Why treating diabetes keeps getting more expensive | Hacker News Reader

Why treating diabetes keeps getting more expensive

washingtonpost.com

57 pointsmhb62 comments

As a type-1 diabetic of 17 years now, I can confirm that the price of Insulin has been steadily rising over the years.

I can also state that the majority of my medical expenses go to insulin pump supplies, not insulin itself. On average, I'm paying roughly $250/mo out of pocket, after 90% insurance coverage for the whole diabetic kit-and-kaboodle. I would be quite troubled if I were to lose my job and/or medical insurance. Thinking about the future, it's definitely a fear of being in a circumstance where I will be without supplies for any amount of time.

As another commenter noted, and got down-voted instantly, a large cause of the insulin usage increase (and therefore pump increases) is due to a dramatic increase in the diagnosis of type 2 diabetics.

Depending on where you're treated, many type-1 diabetics are given a rather thorough crash course on the disease (and it's symptom-based-cousin, type-2, for comparison). In my opinion at least, I don't feel like many type-2 diabetics are given as much information, or are potentially more reluctant to absorb it.

It's a broad generalization, but not necessarily inaccurate, to state that most type-2 patients rely on medicines to treat their symptoms and will not adjust their diets even under the worst case scenario. Type-2 in many ways can have it's symptoms reduced/resolved by something akin to a keto diet. That said, sugar is ridiculously hard to quit.

I think the reason the other comment about the effect of increased type-2 diagnosis on price was downvoted was that it stated a simple and direct causation between growing demand and prices.

I agree that type-2 patients should receive better orientation in terms of dietary treatment, but this growth in demand could (should?) also lead to an economy of scale, especially for pump supplies, and a price drop. I have the impression that it is not the free market (through demand growth) that is increasing the prices, but rather a lack of free market (through cartel).

Thanks for sharing your experience. I have a close friend with type 1 who feels quite trapped in his profession because of dependence on insurance for supplies. It's difficult to see it from afar and not have any solution to offer. Is this a problem unique to the US health care system, or in every first world country?

T2 diabetes can be resolved with a high carb diet too, but people dislike eating vegetables. There's nothing as satiating as fibre filled meal filled with slow release/absorption carbs. No sugar spike, nothing, after 1500kcal cooked beans meal.

“I don’t think it takes a cynic such as myself to see most of these drugs are being developed to preserve patent protection,” said David Nathan, a Harvard Medical School professor. “The truth is they are marginally different, and the clinical benefits of them over the older drugs have been zero.” -- quote from article

And there you have it. I have seen this myself. One year ago, the insulin I was on was removed from the pharmacy, and coverage by my insurance company was also voided. My only choice, I was told, was to switch to a new insulin (which - as article states - was only marginally better, if at all), but which had a fresh patent and thus ensures new profits for another 20 years to come.

And so the wheel keeps churning. Patients are not given a choice, because we are not humans. We are merely a commodity to pharmaceutical companies' profits and shareholder value.

I always thought that when patents expire, a generics company will duplicate the drug (or treatment mechanism) and the prices will plummet to close to marginal cost due to competition. I get the impression that this happens in Europe, given the generic options that I am encouraged to choose when I’m picking up a prescription at the pharmacy. They are invariably cheaper.

What is different for diabetes, or the United States, to cause this to not be an option? Seems almost like a human rights violation, or at least deeply unethical.

Generics still require FDA approval, which costs on the order of single digit $millions to obtain. Plus you’ve got to set up the plant to create the drug, which costs more $. Would you invest $millions in a product when a competitor (who probably already has plant capacity from when they made the drug while it was under patent) could come in and undercut you at a moments notice?

Obviously not - so the system ends up in a metastable state where one monopoly producer can charge high prices for a drug & no competitor will enter the market because they know the producer can and will undercut them the moment they try and do so.

This one of the reasons why the health care system in the US is completely borked.

Only true for rare and ultra-rare diseases.

As far as I’m aware, all generic manufacturers must prove what the FDA calls bioequivalence: https://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrug...

This is accurate for niche drugs, but the business model for producing generics isn't solely one in which small players exist.

Large omnibus generics manufacturers almost always have a larger industrial base and better chemical engineers than one-off drug producers. If the drug has a fairly stable high volume demand, they can finance expenditures for approval, then leverage their production and distribution networks to produce substantial margin even if they dramatically slash prices.

Insulin is being “grown” genetically modified organisms in vats. It is not a simple molecule you get by mixing chemicals together.

The very first application of the human genome project.

The whole process of production is non-trivial, every step heavily patented and secured. Also pretty expensive.

There are new biotechs currently working on CURING diabetes, but no one is doing trials on humans yet. Means we’re at least 10 years away from a cure.

And no, those are not crazy 18 year olds in a garage. Spark Therapeutics now has an injection to cure macular degeneration, Moderna is building a whole RNA modification platform with 19(!) individual drugs in the pipeline.

It is very likely that we’ll see a major shift of medicine to curing, rather than treating in the next 20-25 years. Hep-C now has a cure. Still so, so amazing. The Human Genome project will turn out to be one of the most live-saving accomplishments of humanity, next to the green revolution in farming.

The process for introducing an insulin-gene plasmid, then selecting for and breeding the resulting recombinant bacteria is 101 level biochemistry that a Masters student could do in almost any decently equipped laboratory.

Isolating the chemical on an industrial scale is where the difficulty comes in, but most of the equipment is fairly commoditized and it isn't prohibitively expensive or skill intensive. The marginal cost following the relatively inexpensive setup is exceptionally low, too - you feed the bugs, they make your drugs.

Insulin would be priced as a commodity if not for the IP, approval and distribution issues - small biotech suffers from very poor distribution networks.

what was groundbreaking 25 years ago is now 101 biochem.

progress!

Which is why it's very confusing that products with such an utterly trivial production pipeline are remaining so expensive -- to say nothing of growing in cost over the years.

Don't forget that switching insulin is not easy. You have to adjust and refine the amounts you take for several days or even weeks, while closely monitoring your blood sugar during that period. It's stressful and unpleasant. Here, you are forced to do that once (one year before the patent runs out) and it sucks. Why do it twice? If the insurance company covers the new insulin anyway?

But the insurance company masks the real price. All our insurance policies are getting more expensive and cover less because we are all paying for it, together. We all know it, but we all take the easy way out. Including me. You are right, it is deeply unethical.

Europeans more often think holistically about health care (and its cost), which is a good thing. In the US, health care (and its cost) is primarily driven by corporations whose primary goal is profits and shareholder value. They are not aligned.

Many generics in the US do cost around $5 a month or less.

For some drugs, the manufacturers work the system, withdrawing their previous version from the market and launching a new version with some tweak. Withdrawing the old version makes it more difficult for someone else to get permission to manufacture and sell it.

The basic problem is that (the majority of) the engaged, wealthy part of the country gets their insurance from someone else and doesn't give a shit about how much medical stuff costs. And we have a medical system where the primary regulatory impact on prices is from capture.

From the article:

> There have been few efforts to create a cheaper insulin. Walmart, for instance, sells Novo Nordisk's human insulin under the name ReliOn for $25 a vial. Eli Lilly is expected to release the first copycat insulin analog, a chemically altered form of insulin, at the end of this year.

You can buy this product right now, it is the same formulation you would have taken if you were diabetic in the 1990s. https://www.walmart.com/ip/Pharmacy-Relion-Humulin-Insulin/1...

I am amazed by how many diabetics and GPs don't know this exists.

As the husband of a type-1 wife, I just wanted to add that there is a difference in insulin that isn't just long-acting or short-acting. Different people can react differently to different insulins. My wife used the ReliOn brand for both for a while, and even though the short-acting was fine, the long-acting was way too inconsistent (some very non-deterministic lows and highs). Switching to Levemir long-acting smoothed those out.

That said, nothing inherently wrong with the ReliOn brand if that's all one can afford. My wife forgot her short-acting insulin for a long weekend trip one time and it was nice to know what we could simply buy some insulin out of pocket and not get gouged to death.

> am amazed by how many diabetics and GPs don't know this exists.

I've noticed that GPs don't know enough about diabetes, one needs a specialist to really get control of it.

Whats up with those US prices, Humalog more than $250 per vial? In Europe (Finland) non-subsidized price is $34.

Drug pricing in the US is complicated. Humalog list price has doubled in the last few years, but the rebates have increased faster and the average net price is actually going down. The average discount is 75%!

https://www.bloomberg.com/news/articles/2017-06-29/the-crazy...

So it's $75 a vial, only three times as much as the NHS.

I am not sure that it is complicated so much as, they gouge anyone they can in the US.

Not complicated at all, insulin keeps people alive and our shareholders need a return on their investment.

They gouge anyone they can, but the fact is that they cannot do it as well as before with the “old” products because their sales are going down (in dollars, despite an increase in volumes). And the “new” products are often not good enough to justify higher prices.

Edit: By the way, we’re not talking about insulin (which has been keeping people alive since the 20’s) but about insulin analogues developed in the 90’s.

The NHS pays $23 in the UK. <https://bnf.nice.org.uk/medicinal-forms/insulin-lispro.html>

That's incredible. Humalog is a quite similar low price in Canada. It's strange that it'd actually be economical for many American diabetics to just book a (yearly) flight to Canada and buy 12 months worth of insulin.

As others have stated, pricing and insurance in the US is a complete rats nest. There are rebates and discount card programs available to the vast majority of patients that mean that most patients are paying much much less than that.

Interesting, the response in the UK has been to address this by attempting to pump money into programmes to to try and prevent type 2 diabetes or at least reduce its growth. Still too early to see how these efforts will be.

There have been a few small scale trials in the UK where type II people are put on diet of around 600 to 700 calories a day for a couple of months. Indications are for about 40% of those who took part they returned to normal levels - i.e. no longer had diabetes.

Anecdotal but a 50ish year old friend had Type2 and went to stay with relatives on a farm for a few months. He spent 10-12 hours a day helping out and when he came back he'd lost weight and also was no longer diabetic.

The NHS spends £14Bn a year on diabetes, of which £11Bn on type 2. To put that in perspective the annual budget is £125Bn.

The UK is the second-fattest country in Europe after Malta, and obesity (BMI > 30.0) puts you at risk for type-2 diabetes. It's a public health issue.

Interestingly, the other thing that's a risk factor is lack of sleep. Huge commutes put you at risk for type-2 diabetes. Who'd have thought?

> obesity (BMI > 30.0) puts you at risk

BMI>23 if you are South asian

https://www.diabetes.co.uk/south-asian/

That should be the response everywhere. The soaring cost of diabetes is largely tied to the soaring numbers of Type 2 diabetics, and the treatments are really just alleviating symptoms, and aren't actual cures. The only way to tackle the problem is to get (Type 2) diabetics to lose weight. Though this is obviously easier said than done.

Dr Fung's article [1] is a good complement to this one and explains how the market for insulin has been deliberately increased. As other commentators mentioned, once you can have carbs with insulin, why bother changing and looking for an alternative? Dr Fung treats patients with fasting protocols, where compliance is harder, but costs lower. FTA I just learned that Dr Banting is famous for both insulin and the original (proto) Atkins diet.

[1] https://medium.com/@drjasonfung/the-diabetes-payroll-291649d...

Insulin is just like when you have performance problem in a monolithic app and you throw more hardware at it, but at some point you can't upgrade your server anymore.

Not sure if there's much you can do while diabetic, but cut bread-like and sugary foods, these spike your insulin the most and your body becomes insulin resistant and so you need more and more insulin, more that you can make.

As a type-1 diabetic, your body no longer produces any insulin at all. This means even without eating any carbohydrates, your blood glucose rates will elevate every hour until you eventually succumb into a coma and shortly after, perish. I use about 34 units of insulin per day, excluding any carbohydrates -- this largely depends on body type as well, some people use much more.

A type-2 diabetic on the other hand, depending on how far their disease has progressed, could potentially ween themselves off insulin entirely if they were to completely abandon carbohydrates. These diets are extremely hard to maintain, especially indefinitely, however.

Yes, sorry, I was thinking at type-2 diabetes, I have a relative with type-2 and doctor told her to cut alcohol, sugar, carbs, etc, type-1 is entirely different, the immune system attacks the pancreas.

Thanks for the apology, but you got me quite irritated with your first comment. It was like saying to a paraplegic in a wheelchair to man up and hit the gym because there is only so much you can do with a wheelchair... Dreadful.

Just to add a bit of a positive spin on this: even type-1 diabetics could take measures to both improve their health and reduce the amount of insulin they require.

I consider myself moderately overweight at this point (maybe 10-15kg). If I lost weight, I could reduce the baseline amount of insulin I need every day, thus reducing the amount of insulin overall that I need to pay for.

I also fully acknowledge that, upon getting an insulin pump (16 years ago), I instantly became aware that I had much more freedom to eat what I want, when I wanted and thus, put little effort to cutting back on sugar outside of switching to diet drinks. If I were to switch to a low-carb diet, or no carb (which is admittedly very hard, I've tried), I could further reduce my insulin costs.

Personally (keep in mind these numbers depend highly on each individual), if I got my weight down 10kg, and ate < 100g of carbohydrates per day, I could theoretically only require ~35-40 units of insulin per day. At 40 units, I would only need ~1.35 vials of insulin per month. Ballparking, I'd say my current rate is likely around 2 vials per month.

You still need to have carbs in your diet, it wouldn't be healthy otherwise. Especially if you practice a sport.

I eat whatever I want (mostly pasta usually) and I need 20 units a day at most. (100 units/ml dosage).

Doctors Phinney and Volek would disagree on the carbs/sport connection.

Then they should come with an explanation as to why I want to throw up and can't do anything when doing sport with no insulin to use my carbs.

I think the reasoning goes because you are used to using carbs as your energy source most of the time, your body doesn't know what to do at first when it doesn't have any available. The body adapts surprisingly well to different energy sources, so if you drop all carbs, your body will burn fat for energy and create ketones.

It kinda sounds crazy, and I used to think it was, but I'm currently low carb to lose weight (lost 28 pounds in 3 months with it so far!). It just takes a couple weeks of training while on the diet to get your body to catch on and be back to your usual performance.

There are actually a surprising number of world records set by athletes on low carb diets who destroyed previous records that claim their diet is the main reason they were able to accomplish their goals

There's no dietary or metabolic need for carbohydrate. The human body can survive and thrive perfectly well with only fat and protein as macronutrients. Practically speaking, doing that is challenging and complicated because most foods are a mix of all three macronutrients.

But do you need sugar? Or you don't need either sugar nor carbs? It seems strange to me. EDIT: it seems that if you use only your fat, you'll end up producing too much Ketones which leads to Ketoacidosis. Doesn't sound good.

No, ketosis doesn't lead to ketoacidosis unless you completely neglect to manage your insulin.

Ketosis is perfectly healthy. You are very confused.

This is patently untrue.

No you don't.

Source: The Art and Science of Low Carbohydrate Performance by Phinney and Volek

I wonder if there is open-source equivalent in pharmacology

http://openinsulin.org/

I am not sure if any of these programs are still around, but older, generic forms of insulin are available for free or greatly reduced price at many pharmacies to qualified applicants.

http://www.needymeds.org/ Is a non-profit group that helps provide free/low cost meds.

Many pharmacies listed offer free/reduced price insulin. http://www.freediabetestestsupplies.com/free-diabetes-medica...

The title should be updated to reflect that this article is from 2016.

> Why treating diabetes keeps getting more expensive

Because there's a "type 2" diabetes epidemic, and instead of doctors telling people to stop eating for a while, they sell them insulin.

> and instead of doctors telling people to stop eating for a while

People won't stop eating (and especially drinking) high-sugar stuff unless they're on their deathbed. The stuff is addictive as hell.

i reread the china study. chapter 8 is diabetes. it claims animal protein, not carbs, causes diabetes.

Number of people suffering from diabetes has risen exponentially, demand goes up, so do the prices.

It's going to stabilize as years go on.

Demand has gone up it hasn't risen exponentially. The manufacturers have colluded to raise the price. There is no reason for it to ever come down.

We live in the age of globalization and capitalism. There's bunch of cheap stuff coming from all over the world. Collusion on that scale is not possible.

There's just more people suffering from diabetes T2 than ever before. Someone is just profiting off of large demand.

> There's bunch of cheap stuff coming from all over the world.

Said cheap stuff from everywhere cannot be legally mass-imported into Western countries (and that for good reason).

> Collusion on that scale is not possible

Oh it certainly is. The "old" insulin may be produced as a generic but the new varieties (as described by the article) are patented by a few companies.

In addition insulin production is extremely expensive compared to simple pill pressing as you need bioreactors and GMOs to produce it. Many generics vendors opt out of that complexity.

I would refine "globalism and capitalism" to just "corporatism". It really is socialism for companies and capitalism for you and I. Patent laws suit big Pharma. Trade law and health guidelines suit big Agriculture. (Ketoer here so you know where I'm coming from.) Tough luck for the millions of people caught in the middle between these influential sets of oligarchs. It is abhorrent that regular people subsidize (and pay a high price in life and limb) for government's covert largess to these corporations.

Demand absolutely has skyrocketed. When people think "diabetes" they think of fat people in the US and Europe. The reality is that China and India have developed some of the highest type 2 diabetes rates in the world over the course of the past few decades as their economies have grown and resulted in more overweight people. The two largest nations in the world developing major diabetes problems in a relatively short amount of time is going to have significant effects on demand.

One expects prices to always rise in response to increased demand in the short term. One might call that the short term inelasticity of supply due to economic inertia; it simply takes time to ramp up production.

But what of the long term? With products such as food, one expects that the best land is already in production, so increasing supply will require bringing marginal land into use, at higher cost. Supply is inelastic and prices rise. Similarly for minerals. One is usually mining the richest ores. To increase supply one has to spend more freely refining lower grade ores.

There are no such constraints for producing insulin in medicinal quantities. The supply should be completely elastic, with the result that prices do not rise.

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