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“Professor says capping insulin price doesn’t treat the cause”

Didn’t we already know that?

Thanks to my human network on Twitter, I learned about the existence of this tweet:

https://twitter.com/EmoryRollins/status/851827310873501696

The Emory School of Public Health tweeted an article written by the chair of their Department of Health Management and Policy, Professor Ken Thorpe, PhD. He is the Robert W. Woodruff Professor and Chair of the Department of Health Policy & Management in the Rollins School of Public Health of Emory University, and he is a prominent health policy scholar, having authored and co-authored over 120 articles, book chapters and books. I remember reading his articles during my fellowship!

The article written by Thorpe focuses on a a major pharmaceutical bill, SB265, that is under consideration in the Nevada legislature.

It is a bill that the pharmaceutical companies do not like because of price controls on diabetes drugs.

According to the Nevada Independent:

A substantial portion of the bill, SB265, seeks to improve access to medically necessary diabetes drugs by implementing price controls, which pharmaceutical companies have long resisted. The legislation, which eight of Cancela’s Democratic colleagues have signed onto, would require the state Department of Health and Human Services to compile a list of “essential” drugs that treat diabetes, such as insulin and biguanides, and require drug manufacturers to reimburse purchasers — either the patient or the insurance company — when the manufacturer’s list price of the drug exceeds the highest price paid for the drug in certain countries or if it exceeds annual changes in the Consumer Price Index. The goal, in Cancela’s view, is essentially to stabilize the cost of a drugs such as insulin that have existed for 95 years and yet have seen prices increase 450 percent above inflation.

The title of Professor Thorpe’s article reads:

“Professor says capping insulin price doesn’t treat the cause”.

And here is the full text of the article, published in the Nevada Appeal.

A professor at Emory College in Atlanta says it’s a noble goal to try to slow the rate healthcare costs are rising but that Nevada Senate Bill 265 isn’t the answer.
The bill was introduced to try to get control of the rising number of Nevadans and others who are contracting diabetes. It would do so by imposing a cap on the price of insulin.
“They’re going about doing this the wrong way,” according to Professor Ken Thorpe of Emory’s Rollins School of Public Health. “If they’re really trying to get the cost of healthcare to grow at a slower rate, this is not the way.”
The right way, he said, is a program of exercise and changes in behavior and dietary habits to get people’s blood sugar, weight, blood pressure and other indicators under control.
Simply capping the price of insulin, he said, does nothing to prevent more and more people from becoming diabetic.
The rising cost of healthcare, he said, is being driven by the fact more and more people are contracting chronic conditions like diabetes.
He said the problem with doctors and nurses telling people to change their diets and get some exercise is that there’s no follow through. The solution, he said, is a system now being tried in Vermont, Minnesota and Oregon that creates “community health teams” that follow up after the patients leave their doctor’s office.
Thorpe said the current medical model deals with symptoms of chronic diseases like diabetes.
“It doesn’t deal with the underlying cause,” he said.
Thorpe said his focus in Nevada at this point is the diabetes issue but that the community health care teams would deal with all chronic diseases that he said make up 87 percent of healthcare costs.
Under his plan, patients with chronic health problems would be put through a 16-week class designed to changing their behavior and instill in them the benefits of a better diet and exercise to control their health problems and keep them from needing expensive medical procedures.

I would like to address some of his arguments regarding his lack of support for the bill:

Argument #1:

“Simply capping the price of insulin, he said, does nothing to prevent more and more people from becoming diabetic.”

Yes, that’s true. Capping the price of insulin does not prevent more individuals from developing diabetes. Insulin is required to treat type 1 and type 2 diabetes. If you understood the pathophysiology of the the disease you would know that.

The purpose of the bill is to reduce the price of insulin for patients who need this lifesaving medication, for which the price has skyrocketed in recent years.

Insulin costs are a real problem in this country

An article published in the Journal of the American Medical Association by Clarke et al shows costs per patient for insulin in the United States in 2013, which was greater than all other types of diabetes medications combined (see orange line).

This figure from a New England Journal of Medicine article shows Medicaid reimbursement trends for covered insulin products from 1991 through 2014, which continue to rise.

The authors calculated that for a patient who needs 40 U of insulin per day, the annual inflation-adjusted cost to Medicaid was $370 for an average priced premixed insulin in 1991 vs. $2852 for an average priced rapid-acting insulin in 2014.

Look at the reimbursement for patented insulins vs. non-patented insulins is very revealing. Can you guess which price is higher?

The costs of insulin are so prohibitive for families that there are patients having to use crowdfunding sites like GoFundMe to fundraise to pay for their insulin, and Senator Bernie Sanders has called for a federal investigation of insulin makers for price collusion.

The human consequences of the high cost of insulin are real, as individuals with diabetes are now risking the development of long-term complications, and death because they cannot pay for their medications.

Argument #2

“The rising cost of healthcare, he said, is being driven by the fact more and more people are contracting chronic conditions like diabetes.”

Yes but that’s because the costs of caring for chronic diseases like diabetes are expensive. And one of the most significant costs of diabetes is the cost of insulin!

Argument #3

Thorpe said the current medical model deals with symptoms of chronic diseases like diabetes.
“It doesn’t deal with the underlying cause,” he said.
Thorpe said his focus in Nevada at this point is the diabetes issue but that the community health care teams would deal with all chronic diseases that he said make up 87 percent of healthcare costs.

Yes, I agree that the current medical model is focused on managing disease and that there needs to be more public health investment in preventive care, but this was a bill to address the costs of insulin! Not a bill to fund all of type 2 diabetes prevention in one fell swoop! Pharmaceutical costs are an important and critical contributor to overall healthcare costs in this country.

I am absolutely perplexed by these arguments from an esteemed professor and health policy expert; they could almost be described as Conwayish in nature.

Individuals from the type 1 diabetes online community saw the article and responded to it:

The make this very important point: There is no lifestyle modification that can prevent type 1 diabetes. Patients with diabetes need insulin and they need insulin that is affordable!

James Elliott then made a discovery that put all of this into perspective and has not been disclosed on the blogpost by Dr. Thorpe:

On Dr. Thorpe’s website, it says the following:

Dr. Thorpe is chairman, Partnership to Fight Chronic Disease, an international coalition of over 80 groups focused on highlighting the key role that chronic disease plays in the growth in healthcare spending, and the high rates of morbidity and mortality. PFCD focuses as well on identifying best practice prevention and care coordination strategies and scaling them countrywide.

And guess who the Partnership to Fight Chronic Disease is funded by? It definitely doesn’t say it on his website. It’s funded by PhRMA.

What is PhRMA?

The Pharmaceutical Research and Manufacturers of America (PhRMA) is a trade group for pharmaceutical companies. In a previous blogpost, I describe how they lobbied against Medicare coverage for the diabetes prevention program. Yes, it seems crazy since I am not sure how anyone could be against Americans eating healthier and exercising more, but they were actively lobbying against Americans eating healthier and exercising more! I guess they support it now?

Through my web searches, I found another piece published by Dr. Thorpe in December 2016 titled: Right and Wrong Ways to Address the Drug Cost Conundrum. He makes similar arguments with some additional important comments regarding pharmaceutical companies:

Argument #4

He states that pharmaceutical companies are a “scapegoat” and deflects the problem to the need for better health insurance coverage.

It’s true that Americans do need better coverage but when the cost of prescription medications for a single patient totals thousands to hundreds of thousands of dollars a year, this is an important issue that needs to be addressed, in addition to health insurance.

Argument #5

He states that Americans need health care policies to “foster a climate of innovation.”

Here comes the pitch for PhRMA:

“Better treatments could save $418 billion a year — $6 trillion in the next 15 years. But these medicines will be developed only if America continues to encourage their development. Artificially pushing down prices would cause many pharmaceutical companies to lose the incentive necessary for new research and development.”

As a clinician I absolutely embrace the need for innovation in healthcare. But as Kesselheim et al wrote in the Journal of American Medical Association:

“there is no evidence of an association between research and development costs and prices; rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear.”

Back to Argument #3

He then ends with the diet and exercise argument once again:

“Americans need to make an effort to adopt healthy behaviors.”

At the end of this article he did disclose his role as chairman of the Partnership to Fight Chronic Disease, but not its sponsorship through PhRMA.

Sadly, in the online conversation in Twitter about the Nevada bill, Dr. Thorpe blocked many members of the patient community who commented on his post.

In order to have a transparent and open public dialogue about the costs of healthcare and pharmaceutical pricing, individuals like Dr. Thorpe MUST disclose all of their conflicts of interest.

Furthermore, it is critical for us as healthcare stakeholders to listen to the patient community. Blocking patient voices from our online dialogue about this topic will not help us effectively address the huge design fails of the health system.

I have posted a comment on Dr. Thorpe’s article in the Nevada Appeal to ask that the disclosures be made.

I tweet and blog about design, healthcare, and innovation as “Doctor as Designer”. Follow me on Twitter and sign up for my newsletter.

Of course I need to make my own financial disclosures: JAMA Pediatrics, Unitio. Previous: Verily, Samuelson Associates. Added 4/15/17: Grant funding from Lenovo.

I significantly lengthened this post on 4/17/17 as the plot began to thicken:

I just received this tweet from: @Kidfears99

The article she is referring to in the Elko Daily Free Press, from Larry Hausner, the former CEO of the American Diabetes Association.

Here’s the title, followed by the full text:

http://m.elkodaily.com/lifestyles/commentary-misguided-proposal-sets-nevada-back-in-the-fight-against/article_b89ab67e-469e-5293-b1e8-d45e7b1c237a.html

“Diabetes is one of the most prevalent chronic diseases in Nevada. More than 12 percent of Nevadans have diabetes and, in 2012, diabetes was the seventh leading cause of death in the state. Legislative leaders could work to help address the diabetes epidemic in Nevada, yet some in Carson City are pursuing ill-advised policies.

When I recently read SB 265, a state bill that aims to tackle drug costs for people with diabetes, it became quite clear to me that our public officials, while well intentioned in their desire to help patients, do not realize what is truly driving the costs associated with the disease.

Caring for people with diabetes involves more than what they pay for insulin or another medication. In fact, most of the medical costs a person living with diabetes incurs has to do with other ailments, but having diabetes increases complexity of treatment and the costs of treatment with it.

Also, diabetes seldom occurs alone. It’s often accompanied by complications relating to high blood pressure, dyslipidemia, heart failure, kidney disease, and obesity. The complications relating to diabetes are the leading causes of lower limb amputations not relating to accidents or trauma and blindness.

Proponents of SB 265, led by some unions, casinos, and big health insurers, assert that price controls will help lower drug costs for patients. That simply is not the case. The proposal sets arbitrary price limits on certain diabetes medicines, with a focus on insulin, and requires drug makers to pay health insurance companies the difference. In fact, multiple witnesses at a recent hearing for the bill stated that there is no guarantee that patients will benefit.

Even the bill’s sponsor indicated there is much work yet to be done and that the language is intentionally vague because it’s unclear how the legislation might actually work. If this bill goes through, patients would pay the same for medications, insurers would increase their profits, and drug companies would have less reason and capital to invest in the innovative drugs for diabetes that are desperately needed. This is concerning.

The number of people diagnosed with diabetes has tripled in the last three decades. This increase means that more patients need high-quality care, including different medication options, to help manage their disease. Innovative treatments, including oral medications and new forms of insulin, are absolutely critical. Unfortunately, SB 265 singles out diabetes patients, creates the high probability of access restrictions, and undermines their overall needs. With SB 265, patients would have fewer options when it comes to fully managing their disease and, as a result, every Nevadan would pay the price.

Instead of restricting access to care, Nevada should be exploring public policies that help us get in front of rising diabetes rates through prevention and actions to reduce the toll of diabetes on those already affected. This can be accomplished through greater access to innovative care, education and awareness initiatives, and bringing all stakeholders to the table to work together to reverse the growth in diabetes prevalence.

Patients must have information needed to choose the right insurance plan to help achieve positive results. Insulin research must continue to evolve, allowing patients superior control, less frequent injections, and better outcomes.

As a lifelong patient advocate, I know Nevadans expect more out of their elected officials.”

Do you recognize the arguments? Some are new and some are old.

Argument #6

“Caring for people with diabetes involves more than what they pay for insulin or another medication. In fact, most of the medical costs a person living with diabetes incurs has to do with other ailments, but having diabetes increases complexity of treatment and the costs of treatment with it.”

Since medical care for diabetes costs a lot anyway, we might as well pay higher prices for insulin?

Back to Argument #5

“If this bill goes through, patients would pay the same for medications, insurers would increase their profits, and drug companies would have less reason and capital to invest in the innovative drugs for diabetes that are desperately needed. This is concerning.”

If you lower the cost of an insulin vial it will kill innovation!

Argument #7

“Unfortunately, SB 265 singles out diabetes patients, creates the high probability of access restrictions, and undermines their overall needs. With SB 265, patients would have fewer options when it comes to fully managing their disease and, as a result, every Nevadan would pay the price.”

I am not sure how making insulin cheaper for patients with diabetes decreases access to care for the rest of the Nevadan population, but a false dichotomy has been created that is pitting diabetes patients against the rest of the population, and against other patient groups.

Health care nonprofits backed by pharma are now sending nearly identical letters to Senator Yvanna Cancela to oppose the legislation. Are the kids with epilepsy trying to take down the kids with diabetes?

https://twitter.com/joyclee/status/854160965323165697

Back to Argument #3

“Instead of restricting access to care, Nevada should be exploring public policies that help us get in front of rising diabetes rates through prevention and actions to reduce the toll of diabetes on those already affected.

Yes we knew that making insulin affordable does not prevent diabetes. Furthermore he has created a strawman, asserting affordable insulin=restricted access to care! He doesn’t explain in a cogent way how or why this would happen.

Regarding his final comments:

“Patients must have information needed to choose the right insurance plan to help achieve positive results.”

Information doesn’t pay for insulin.

“Insulin research must continue to evolve, allowing patients superior control, less frequent injections, and better outcomes.”

Yes we want research into better insulins, but it would be nice if we could afford the insulin that we have access to now. What good is any type of insulin if you can’t use it?

“As a lifelong patient advocate, I know Nevadans expect more out of their elected officials.”

He’s a patient advocate? He wants patients with diabetes to pay more for their insulin and then calls himself an advocate?

At the bottom, Larry Hausner makes this disclosure:

However, he has another role that he didn’t disclose in this article:

Based on other articles from the internet, he is described as the chief patient advocate of the Partnership to Fight Chronic Disease. That’s right he knows our friend Ken Thorpe, the chairman of the Partnership to Fight Chronic Disease, which is supported by PhRMA!

But unlike Ken, his photo, which used to look like this on the PhRMA website,

https://twitter.com/Jandelliott/status/854109775629623298

Now looks like this.

https://twitter.com/Kidfears99/status/854104850837196800

And he pens articles on the internet with titles like this: Medicare ‘negotiation’ is a farce that can hurt patients. Hmm.

Just like with national politics, make sure you understand the ties that bind, before you believe anything written on the internet these days:

And don’t forget the 7 major arguments regarding we can’t cap the price of insulin, according to Ken and Larry:

Thanks to the human network and in particular to @Kidfears99, @Jandelliott @MelindaMWedding for keeping me in the loop.

For more information, read this article by Jon Ralston of the Nevada Independent about the current lobbying fight of Big PhRMA.

https://twitter.com/joyclee/status/854172865637351424