Primary Care Corner with Geoffrey Modest MD: Big pharma – the beat goes on

front page article in NY Times on excessive (extortive) costs of medical equipment/meds (see here). from my extrapolation (pretty crude) of their graph, between 1987 and 2008, outpatient costs have stayed flat at about $750, inpatient costs have gone down a bit from $1550 to $1400, while prescription drugs increased from $450 to $2200.

the article highlights type 1 diabetes and insulin pump therapy, though mentions the dramatic increase in costs for rheumatoid arthritis, etc [on that note, it was a great pleasure posting the blog on rheum arthritis drugs last june — will append to end of this blog]. they highlight a woman with an insulin pump. cost of pump $26,400. her cost after insurance $4224. monitor probes at $100 and need to be replaced every 6 days, disposable tubing replaceable every 3 days, 10 or so teststrips (which can be $1.50/strip),  and insulin which has sky-rocketed to $200/bottle essentially through monopoly pricing.

and, of course, she is mostly a captive audience, assuming she wants optimal treatment to decrease complications (which, in addition to improving her quality of life, saves the system huge amounts of money later on). the article adds that in “most other developed countries, with or without national health systems, provide free care and supplies for people with chronic diseases,… and they bargain hard with drug and device makers to bring down list prices”.  eg “the vial of insulin .. for $200 in an American pharmacy is typically bought by British pharmacists for under $30 and dispensed free.”

this also brings up the trawling that medical suppliers do directly to patients and to us guys: faxing us papers to sign to give new “and better” equipment for patients (no charges for the equipment included, of course), soliciting patients to ask us for a motorized scooter or wheelchair, or a recent patient of mine: he had type 2 diabetes but needed a 3-day continuous glucose monitor to figure out why his A1c was so high despite his multiple well-controlled fingersticks taken many different times of the day; i was then confronted by the company doing the monitor to see if i would sign an order for him to get an insulin pump!!!! (again with no mention of the exorbitant charge)…

Rheumatoid arthritis blog from june 2013:

NEJM with recent article on therapy for rheumatoid arthritis refractory to methotrexate as single agent (mean dose 20mg/wk), comparing adding on sulfasalazine (titrate up to 2 gm/d) plus hydroxychloroquine (400 mg/d) to adding on etanercept. (see DOI: 10.1056/NEJMoa1303006).  353 pts from VA hospitals.

 –no difference in clinical scores (ACR20 and ACR50) at either 34 or 48 weeks
–no diff in radiographic progression at 48 weeks
–similar improvement in functional outcomes
–similar number of adverse events (GI mostly with triple therapy, infections more with etanercept)

 so, there are many potential advantages in the triple therapy: it is a lot cheaper, it has been around for a long time (one concern is that the TNF inhibitors may cause long-term problems, like cancer, by their profound immunologic effects — and is associated with more infections in the short-term), and rheum arthritis can again be treated in the primary care setting (i had treated many RA patients in the past, but have been referring them to rheumatology because of the imperative to treat early and aggressively, esp with the new-fangled biologics…..)