is $1500/ month. The vast difference in prices is concerning.
It’s frustrating to see patient’s health crumble due to financially prohibitive medication. Patients lose hope in the medical system. High costs cause patients to avoid filling the prescription altogether, forgo other medical treatments or tests, or turn to alternative and often substandard options. The US has a unique problem with pharmaceuticals. We lack federal law and regulation to effectively keep drug prices in check.
The middleman system we have has part to do with this. These middlemen are PBMs who work directly with insurance companies. They make a formulary, which is a list of drugs the insurer agrees to cover. They manage the prescription drug claims. The drug makers want their meds on these lists and then offer rebate payments. All this business between these entities determines what’s “preferred.” … Preferred by the middlemen’s pockets!
For some plans, Proair was once covered and Ventolin was not. Now that has switched. Protonix was covered, but now Nexium is preferred. The middlemen hugely influence the medication the patient receives.
PBMs have power. The three that dominate are the common mail order pharmacies which cover over 150 million Americans. This allows them to be aggressive when negotiating with drug manufacturers.
Humira’s price has been driven up 78% due to the cost the pharmaceutical company has to pay the PBM.
Some have proposed eliminating the rebate system, changing the way PBMs are paid, reducing patent times, capping a patient’s financial responsibility, or sharing the rebate between insurer and patient. Unfortunately, many insurance plans now tend to make patients pay a percentage instead, which can be very expensive.
More Americans are also purchasing high deductible plans to keep monthly costs low, which becomes a problem when expensive meds are prescribed. What can we do?
Both political parties have made many recommendations, but putting them into legislation has been a challenge. Currently the Biden Administration hopes to address high drug prices and released a report September 2021 that supports drug cost transparency, price negotiation, Medicare Part D reform, and caps on spending and legislation that would slow price increases over time on existing drugs and speed entry of biosimilars and generics to the marketplace.
Until then, as physicians, to help patients, we can offer generics, have conversations with patients about affordability, offer alternatives and over the counter options, remind patients about manufacturer discounts and patient assist programs (NeedyMeds and GoodRx).
The American Dream has always been about progress yielding security and increased opportunity for the future generations. Drowning in medical bills threatens this dream which has now changed, for many, to simply having medical insurance access and affordability.
Priti Gagneja, MD President
Some have proposed eliminating the rebate system, changing the way PBMs are paid, reducing patent times, capping a patient’s financial responsibility, or sharing the rebate between insurer and patient. Unfortunately, many insurance plans now tend to make patients pay a percentage instead, which can be very expensive.
Tenet Health Central Coast Health
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