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Do I Want to Take a Drug That’s So Expensive?
from Bryce M.

Hello Ed. I am another lurker deciding to write. You appear to be a fan of the biologic shots taken for psoriasis. I remember you’ve taken at least a couple. My dermatologist is recommending that I start using Enbrel, but the cost has blown me away. I have insurance with modest co pay (I think Enbrel at two shots a week would cost me $45 a month as co pay), so I can probably use the drug without too much financial grief. However, I’m concerned about the $1,000+ bill my insurance company will pay every month. My doctor has not cleared this prescription through the insurance company, yet, but he has other clients using my insurer who have had no problem getting approval. My family is encouraging me to try the shots. They say I shouldn’t worry about it. Still, I do worry about the cost, or getting hooked on the drug and then have the insurance coverage change to my disadvantage. The overall dismal economic climate doesn’t help my peace of mind, either.

You wrote once before (can’t remember where) that the high cost of these most-effective drugs creates a “haves and have-nots” society. I agree that’s part of the problem, but only a consequence of the most IMPORTANT problem, which is our skyrocketing cost of health care in the United States. In another place you mentioned that somehow this class of drugs has escaped the patent (or whatever) limitations FDA allows on manufacturers of new drugs. This is the policy that allows generic versions of a drug to be manufactured and sold by others after the originator of the drug has had a monopoly for some specified period of time. Is that still true? Are we never to get generic versions of drugs like Enbrel?

It bothers me that at one end of the prescription drug business we’ve got retailers like Wal-Mart offering $4 prescriptions for generic drugs and then, on the other end, we’ve got the manufacturers of these shots for psoriasis, getting well over a $1,000 per month with no end in sight.

I also remember you writing that the high cost of new drugs that work for psoriasis is probably a contributing factor to an increased interest in alternative therapies. Speaking from my own experience, I can certainly verify that I am taking a closer look at the ‘cure psoriasis’ diets before I jump into using the shots.

Finally, you mentioned in something you wrote that you will be in trouble, shots-wise, if you lost your insurance.

All of this makes me wonder if I even want to TRY the shots? According to the palm=1% deal, I’m only 10-20% covered at my worst, but one of the reasons my dermatologist is pushing the shots is I have lesions SOMEWHERE all the time. So, I guess you would say I am a “full time moderate” flaker. –Bryce M.

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Ed’s Response: Tell me, Bryce, have you used any other systemic meds that aren’t shots? That would be methotrexate, cyclosporine or Soriatane in the U.S.  –Ed

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Bryce’s Response:  No. My doctor talked to me about methotrexate but because of side effects (and a borderline liver test not long ago) he said the shots would be safer. I have already taken the TB test and have been cleared for Enbrel if I make the decision. –Bryce M.

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Ed’s Response: I had hoped that the slow-but-dependable growth in the number of biologics approved for use as psoriasis/psoriatic arthritis therapies would result in a drop in overall costs, and I’m not a savvy enough businessman to state with authority why this is not so. But three things come to mind.

One, I don’t think any of the manufacturers has generated the psoriasis-business at levels they anticipated or set as goals. This means their incomes from these meds are probably behind schedule and keeping prices the same (high) is a good response as far as stockholders may be concerned.

Two, they are not compelled to lower prices so long as they have that monopoly on their particular product. The way most of us are bouncing around from bio to bio trying to find one that works with staying power suggests to me that efficacy, more than cost, is currently limiting the market. They’re ALL expensive.  (Can’t wait to see what the price will be on the new 4-times-a-year infusion drug now in the final stages of approval; i.e. Centocor’s Ustekinumab.)

(NOTE: When I failed to respond as desired to Humira, two years ago, my rheumatologist doubled the dose. I learned not long ago that, while I’m paying $30 a month co pay for this double dose, my insurance company is paying $2,080 a month. It’s like sticker shock, vicariously.)

Three, for reasons being enacted every day, but still not explained, some flakers just do not respond as desired to some biologics. In my correspondence here I’m detecting massive amounts of churn, though slowly. Docs are compelling flakers to “stick with” a biologic for at least six months before throwing up hands and seeking something new. I hear from more and more people who have been quite happy with their biologic’s performance until suddenly — after a year or two — it just stops working. This baffles the docs, too. My rheumatologist says most of her patients who abandon a course of biologics do it quickly (after the six month try-it period) and that, if a patient sees good results initially they will probably continue to see good results. She told me a few days ago that some of her Humira patients (taking it for rheumatoid arthritis) have been on it for a decade. If the churn I’m detecting is detected by the pharmaceutical companies, too, it probably shows up as jaggies in the income curve. A patient on a med like a biologic represents something like subscription income.  That is, the med becomes a monthly expense paid just a reliably — if not more reliably — than rent and the utility bills. Therefore, it’s anticipated that the income curve and the number of prescriptions curve might be similar for a drug that’s supposed to work in perpetuity on chronic conditions. For the time being, at least, that theory of parallel curves does not seem to apply to biologics for psoriasis. Of course, I’m not responding from raw data; I’m responding to emails I receive. Those flakers living well and continually on their biologics are the least likely folks to drop me a line.

Aside from these three gut level responses, I think I’m in the same boat as you, Bryce. Only I’ve made a decision already. I did write that I’d be S.O.L. if I lost my insurance coverage, and the biologic would be the first prescribed drug to go (the heart meds would probably be the last). Meanwhile, am I uncomfortable with such large amounts of money supporting my “bio habit” (almost $25,000 per year)? Yes, I am. What rationalization do I use to sleep nights? Well, here’s one version:

I function better when I’m not flaking, therefore it’s to be expected that I value my non-flaking state. I certainly could not pay $25,000 per year to preserve that state, but I happen to be, for the time being, part of a system that enables me to be there without personally paying the tab. That’s what the concept of insurance is all about.  But I also believe all of it — the pharmaceutical price-setters, the insurance payers, the doctor prescribers, and we go-along patients... — amount to a house of cards. A house that is structurally unsound and in need of change; all of healthcare in the U.S. today is one of the children of a free market economy that needs better standards — self-imposed and/or regulated.

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