Drugs, drugs, drugs. We hear a lot about drugs. Especially about
the Opioid Crisis, which is a very serious problem in the US. But the other
drug problem we hear about is also very serious: the cost of drugs and the
inability of people to access the drugs that they need, not to mention to save
their lives, because of the cost.
One such drug is insulin, needed by people with Type 1
diabetes to survive. Stories of people dying from, or almost dying from, lack
of access to insulin, or having to go to Canada or Mexico to buy it, are both
sad and galling. It is particularly so in
the case of insulin because its discoverers wanted it to be free. In
1923, Frederick Banting and his colleagues Charles Best and James Collip sold
the patent to the University of Toronto for $1 each, worried that if
they did not patent it drug companies would patent an inferior version of
insulin (imagine that!) and people would die. The
University of Toronto gave the patent royalty-free to drug companies,
specifically Eli Lilly.
Unsurprisingly, that marked the end of being motivated by the
public interest. As
early as 1941, Lilly and two other companies were indicted for price fixing of
insulin, and it has gone on from there. In 1982, Lilly was able
to synthesize human insulin (previously insulin was made from beef or pork
pancreas, which had a lot of reactions, although pork was closer to human and
thus preferred). Of course, the price took off. With the complicity of the
government, worse in administrations that believed corporate profit (especially
for big donors) was more important than human lives, the price continued to
rise. This has led us to story after story
about people with diabetes, like Josh Wilkerson, dying because they could not
afford $1,200 co-pays. Banting and Best are turning in their graves.
Yes, pharmaceutical manufacturers are greedy and evil,
whether they make insulin or Epi-Pen
or colchicine,
or other drugs (like
pyrimethamine – see Martin Shrkeli) and deserve every bit of anger,
hatred, and scorn that has been visited on them. They are continually the #1
(or, sometimes, #1!) profitable industry in the US, making lots of money
because, well, people need their products to live. But they are not the only part
of the drug industry that is responsible for bleeding us for profit. They are
complicit with insurance companies, who agree to pay the outrageous prices that
they demand (because, after all, they just raise their premiums), and with our
bought-and-paid-for Congress. For example, when Congress passed the Medicare
Part D Drug Act in 2003 it contained a prohibition against Medicare, the nation’s
largest insurer, negotiating drug prices, thus ensuring that American pay far
more for drugs than people in other countries (there is a reason uninsured
folks go to Canada or Mexico)! As
I noted recently, the idea is often put forward that without drug company
profit, innovation in pharmaceutical discovery would grind to a halt,
but in fact nearly 2/3 of discoveries are made outside the US and most of those
in the US are discovered through research funded by the National Institutes of
Health.
But beyond the usual villains, pharmaceutical and insurance
companies, we have the wholesalers, retailers, and “bundlers” of drugs also making
out like bandits (they are bandits, even if, thanks to that bought-and-paid-for
Congress, their schemes are often legal) from our health needs. The “bundlers”,
called Pharmacy Benefit Managers (PBMs) are contracted by large insurers to
negotiate for the “best prices” with pharmacy retailers. For
a positive spin on what they do, see this piece from “The Balance”.
However, they are also responsible for a lot of the high cost of drugs,
especially for those with worse, or no, insurance. In addition, they have a lot
of practices that enhance their profit at your expense, many explained in this piece from the Commonwealth Fund,
such as jacking up the price charged to insurers and pocketing the difference
(“spread pricing”) and pocketing rebates from manufacturers. The entire role of
PBMs is complex and bewildering, but they play a critical role in the important
process of profiting off of your illness.
More recently, we have seen exposure of the nefarious
practices of the final link in the chain of getting you your needed medicines,
the retail pharmacies themselves. Of course, the old mom-and-pop drugstore on
the corner is almost a thing of the past, having been replaced by mega-chain
pharmacies such as CVS, Walgreens, Rite Aid and Duane Reed. (Of course, in many
big cities they are still on every corner, not just competing with each other
but with themselves; in places like New York City they are more ubiquitous than
Starbucks!) These chains drove out the small drugstores by underpricing them,
but having been successful in that, they have adopted practices that are
frequently unethical, sometimes illegal, and always guaranteed to make them
more profit. Indeed, two of the largest PBMs are now owned by these chains
(Caremark by CVS and Envision by Walgreens), enhancing the vertical integration
of the industry.
A New York Times exposé of January 31,
2020 by Ellen Gabler tells how retail pharmacies overwork their employees, sometimes
with resultant errors such as patients getting the wrong medicines and often
having adverse effects. It was titled “How
Chaos at Chain Pharmacies is Putting Patients at Risk”, but this
headline, while accurate, does not explain the real reason for the chaos, which
is that these pharmacies are using an old and dishonorable technique made
famous by Henry Ford in the early days of assembly lines called “speed up”.
Speed-up, increasing the expectations for “production” (in this case, number of
prescriptions filled per hour) has been a target of union contracts since the
1930s, but as the influence of unions has waned (with the collaboration of
pro-corporate legislatures) these practices have increased. Pharmacists may be
“professionals” (like nurses and doctors) but whatever your education and
training, if you work for a large corporation who sets the rules and standard
and has control, you are a worker, and need the protections that all workers
should have. The most conscientious of these professionals have protested,
often to the state boards that regulate them, as cited in the Gabler article:
In
letters to state regulatory boards and in interviews with The New York Times,
many pharmacists at companies like CVS, Rite Aid and Walgreens described
understaffed and chaotic workplaces where they said it had become difficult to
perform their jobs safely, putting the public at risk of medication errors.
They
struggle to fill prescriptions, give flu shots, tend the drive-through, answer
phones, work the register, counsel patients and call doctors and insurance companies,
they said — all the while racing to meet corporate performance metrics that
they characterized as unreasonable and unsafe in an industry squeezed to do
more with less.
“I
am a danger to the public working for CVS,” one pharmacist wrote in an anonymous
letter to the Texas State Board of Pharmacy in April.
“The
amount of busywork we must do while verifying prescriptions is absolutely
dangerous,” another wrote to the Pennsylvania board in February. “Mistakes are
going to be made and the patients are going to be the ones suffering.
So is the problem being addressed? You can be sure that it
is, by the corporations that run these pharmacies. How? The complaints of the
pharmacists are being taken care of in the way that big corporations often do, that
is, ignoring them and deleting mention of them from their reports. In a follow
up on February 21, 2020, “At
Walgreens, complaints of medication errors go missing”, Ms. Gabler
writes:
Pharmacy
employees at Walgreens told consultants late last year that high levels of
stress and “unreasonable” expectations had led them to make mistakes while
filling prescriptions and to ignore some safety procedures.
But
when the consultants presented their findings at Walgreens’s corporate offices
this month, there was no reference to the errors and little mention of other
concerns the employees had raised.
That’s
because senior leaders at Walgreens had directed the consultants to remove some
damaging findings after seeing a draft of their presentation, a review of
internal emails, chat logs and two versions of the report shows.
In
one instance, Amy Bixler, the director of pharmacy and retail operations at
Walgreens, told them to delete a bullet point last month that mentioned how
employees “sometimes skirted or completely ignored” proper procedures to meet
corporate metrics, according to the chat logs and the draft report.
Good for you, Ms. Bixler! Took care of that problem! You
should get a nice bonus this year!
If these practice are of concern to you, they should be. So
should the price gouging up and down the line in the pharmaceutical industry,
the drive to profit for manufacturers, PBMs, insurance companies, and retail
pharmacies to make lots of money off you, or you die. “Your money or your
life!” is an old cliché attributed to highwaymen. It should be the mantra of
the pharmaceutical industry in this age of unfettered capitalism.
But no highwayman ever had the reach or power or ownership
of politicians that these folks do.
