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Comment by sithlord | Hacker News Reader

This is so incredibly wrong - and trying to claim something you know obviously nothing about is hilarious.

The different between NPH (regular insulin) (maybe R too, not sure??) sold by walmart and Fast Acting insulins (Novolog, Humalog, Apidra) is massive.

Fast acting insulins start working at about in about 30 minutes and "peak" at like 2 hours, and may slowly have some effects for another 1-2 hours.

NPH on the other hand, starts working at ~2 hour mark and continues to work slowly until peaking at like 6 hours and slowly degrades away, that means its in your system for something like 9 hours - trying to meal plan around multiple doses of that is unsafe at best.

R is slightly better but still remains and slowly peaks closer to 4 hours.

These are obviously GREAT IF and only IF you dont have access to fast acting. I applaud Walmart for giving access to these, as they are way better than nothing.

source: Type 1 diabetic

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I do know what I'm talking about. Also diabetic.

Yes, there are different insulins and Novolin is an intermediate-acting insulin like you describe and available at those prices.

Thanks, sithlord. My wife is a type 1 diabetic and it's even worse than your comment suggests, because the different fast acting insulins have a different curve (when do they start working, when is the peak, how long do they have an effect) and our insurance company keeps making her switch to a different "equivalent" formulation because the price to them is lower this month. This means that there's a learning curve, more highs and lows, when she has to switch.

Humalog's patents have expired, as I understand it, but cartel behavior has kept the price high in the US.

The net price on Humalog has gone down since 2014. The PBMs are the ones who distort list prices.

The PBMs are mostly owned and operated by the managed care organizations (insurance companies). The insurance companies have profit margins of less than 5%.

This is not true and just an industry talking point from the PBMs. They use revenue tricks to hide their profit margin.

See https://www.fiercehealthcare.com/payer/facing-criticism-pbms...

My information is from 10-K filings with SEC, and my statement is referring to net profit margins, which are what they are. Unless there is massive fraud going on, managed care organizations are not earning massive profits. If their PBM divisions are, then they are simply subsidizing the insurance division, but it would make no difference to people. The total expense for premium plus out of pocket expenses would not change, it would just shift from one to the other.

> Unless there is massive fraud going on

That is exactly what is happening, and it's legal. It's very easy to hide profits and move them around.

One big element is that a lot of large companies and non-profits run their insurance programs as self-insured. They pay the direct costs of the medical care of their insureds, and keep the annual premiums the entire employee-base pays. The "insurance companies" are paid a percentage of the total revenue/claims as an administration fee, so they have incentives to push the overall amounts paid up, not down. Self-insuring eliminates the profit overhead of the insurance companies, but screws the incentives.

There are quite a few big insurers (better known as managed care organizations) competing for business, so the incentives are there to limit expenses so they don’t have the most expensive premiums.

Some insurers (looking at you United Health Care) have wholly owned PBMs. Thus, the PBM is an asset in its insurance trust. Any profit the PBM makes will appear as in increase in asset valuation for their insurance trust, or balance sheet in some cases.

However, insurance margins remain unaffected as the money did, in some sense, go out the door and is no longer in control by the insurer directly. It's not fraud. It's just anti-competivie self-dealing. So, no, it's not profits per se, but rather increased valuation via clever financial engineering.

All the big managed care organizations (better word than insurer) have their own PBM. I would need to read more about how an MCO accounts for assets set aside for insurance, but I would be surprised if insurance regulators are allowing it, considering how strict insurance regulators are.

A quick search shows me that on page 73 of Cigna’s 10-K, it clearly does not have its Express Scripts division accounted for in the “Investment Assets” section, based on how low those numbers are.

It just does not pass the smell test to me. The simpler answer, based on all the numbers, is that managed care organizations are squeezing other entities in the healthcare chain, but due to competitive pressure and upper profit margin limits due to ACA, they are not raking in big bucks.

This is probably true - and I am not here to point fingers - but I will say that the insulin manufacturers are at some fault too, they do just enough to keep renewing their rights to their insulins every time they come around.

You cannot renew a patent in the US. They get a new product patented, but anyone is still free to come along and make the older one. However, I bet there is a ton of expertise and cost required with doing that, and that is what is stopping others.

they "renew" by "improving" their existing product enough to make it obsolete, and to get a new patent. Per the article below this has been happening since 1923

https://www.hopkinsmedicine.org/news/media/releases/why_peop...

That is better described as a new patent. The product for the patent that expired is expired, and can be made by others.

Would it be possible to get a limited amount of the fast acting stuff for unpredictable situations and then normally use the "cheap" stuff? I don't know how this works so I would like some info from someone who seems to know.

Possible, sure, but not ideal. The "fun" thing about T1 diabetes is that every meal becomes an unpredictable situation based on exercise, sleep, stress, etc etc.

Slightly exaggerated, but only slightly: Imagine you could only drink water 6 hours before you got thirsty, but if you drank too much you might pass out (at any point 2-6 hours from now) or if you drank too little you're doing major damage to your body.

Really the only way to manage with that kind of insulin is to live a very, very low carb lifestyle. Its doable, but it limits your variety and leaves you prone to other potential issues.

Not likely, also lets not forget - as a Type 1 diabetic, you also take long acting insuling (unless you are on a pump). So, for example, a pump uses only fast acting insulin - and it gives a small amount (known as "basil") every 5 minutes (+/- depending on pump).

Whereas, if you use pens (or from a vial) with direct injection, you also take a long acting insulin (levemir, Lantus, etc) once or twice a day (they are supposed to last 24ish hours but often people find splitting their total daily dose up into morning and night has better results). And these insulins cost even more than the fast-acting stuff.

I thought it was “basal”, not “basil”.

That's mobile autoformatting for ya, you are correct. I would correct, but edit limits...

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