Four strategies to obtain affordable insulin
CHICAGO — As the cost for insulin continues to rise, clinicians can take several proactive steps to help uninsured and underinsured patients afford their medications today, according to a speaker at the Cardiometabolic Health Congress.
Insulin prices, which tripled from 2002 to 2013, continue to climb, nearly doubling between 2012 and 2016, according to 2017 data from the Health Care Cost Institute. The steady increase in prices has led to an outcry from stakeholders on all sides, including clinicians, patient advocates and the federal government, yet little has changed with respect to the high list prices, said Irl B. Hirsch, MD, professor of medicine at the University of Washington School of Medicine in Seattle.
“At the end of the day, this should not be about politics,” Hirsch said during a workshop dedicated to insulin affordability. “This should be about we as physicians asking the question, is having access to insulin a privilege or a right?”
A complex web of insulin supply chain members, beginning with manufacturers but also including insurance companies, drug wholesalers, pharmacies and pharmacy benefit managers (PBMs) has made the problem of high insulin prices a difficult one to solve, Hirsch said.
“Most people want to put the blame with the pharmaceutical companies,” Hirsch said. “I consider the PBMs the pituitary. This is really the center hub of how the money flows. It starts at the drug company ... but to get to the patient, all of these other parts [in the supply chain] want a cut. The consumer gets it, but these other entities want a cut of this money.”
The complexity of the system makes it nearly impossible for changes to happen anytime soon, even though people with diabetes are rationing their insulin today, Hirsch said.
“None of us individually can change our dysfunctional system, but we need to help our patients,” Hirsch said.
Hirsch outlined several strategies for clinicians to share with patients to help them gain access to insulins they can afford:
Human insulin — Both NPH and regular insulin can be purchased for just $25 at Walmart and, now, CVS, Hirsch said, though some states may require a prescription. Due to kinetics, NPH insulin can act as both prandial and basal insulin, Hirsch said. These insulins, he cautioned, do not come without risk — NPH insulin needs to be gently agitated to mix the suspension, and studies show there is greater risk for nocturnal hypoglycemia when starting NPH insulin vs. insulin glargine. However, with careful education and support, including tips like “strategic snacking” to avoid large glucose excursions, this risk can be safely managed, Hirsch said.
Additionally, real-world data from a JAMA study that assessed outcomes from a cohort of Kaiser Permanente Northern California patients with type 2 diabetes using insulin suggested there was no difference in the primary endpoint of hypoglycemia-related ED visits or hospital admission when comparing NPH insulin with analog insulin, Hirsch said.
“We’ve all been brainwashed that we need to put people on analog insulin,” Hirsch said. “Don’t get me wrong, I’d love to use analog insulin, but it is just unaffordable. Human insulin requires a different understanding of its use, but it is doable and effective.”
Patient assistance programs — The three manufacturers of insulin — Eli Lilly, Novo Nordisk and Sanofi — each offer their own patient assistance programs for patients with no insurance or high deductible insurance plans, Hirsch said, adding that, after much scrutiny, the available programs are now “easier to use than they were 3 years ago.”
These include the Lilly Cares patient assistance program, available at www.lillycares.com, Sanofi’s RX Assist program available at www.sanofipatientconnection.com and the Novo Nordisk Diabetes Care patient assistance program, available at www.novonordisk-us.com/patients-and-providers/patient-assistance-programs/diabetes-care.html
“Please share these with your patients,” Hirsch said.
Lilly and Novo Nordisk also now offer “authorized generic” versions of their rapid-acting insulins, promising list prices that are 50% lower than their brand-name counterparts, Hirsch said.
“I would argue that those prices are still unaffordable,” Hirsch said.
As a short-term solution, co-pay cards are an option for some patients, Hirsch said; however, the insurer still has to pay the cost difference to the drug manufacturer. Such coupons also “sabotage the tiering system,” he said, noting that with co-pay cards, there is no incentive to negotiate a lower tier with insurance companies.
340B pricing plans — A U.S. federal government program created in 1992, 340B pricing plans require drug manufacturers to provide outpatient drugs to eligible health care organizations and covered entities at significantly reduced prices, according to the federal Office of Pharmacy Affairs.
“If you are in a hospital setting where you qualify, you can get insulin for $10 or $20 per vial,” Hirsch said. “Nobody talks about this, and if you don’t know if you have 340B, you need to find out.”
As of October 2017, there were 12,722 covered entities participating in the program, according to Hirsch. One-third of U.S. hospitals participate, and 340B accounts for 5% of all medicines purchased in the U.S.
“I have no doubt that there is somebody in this room who has access to this and does not know about it, so, ask a hospital administrator,” Hirsch said. “This is so important, and not just for insulin.”
Insulin from other countries — It remains illegal for Americans to order and receive prescriptions online or through the mail from pharmacies in Canada, Hirsch said. However, Canadian pharmacies can ship prescriptions to the U.S. under Canadian law. Additionally, bringing small quantities of medication across the U.S. border for personal use is allowed, Hirsch said. In-person, insulin can be purchased throughout Canada for about $30 per vial or $50 for a box of insulin pens, though it is more expensive if purchased online, he said. Only Australia, the United Kingdom and the U.S. require a prescription for insulin.
“My patients go to Canada and sometimes they just go across the border, get their insulin and come back,” said Hirsch, who estimates that 20% of his patients pay for their insulin by crossing the border. “This is what people do.” – by Regina Schaffer
Hirsch IB. Navigating insulin access and cost. Presented at: Cardiometabolic Health Congress; Oct. 10-13, 2019; Chicago.
Disclosure: Hirsch reports he has received research support from Medtronic Diabetes and is a consultant for Abbott Diabetes Care, Bigfoot and Roche.