Thursday, December 20, 2018

Insulin: The Canary in the Coal Mine?

First, a word about insulin. Insulin is a hormone produced in the pancreas that has many roles in the body, but most importantly regulation of the way the body uses sugar. Some people develop an “auto-immunity” against the islet cells that produce insulin and stop making it: this is Type 1 diabetes (which used to be called Juvenile diabetes because it is the commonest type in young people). Before the discovery of insulin, patients with Type 1 diabetes all died very soon after the disease developed. Many more people have Type 2 diabetes, in which their islet cells still exist, but are not able to secret enough insulin, and their bodies resist the effects of insulin. Patients with Type 2 diabetes do not usually die of the diabetes itself but develop many complications affecting the heart, kidneys, eyes and blood vessels.
In the early 1920’s, Frederick Banting and Charles Best, working at the University of Toronto, discovered insulin and were able to extract it from the pancreases of animals. For patients with diabetes this was a life-saving miracle and Dr. Banting won a Nobel prize in 1923 for the discovery. For almost 70 years, beef and pork-derived insulin remained the main forms of insulin marketed. Late in the 20th century one of the first medical uses of genetic engineering allowed the production of synthetic insulins from modified yeast and bacteria. These are now the forms used by 99% of patients with diabetes. As I note in Prescription for Bankruptcy, the discoverers felt that insulin should be freely available to all patients who needed it, so they sold the patent to the University of Toronto for $1. If they knew what Big Pharma had done with their discovery, they would be spinning in their graves.
In the book I told about “Jack,” whose diabetes was never well-controlled because he was unable to afford the amount of insulin he needed, despite having employer-paid health insurance. Well, “Jack” was not alone. A survey by the American Diabetes Association early this year found that 27% of patients prescribed insulin were using less than the prescribed dose because of cost. A study published on-line on December 3, 2018 by JAMA Internal Medicine surveyed 199 patients attending the Yale Diabetes Center over the summer of 2017. Of their patients, 25.5% reported cost-related under-use of insulin. This pattern bore no relation to the type of insurance they had but did relate to their incomes. Patients with lower incomes were much more likely to under-use their insulin (except for those at the lowest level, who presumably had Medicaid, which does cover 100% of the cost of insulin).
Why is this so prevalent? Well, between 2007 and 2017, the average wholesale price (AWP) of four of the most popular insulins almost tripled in price. The AWP of Humulin, the most-prescribed insulin, rose from $258 in 2010 to $1100 in 2015. As employers have responded to the skyrocketing cost of health insurance by offering plans with higher deductibles and co-pays, the cost of insulin has put many lower and even middle-income patients in the position of choosing between optimal control of their diabetes and buying new school clothes for their children.
Remember: this soaring cost is not for a “elective” treatment or a convenience; it is for a critical medicine needed to keep people alive. Nor is it to support research; there was no improvement in the products as the price went up 3-4 fold. The price of insulin simply went up to give the manufacturers higher profits.
The “free market” is not working in pharmaceuticals. We must demand change.

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  1. Because of the tremendously high price of insulin, seniors with diabetes also get caught up in the infamous "donut-hole". My brother is on 2 types of insulin, Levemir and Novolog. His first order of insulin using his Medicare D is subject to a hefty deductible. His next order is expensive, but much less, but by the time he orders his third or fourth insulin order of the year, he's in that "donut-hole" and has to pay the full price the insurance would have paid. The "donut-hole" was supposed to shrink under the ACA, but at this point, I'm not sure what changes were made to the law. Any senior taking higher price drugs face this issue. You pay your medicare premiums for A,B, and D, and pay for a medicare supplement, and still get stuck with a big bill!

  2. A perfect example of why we need to rein in prices and provide better coverage. Being sick should not cause poverty.

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