This past Friday night we had dinner with some of our family in South Georgia. Two of those present besides me were an independent pharmacist in a small town and my wife, who is a gynecologist.
They got into an interesting conversation about the experience of a patient who needed a particular well-accepted and researched standard hormone blocking treatment for a gynecologic condition. (At least it wasn’t about politics!)
The patient happened to be on Medicaid, and for whatever reason the state Medicaid care plan wouldn’t cover the medicine, leaving the patient to try to pay for it and bring it to the office. Sadly, can’t be done: the cost according to the patient was $2500, far outside their ability to pay. So the treatment can’t be given.
My reaction was that it can’t be that expensive. There must be some mistake, I said. After all, the medication—an injectable drug called Lupron, which is a well-used treatment for various cancers, including prostate cancer in men and breast cancer in pre-menopausal women as well as other medical conditions that require hormone blockade—has been around for a long time.
We stopped the dinner and the conversation and went to Dr. Google to look up the cost on one of those discount pharmacy plans advertised regularly on TV. Turns out the patient was not correct: the prices we found online were—drumroll—only $1500 with the discount card. Small comfort. To make matters worse: there doesn’t appear to be a generic available for this particular dose formulation.
Our next question was to figure out how long this medicine has been available. Medicines that are so expensive tend to be new and unique (except maybe insulin!!!).
A quick search (love these smart phones!!!!) answered that question: since 1989. Yes, the Food and Drug Administration approved Lupron in 1989. That was 33 years ago!!!
So, after 33 years, this medication still costs a small fortune. Hasn’t changed in those 33 years. And I doubt it cost $1500 or $2500 or anywhere near that when it was introduced.
What has changed to justify such enormous costs for a standard pharmacy product? The real answer is I don’t know.
What I do know is that we now have insurance coverage for most of the medicines we take. And the behind-the-scenes deals by all the companies involved in the process of making the drug, paying for the drug, getting the drug to the pharmacy, and then getting it to you all have their hands in the pie.
And everyone seems to figure that the price doesn’t matter because there is little transparency, so what the heck? Most patients don’t realize how much these medicines cost because their insurance covers them. They are insulated from true cost—except for our patient, who really can’t come up with the cash (and neither could most of us, I might add).
What we have here is a fundamental failure of our medical care-free market system: a drug with many uses, high demand, long history of use in treating various medical maladies, not representing brand new research, and costing a small fortune especially for those who really can’t afford it. The alternative? Surgery. Any idea how much that will cost?????
As an oncologist, I appreciate and to some degree understand that the significant pharmaceutical breakthroughs we have made in cancer care over the last several years cost money for research, drug development, clinical trials and meeting regulatory requirements. I also appreciate that for some drugs, the time from going to market until a drug is replaced by another therapy may be relatively short. So occasionally there is some justification for high prices if we are to continue to advance our treatment options, especially when those drugs—such as certain targeted therapies—may have a very small number of patients who could have the relevant genetic profile to make them candidates for the drug in the first place.
On the other hand, we should be aware that several of the newer drugs in cancer start out with very limited indications to treat only a small number of cancer patients and see their “market” grow considerably as more indications are added to the list. Rarely does the price go down to reflect that larger market utilization.
Lupron doesn’t fit that bill. It was developed decades ago. It is a standard “go-to” drug, especially for prostate cancer. It doesn’t require new research. It is, in short, a cash cow—and someone is busy milking that cow for all that it is worth.
Unfortunately, there isn’t much that any of us can do about it. We rely on the goodwill of the pharma companies to price their drugs appropriately. They will undoubtedly say that the patient in question could get a significant discount through a pharma-based support program. However, since the patient is on a government insurance program that is not an option—not to forget the fact that the reason they are on that program is because they have no income to begin with.
No, in this situation a charity program doesn’t make up for the fact that a lot of us are getting soaked for an old-time drug that may have had its dispensing formulation (the way the drug is packaged such as in a single dose syringe with a very specific amount of medicine) changed over time to protect a patent but had nothing fundamentally different done to it since 1989.
There are a number of egregious examples of drug price gouging, or inflated prices not justified by anything rational: the rights to market a drug are “sold” from one company to another company, and the receiving company uses the opportunity to jack up the price of a formerly cheap medicine to astronomical levels; a pill in use for decades and “grandfathered” by the FDA has a company that runs a clinical trial with a predictable result (the drug worked as intended) and they end up with new FDA approval of a very old medicine. The drug goes from pennies to dollars a pill (colchicine, anyone?). A life-saving cancer drug is approved in the early part of this century, and over time sees its price increased and increased and increased. The original cost is way far away in the rearview mirror. No change, except for the price.
There are numerous articles in the medical literature discussing these issues. Yet with all the publicity and all the evidence, nothing much has changed to put the brakes on inappropriate and unjustified price increases.
I don’t expect or even want a pharma company or a drug executive to be personally punished over pricing, although some have (obviously for a lot more than just increasing the price). I do expect and want them to be rational, be sensitive, be appropriate and price accordingly. Maybe that’s asking too much, but this is a case that seems to me to be a prime example of misplaced greed. There is no justification that I can think of to explain why Lupron costs $1500 or $2500 or whatever.
Everyone seems to have their hands in the till—except us, the people who pay for the medicines whether we do so directly or through our insurance companies or through our state and federal governments.
We are getting hosed. Somehow, this just doesn’t seem right. Sadly, there is nothing new about that.
Len, maybe share this with Mark Cuban – as he is trying to create a transparent and affordable pharmaceutical drug supply chain. I don’t know all the details, but any mechanism that can act as a check and balance on these run away prices, so as to make pharmaceutical drugs more affordable – would be a good thing.
Let’s take a closer look at the intermediaries involved in the supply chain from the manufacturer to the ultimate delivery of this drug to that patient. It’s so easy to vilify the one entity that manufactures the only possibility of a longer life or a cure for cancer. Drug pricing is complex. The manufacturers are not blameless. However, the real villains in all of this are the insurers and the PBM’s who are enacting more and more schemes to profit on the backs of patients and employers. They are simply disgusting. I know. We see this each and every day!