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  #51  
Old 06-19-2019, 09:22 AM
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I'm on Medicare, and also pay for supplemental insurance (which has gone up in price). I need to take 300 units of insulin every day, a combination of Humulin N and R. I already have stage 3 kidney disease, plus vision problems and nerve damage.

I will vote for any candidate who will make this more affordable.

I'm waiting for doctors to be able to create a new pancreas and kidneys out of my own stem cells... or print them with a 3D printer. According to my nephrologist, that may be possible in 10-15 years, if I live that long.
  #52  
Old 06-19-2019, 09:44 AM
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I'm waiting for doctors to be able to create a new pancreas and kidneys out of my own stem cells... or print them with a 3D printer. According to my nephrologist, that may be possible in 10-15 years, if I live that long.
We see a lot of commercials for drugs to cure hepatitis C and for preventing HIV infections. Mrs. L.A., RN, often comments how great it is that these drugs are available. We also see a lot of commercials about 'lowering your A1C'. There was another thread where I wondered why no one has come up with stem cell or gene therapy to cure diabetes. The Hep C and anti-HIV drugs are enormously expensive. I'm guessing stem cell/gene therapy would be as costly as hell too. But people would pay it. I have the idea that the health industry isn't so much interested in curing diseases (in spite of the Hep C treatment), but in merely treating diseases without curing them for as long as possible.

I hope your nephrologist is right about growing new pancreases, and that other chronic diseases such as heart disease, cancers, and such can be similarly cured. But I have the feeling that there won't be much interest until the calculus is done to maximise profits. There are plenty of people, so it doesn't matter if a few thousand or a few million die. The important thing is money.
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Old 06-19-2019, 10:15 AM
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A problem with growing a new pancreas for someone with Type I diabetes is that Type I is considered an auto-immune disease (at least in most cases). Even if you could 3D print a new pancreas if you just plop it into the recipient's body their immune system will destroy the new one, too.

For people whose pancreas was damaged/destroyed by something else - injury, perhaps - it would work. Presumably. But not for people whose immune systems are on a search-and-destroy mission. Well, suppose you could administer immune suppressants, but then they have to pay for those....

I do believe there are people in medicine who genuinely want to cure disease and fix problems permanently. I also believe there are some greedy assholes who want to make money and don't care who they hurt.
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Old 06-19-2019, 10:19 AM
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I can't speak for Beck, but if you were talking about my insurance group, the answer would be 'hell, yes.' It's the insurance company that insists on it, because patients with chronic diseases cost them money that they'd rather keep for themselves. Anything they can do to attempt to lower their costs, they'll do.
Huh, well I learned something new today. Insurance companies take attendance at support group meetings.
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Old 06-19-2019, 10:20 AM
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A problem with growing a new pancreas for someone with Type I diabetes is that Type I is considered an auto-immune disease (at least in most cases).
What's the difference between Type I and Type II?
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Old 06-19-2019, 10:37 AM
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What's the difference between Type I and Type II?
Type I usually begins in childhood. The body's immune cells attack the pancreas so it doesn't produce insulin. Type II diabetics usually get it when they're adults. The pancreas either doesn't produce enough insulin, or the body cells can't utilize it properly.
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Old 06-19-2019, 10:44 AM
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Medicare is done state-by-state. The federal government gives a block of money to the state and they choose how to use it. In some states, the governors have resisted Medicare Expansion, leaving the citizens of that state with less coverage than other states. You can check what type of medicare your state has at the link above.
You are thinking of Medicaid (for the poor), not Medicare (for the elderly and disabled). Medicare is administered exclusively at the federal level.
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  #58  
Old 06-19-2019, 10:45 AM
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Type I means little or no insulin is produced in the body. It is believed to usually be an auto-immune disorder although severe injury or surgical removal of a diseased pancreas (such as with pancreatic cancer) can also induce the disease. If you have this and you don't get insulin you will die. Extreme low calorie diets and/or fasting can buy a little time, but if you go that route it's a race between death by rising blood sugar or death by starvation.

In Type II diabetes the pancreas still produces some insulin, but either it's not enough or there are adequate amounts of insulin but the body's cells have become resistant to it and it doesn't work as well as it should. It is possible to have both of those problems at the same time. Many, if not most, Type II diabetics do not require insulin except in unusual circumstances but the older and individual diabetic gets/the longer they've had the disease the more likely they are to start requiring some form of insulin to keep their condition under control. In other words, this can get worse with time.

Type II diabetics have a potential advantage in that exercise, proper diet, and weight loss can either reduce the amount of medication they require, or in some instances go into a sort of remission where they don't require daily medicine... but regular monitoring is very much suggested. The only hitch is that keeping to a rigorous diet and losing weight are very hard, especially if you have additional problems you have to deal with (like poverty, or a heart condition that limits the exercise you can do). And for a substantial portion of Type II diabetics even the best dietary control and exercise regimen still won't eliminate the need for some medication to keep their blood sugar under control and prevent long term damage.

Medications for Type II diabetics start with drugs that either increase natural insulin production, increase the sensitivity of body cells to insulin so it and sugar are better utilized, or both. Medications for Type I start with insulin because if the pancreas ain't producing at all there is no point in trying stimulate it.
  #59  
Old 06-19-2019, 10:47 AM
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You are thinking of Medicaid (for the poor), not Medicare (for the elderly and disabled). Medicare is administered exclusively at the federal level.
It is also possible to qualify for both of those programs at the same time.
  #60  
Old 06-19-2019, 10:48 AM
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Type I usually begins in childhood. The body's immune cells attack the pancreas so it doesn't produce insulin. Type II diabetics usually get it when they're adults. The pancreas either doesn't produce enough insulin, or the body cells can't utilize it properly.
That used to be the party line, but it's gotten fuzzy over time.

Morbidly obese kids can certainly get Type II as kids. Plenty of adults have spontaneously developed Type I. which is why they are no longer referred to as "juvenile diabetes" and "adult-onset diabetes" as much as they used to be.
  #61  
Old 06-19-2019, 11:16 AM
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That used to be the party line, but it's gotten fuzzy over time.

Morbidly obese kids can certainly get Type II as kids. Plenty of adults have spontaneously developed Type I. which is why they are no longer referred to as "juvenile diabetes" and "adult-onset diabetes" as much as they used to be.
We need to get better DM nomenclature. Right now there's type 1, type 1.5 (LADA), type 2, type 3 (proposed), CFR DM, Hemochrome DM, glucagonoma DM, MODY, gestational DM, and a host of other even more niche types.

Also diabetes insipidus, which has nothing to do with blood sugar.
  #62  
Old 06-19-2019, 11:31 AM
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Also diabetes insipidus, which has nothing to do with blood sugar.
Sounds like a particularly mean Harry Potter style hex.
  #63  
Old 06-19-2019, 11:34 AM
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You are thinking of Medicaid (for the poor), not Medicare (for the elderly and disabled). Medicare is administered exclusively at the federal level.
The base program, yes. Medicare Extra Help, which is income-related and will sometimes pay for things regular Medicare doesn't, goes through the states. In NY it's administered through the county. (Cite: that's who I had to deal with to get it.)
  #64  
Old 06-19-2019, 11:34 AM
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Sounds like a particularly mean Harry Potter style hex.
Great, a hex to make one pee endlessly.
  #65  
Old 06-19-2019, 01:45 PM
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Anyone more advanced than a rookie Medical assistant knows insulin dosing, you don't need a dedicated doctor to help you. Insulin dosing is not an arcane formula only pharmacists and endocrinologists can understand.
Ummmm, no.

We can start with the fact that my diabetes specialist somehow managed to graduate (elementary school) without any advanced math skills. She normally applies conversions backwards, but being aware of her issue, I check the math. Twice.

Then figure in the new insulin's are not only concentrated (2X, 3X, or 5X) and are good for anyware from 12 hours to 30+ hours, and if your on dialysis, any rational response curve goes out the window, and dosing devolves to an arcane art, not a science.

Yes, I'm getting my Borg blood sugar sensor this week. Waking up with a BS of 63 is getting old.
  #66  
Old 06-19-2019, 01:57 PM
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I'm waiting for doctors to be able to create a new pancreas and kidneys out of my own stem cells... or print them with a 3D printer. According to my nephrologist, that may be possible in 10-15 years, if I live that long.


Not from Big Pharma, but there is a group of Type-1's that have hacked the new constant metering blood sugar meters and a particular older insulin pump together to form a crude artificial pancreas.


I'm sure the FDA is making the sign of the cross.
  #67  
Old 06-19-2019, 02:03 PM
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To clarify the mystery of dosing a little bit...

Insulin is dosed on units. As long as you are using the same general type of insulin - and by that I mean rapid acting. long acting, mixed, etc. - a unit is a unit is a unit.

Put another way, 10 units of Novolog = 10 units of Humalog = 10 units of Admelog.

10 units of Lantus = 10 units of Levemir = 10 units of Basaglar.

So, if you are merely switching brands from brand A to similar-acting brand B, the dose is unchanged.

But if you are switching from a medium-acting to a rapid-acting, or a long-acting to an ultra long acting, yeah, you have to know how to convert the dose.


mmm
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Old 06-19-2019, 03:23 PM
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Just to add that the older insulins have to be taken at least twice daily and are less forgiving in terms of control. That means that rather than checking sugars one to two times daily, patients have to check their sugars at least 3x a day. Every time they check a patient has to pay for test strips and lancets which are not cheap. Strips can cost upwards of 50 cents each and even a box of 100 lancets is $15 at Walmart. Also even if you are only paying $25 for a vial of insulin, if you take 100 units a day, you will need 3 vials a month, plus at least 60 syringes which with cost another $10-20. My cat's insulin cost $80 and an additional $45 for needles every 3 weeks and she was on about a tenth the dose of a usual human (although I did use then pens for her because it was easier and I could hit up the drug reps for samples for her as well as for the human patients). There are so many new good medications available for diabetes and it frustrates me that I cannot use them. Medicare is particularly bad because the government will not let the pharmaceutic companies give discounts to Medicare patients and older patients are the ones more likely to have trouble with insulin.
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  #69  
Old 06-19-2019, 03:28 PM
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Medicare is particularly bad because the government will not let the pharmaceutic companies give discounts to Medicare patients and older patients are the ones more likely to have trouble with insulin.
This seems to contradict what a previous poster said about Medicare and insulin.
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Old 06-19-2019, 07:25 PM
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Let me clarify what I was talking about. First of all, when we talk about type 2 diabetes, there are a lot of medications that improve the body's use of insulin and may prolong pancreatic life. However, many of these are very expensive. Because there is competition, the drug companies subsidize copayments. If, for example, a medication costs them $10 to produce they may then sell it for $400. They contract with the insurance companies who agree to pay $200 and charge a 40% copay of $80. So, the insurance company pays $120 and the patient pays $80. When there is more than one medication in a class, the companies want patients to use their medication. They usually have coupons that subsidize the copayments, so that, for example, they will pay up to $120 per month of the patient's copayment after the first $5. They still receive $125 for the medication ($120 + $5) and make a profit, and the patient feels like they got a great deal and only pays $5. However, the government has decreed that these coupons cannot be used for any federally subsidized insurances (medicare, medicaid and sometimes federal employee-which is a big deal here in the DC area).

Medicare itself does not cover medications at all. You need to buy a Medicare part D plan to cover medications or be part of a Medicare Advantage (HMO) plan. Many patients cannot afford any part D plan or buy the cheapest one which has poor medication coverage.They are then stuck paying whatever their part D insurance allows.

For those Medicare patients who are truly indigent, they can get Medicaid as their supplements which will cover Part D and medications. For those whose incomes meet certain limits, they can get assistance under the Low Income Subsidy program LIS which does have income limitations income limitations-pdf. That is where the $8.50 comes in.

Let's also not forget about the infamous "donut hole". This year, Part D plans will cover their usual amounts up to a total cost (not out of pocket) of $3820. After that, they are in "the hole" which in previous years meant that they paid 100% for medications. However, this year they pay only 25% for brand-name medications and 37% for generic medications until total costs reach $5100 after which they pay 5% for all medications. Confused yet? donut hole.

If you do not qualify under LIS and meet other criteria, sometimes the drug companies have compassionate use program that will send you free medication.

Now imagine you are an elderly person who is not computer literate trying to navigate this. (Also now see why as a primary care physician I am at the office until midnight every night dealing with this. There is a reason I know all of the programs and all of the prices-because I am dealing with them constantly).
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  #71  
Old 06-19-2019, 07:43 PM
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(Also now see why as a primary care physician I am at the office until midnight every night dealing with this. There is a reason I know all of the programs and all of the prices-because I am dealing with them constantly).
And isn't it terrible that physicians need to know that sort of stuff in order to serve their patients? I applaud your work on their behalf, but it should never have been necessary. There's so much actual medical knowledge to keep up with . . .
  #72  
Old 06-19-2019, 08:23 PM
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PSA for anyone in the U.S. having a hard time paying for prescription drugs, either with or without insurance: check out Goodrx.com (there's even a smartphone app). It gives you the prices of every drug I have ever checked at the several pharmacies neatest to you with their own electronic coupons.

Sometimes there isn't much of a discount over sticker price (usually that's the case with brand-name drugs still under patent), but sometimes the discounts are substantial, on the order of 80% or even more. This info came in mighty handy when my MIL was visiting from overseas and needed meds unexpectedly (she never signed up for Medicare Part B because you can't use it outside the U.S. anyway).

Novolin-N, for example.

Or one I am more familiar with: Advair. The last time I had to buy a disk and hadn't met my deductible yet, it was over $350. (Of course the disk I bought in Cyprus was 1/10 the price, but that's a rant for another day.)
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Old 06-19-2019, 08:35 PM
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Now imagine you are an elderly person who is not computer literate trying to navigate this. (Also now see why as a primary care physician I am at the office until midnight every night dealing with this. There is a reason I know all of the programs and all of the prices-because I am dealing with them constantly).
I'm fairly certain there are telephone numbers that people can call to get explanations about all of this.
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Old 06-19-2019, 09:53 PM
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I'm fairly certain there are telephone numbers that people can call to get explanations about all of this.
Is this a joke?
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Old 06-19-2019, 10:01 PM
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Is this a joke?
No it's not. Since I know for a fact that there are places that exist that explain this information.
  #76  
Old 06-19-2019, 10:06 PM
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Diabetics should suck it up, we need to do some studies about reparations!
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  #77  
Old 06-20-2019, 12:18 AM
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It is also possible to qualify for both of those programs at the same time.
My grandmother was for about the last 10 years of her life. Before she went into a nursing home, all she owned was the furniture and other contents of a 1BR apartment, and her only income was Social Security.

Type 1 diabetes may also be a viral disease, whether directly, or that the virus does something to the immune system to destroy those beta cells.

Both types, but especially Type 2, have many subtypes, and we really don't know what causes any of them.

About 15 years ago, I visited the Banting Museum in London, Ontario, which has a torch in the front yard that was lit by the Queen Mother when the museum was dedicated in the late 1980s. That torch will be extinguished when diabetes is cured; unfortunately, that's going to be a while.
  #78  
Old 06-20-2019, 03:08 PM
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I'm fairly certain there are telephone numbers that people can call to get explanations about all of this.
Yup. And you can call six numbers and get six different answers.

Then there's the ever-popular circle: Agency A: Sorry, we can't answer that particular question, you need to talk to agency B. Agency B: sorry, we can't answer that particular question, you need to talk to agency C. Agency C: sorry, we can't answer that particular question, you need to talk to agency A . . . .
  #79  
Old 06-20-2019, 04:35 PM
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Yup. And you can call six numbers and get six different answers.

Then there's the ever-popular circle: Agency A: Sorry, we can't answer that particular question, you need to talk to agency B. Agency B: sorry, we can't answer that particular question, you need to talk to agency C. Agency C: sorry, we can't answer that particular question, you need to talk to agency A . . . .
So? Is dying better than waiting on the phone?
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Old 06-20-2019, 05:36 PM
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At some point you guys will get tired of killing each other off via guns, mercenary medicine, imposed poverty and McDonald's. When you do, the civilized world is ready to embrace you.
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Old 06-20-2019, 05:38 PM
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Broomstick, have you even tried thoughts or prayers?
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Old 06-20-2019, 07:08 PM
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Yup. And you can call six numbers and get six different answers.

Then there's the ever-popular circle: Agency A: Sorry, we can't answer that particular question, you need to talk to agency B. Agency B: sorry, we can't answer that particular question, you need to talk to agency C. Agency C: sorry, we can't answer that particular question, you need to talk to agency A . . . .
So? Is dying better than waiting on the phone?
Do you know any elderly people? How many of them do you think could navigate that? Particularly if it really is a circle (you know that those have no end point, right?).

My wife's spinster aunt would have died long before she did if her various nieces and nephews hadn't kept an eye on her. And to my knowledge she never suffered from any form of dementia/diminished capacity, beyond not being terribly bright to start with.
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Old 06-20-2019, 07:25 PM
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Do you know any elderly people? How many of them do you think could navigate that? Particularly if it really is a circle (you know that those have no end point, right?).

My wife's spinster aunt would have died long before she did if her various nieces and nephews hadn't kept an eye on her. And to my knowledge she never suffered from any form of dementia/diminished capacity, beyond not being terribly bright to start with.
Yeah, I do. My dad. And guess what he did? Called the Medicare number and asked questions.

About how old do you think people need to be before you add them to poor people in the group of "Can't possibly figure anything out or get answers to anything"?
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Old 06-20-2019, 08:27 PM
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Yeah, I do. My dad. And guess what he did? Called the Medicare number and asked questions.

About how old do you think people need to be before you add them to poor people in the group of "Can't possibly figure anything out or get answers to anything"?
My dad did also, just last week. He even got the answers he needed.
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Old 06-20-2019, 08:58 PM
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My dad did also, just last week. He even got the answers he needed.
That's great! It's almost as if they set up a number for people to call with questions.
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Old 06-20-2019, 09:13 PM
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So? Is dying better than waiting on the phone?
Took me several months to get a clear answer to such a question.

Luckily, I wasn't sick at the time. If I had been, I could easily have been dead by then.
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Old 06-20-2019, 09:19 PM
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Took me several months to get a clear answer to such a question.

Luckily, I wasn't sick at the time. If I had been, I could easily have been dead by then.
Perhaps your method of asking questions and getting answers was faulty?
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Old 06-20-2019, 09:25 PM
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Perhaps your method of asking questions and getting answers was faulty?
Perhaps your attitude towards other people's difficulties is faulty?
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Old 06-20-2019, 09:31 PM
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Perhaps your attitude towards other people's difficulties is faulty?
Perhaps, but attitude is irrelevant. What a person does is relevant.

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Old 06-21-2019, 09:30 AM
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What the people on the other end of those phone calls, emails, and snail mail letters did (or, in a number of cases, didn't do) is also relevant. As is the way the system as a whole is set up.
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Old 06-22-2019, 05:26 PM
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I'm also puzzled by the insulin market in the US. I understand that newer versions of the drug, which are patented, and whose prices have been jacked up in the US, are better than old-fashioned pork insulin or humulin. But surely humulin is off-patent by now? And surely it would be better to have enough of that than to ration "newer" forumations and not take as much as you need?

Is humulin still available? Is it affordable? What is the barrier to using it?
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Old 06-23-2019, 01:58 AM
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Perhaps, but attitude is irrelevant. What a person does is relevant.
Needless complexity and expense in a system that's supposedly designed to serve the public is also relevant. Exhorting people who are complaining, with reason, about serious systemic problems to just take some initiative and bootstrap their way through their difficulties comes across as kinda threadshitty.

Yes, "there are telephone numbers you can call". And some of those calls do successfully answer the questions that people have about this needlessly complex and expensive system. Good!

Does that mean that the people complaining about the needless complexity and expense of the system don't have a valid point? No. So, you know, "fuck a bunch of 'what a person does is relevant' personal-responsibility pep talk" is not an unreasonable reaction.
  #93  
Old 06-23-2019, 06:22 AM
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Perhaps, but attitude is irrelevant. What a person does is relevant.
I once called la migra, explained that my work permit was about to expire and my employer's legal department was refusing to provide me with a Proof of Employment letter and asked if one from my manager along with my W-2 and last paystub would suffice.

The lady on the other end of the phone called me a "stupid fucking Hispanic whore".

Maybe there was something I could have done, but apparently I was too stupid to know what and that lady's attitude can't be called "helpful".
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Last edited by Nava; 06-23-2019 at 06:23 AM.
  #94  
Old 06-23-2019, 06:53 AM
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Maybe that's just a term of art ?
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  #95  
Old 06-23-2019, 07:40 AM
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I've had a dog on the $25 Walmart insulin -- and it was only $25 if you could get to Walmart. The local pharmacy, which is a lot closer to me than Walmart (which is in a different village entirely, and difficult for anyone who can't drive to get to) advised I go to Walmart because they had to charge $150 per vial for it; apparently Walmart had struck some sort of special deal.
So instead of the Federal government, it's a corporation (Wal-Mart) that's negotiating cheaper prices with drug companies.

So......... in order to get a halfway affordable price we will have to buy each different drug we need from separate corporations (i.e. Wal-Mart) that negotiated (separately) with separate pharmaceutical companies?

Wouldn't it be better to have just one organization do the price negotiations for all the drugs used by all the people? Seems more efficient that way. Like it'd be cheaper, yo.
  #96  
Old 06-23-2019, 10:15 AM
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Yeah, I do. My dad. And guess what he did? Called the Medicare number and asked questions.

About how old do you think people need to be before you add them to poor people in the group of "Can't possibly figure anything out or get answers to anything"?
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My dad did also, just last week. He even got the answers he needed.
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That's great! It's almost as if they set up a number for people to call with questions.
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Perhaps your attitude towards other people's difficulties is faulty?
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Originally Posted by thorny locust View Post
What the people on the other end of those phone calls, emails, and snail mail letters did (or, in a number of cases, didn't do) is also relevant. As is the way the system as a whole is set up.
“There can be no doubt but that the statutes and provisions in question, involving the financing of Medicare and Medicaid, are among the most completely impenetrable texts within human experience. Indeed, one approaches them at the level of specificity herein demanded with dread, because not only are they dense reading of the most tortuous kind, but Congress also revisits the area frequently, generously cutting and pruning in the process and making any solid grasp of the matters addressed merely a passing phase.”
Rehabilitation Association of Virginia vs Kowolski

It’s a mistake to be dismissive of the complexity of Medicare and Medicaid benefits. And it’s ridiculous to think that anything but the most basic questions can be answered correctly by whoever is on the other end of some 800 number.

The stakes can be incredibly high when applying for benefits. My brother was recently given a Medicaid application by an administrative employee of my mother’s nursing home, who basically told him just to fill it out and send it to a particular address. Luckily for us, my brother forgot. If we had filled out and submitted that form without further investigation, we would’ve lost our house upon her death. Plus we would have been liable for several thousand in nursing home expenses out of pocket.

This would have happened because we didn’t fully understand the complex rules around Medicaid eligibility. So, a word of warning, be careful when applying for a benefit based on phone advice.

Last edited by Ann Hedonia; 06-23-2019 at 10:19 AM.
  #97  
Old 06-23-2019, 10:35 AM
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And just by looking at this thread, you can see how varied the prices are - depending on 1) whether you have insurance or not 2) what kind of insurance you have 3) how well you know the (often very complex) rules governing your insurance in order to get the most out of your plan 4) whether there are any outside programs or discounts available depending on how much money you make, who makes the insulin you need, or where you buy your insulin. This has been true for a long time for a lot of drugs and procedures and I am continually gobsmacked that so many of us have put up with this sort of bullshit for so long. I am sure a lot of the reason is how fragmented our health care system is - there are so many variables there is no way to compare plans or prices in any meaningful way and I'm pretty sure our 'system,' such as it is, is pretty happy with keeping things that way.
Yep, it's the labyrinthine, patchwork healthcare system in the US that screws us. Shit, even when you buy insurance, you don't know what it does and does not cover.

"Well your ambulance that took you to the hospital while you were in a coma is technically out of network now, so we can't cover that 35,000 bill. So-reee."

Or...

"We actually contract with an out-of-network anesthesia monitor to assist the anesthesiologist. So unfortunately, even though your hospital is in the network, that specialist was not. That'll be $85,000 please. Would you like to set up a direct debit payment plan?"

p.s. Oh, wait, one more thing: Your premiums just went up by 15%

Last edited by asahi; 06-23-2019 at 10:36 AM.
  #98  
Old 06-23-2019, 10:56 AM
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Yep, it's the labyrinthine, patchwork healthcare system in the US that screws us. Shit, even when you buy insurance, you don't know what it does and does not cover.

"Well your ambulance that took you to the hospital while you were in a coma is technically out of network now, so we can't cover that 35,000 bill. So-reee."

Or...

"We actually contract with an out-of-network anesthesia monitor to assist the anesthesiologist. So unfortunately, even though your hospital is in the network, that specialist was not. That'll be $85,000 please. Would you like to set up a direct debit payment plan?"

p.s. Oh, wait, one more thing: Your premiums just went up by 15%

I'm always amazed that you guys stick with your bullshit. Even in the age of mass media, mass global comms and so on. I hit Twitter and about once a month I land upon some US person who had an accident or illness and is just flabbergasted at how it's handled in Ireland, in German, hell even in Canada. Flummoxed that, yeah, no, they'll take you in right away for tests without seven forms from three different organizations, and they'll do the tests within the day and oh yeah they're a little expensive at 25 kröner (or whatever) but don't worry you'll get most of it back at the end of the month.
And yet, while I suspect the majority of you guys actually *know* this, or suspect it at least, there are no guillotines anywhere. Worse, for every last one of these Twitter threads you'll have a regular contingent of dudes trying to find faults in those other systems or praising US healthcare anyway.



Americans have insurance Stockholm syndrome. Ask your doctor about it.
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  #99  
Old 06-23-2019, 02:44 PM
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I'm always amazed that you guys stick with your bullshit. Even in the age of mass media, mass global comms and so on. I hit Twitter and about once a month I land upon some US person who had an accident or illness and is just flabbergasted at how it's handled in Ireland, in German, hell even in Canada.
I don't know why you say "even" Canada. If you need an ambulance in Ontario the cost is a flat fee of $45 which is waived in many circumstances (I think it's higher in other provinces). And for any medically necessary care there is no cost at all. In fact doctors' offices are typically not set up to deal with any kind of monetary transactions, which can actually make it tricky in some unusual case where you do actually have to pay for something, like a missed appointment.

Anyway the point is, if you suddenly need an emergency trip to the hospital, in Ontario your maximum out-of-pocket cost will be $45 no matter what care you receive or how long you stay, unless you opt for extra amenities like a fully private room or cable TV.
  #100  
Old 06-23-2019, 03:02 PM
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I'm also puzzled by the insulin market in the US. I understand that newer versions of the drug, which are patented, and whose prices have been jacked up in the US, are better than old-fashioned pork insulin or humulin. But surely humulin is off-patent by now? And surely it would be better to have enough of that than to ration "newer" forumations and not take as much as you need?

Is humulin still available? Is it affordable? What is the barrier to using it?
My bolding added.

TLDR: being off-patent isn't enough, there is also a period you have to wait before you can apply to market a copy product; and the FDA need to reclassify insulins from chemical drugs to biologicals before copy drugs can be authorised. They are doing this now.

Detail:

Upthread I linked to this FDA statement on attempts to bring competition into the insulin market. I'll give the technical explanation of what I understand the situation to be. If this is unclear, tell me how and I'll try to clarify. And of course I'm cutting corners with these explanations.

Back in the day, drugs were pretty much always chemicals. By which I mean they were simple molecular structures - link to show the chemical structure of simvastatin, as an example.

This was patent protected, of course (and typically molecules were also protected with further patents on synthetic processes used and so on). Once the patents all expire, you can make and sell the molecule - in principle. But (in principle) if you want a licence to market the drug, you should do all the preclinical testing and clinical trials that would be expected for a new drug - after all, you should know that it is safe and effective - right?

This is of course absurd and unacceptable for all manner of reasons - not least because doing needless clinical trials on humans for a chemical whose properties are well understood is pointless and unethical. Over the years rules for the licensing of generics were developed, based on the fact that the properties of the chemical were well understood. After a certain time has elapsed since the originator product - Zocor in the example of simvastatin - was first marketed (the period of "data exclusivity"), you are allowed to say to the FDA "Guys, this is our application for our simvastatin product - for all the preclinical tests and clinical studies, can you just refer to the stuff that was provided with the application for Zocor?". So the Zocor data was used for the generic simvastatin applications - and it's possible to do this because, y'know, a chemical is just a chemical, it doesn't matter who makes it or even (with caveats) how it's made. All you really have to show is that your generic is absorbed at the same speed and to the same extent as the originator in a bioequivalence test. No preclinical testing, no clinical trials.

HOWEVER - these days there are a lot of biological drugs (like EPO, for example). And because the folding of these complex molecules is critical to how they work, who makes them and how they are made is critically important to their properties. So you can't just make a generic and support it with a bioequivalence test. Even after you have shown that it has the same "structure" in terms of chemical bonds, a (limited) clinical and pre-clinical package is required to show that it works in the same way as the originator. These are biosimilar producs - it's more difficult and expensive than developing a chemical generic, but it's the best way to get to cheap copy products for biologicals onto the market.

And here's the complicating factor with insulins - they are really old biological drugs. So old that they were classified as chemical drugs because there wasn't a classification for biological drugs at the time. And once you start classifying examples in a particular way, then it's hard to change what you do with further examples as they arrive.

So insulins ended up in a class where a copy of the drug would have to be a generic; but with no mechanism for making a generic, because it isn't a chemical drug. Hence the profound significance of the FDA announcement that they will solve this - by reclassifying all insulins as biologicals, thus making the development of biosimilar products possible:

Quote:
.......Transitioning biological products currently regulated as drugs to being regulated as biologics will enable – for the first time – products that are biosimilar to, or interchangeable with, these products to come to market.......

.......This transition is particularly important for insulin

Although they are biologics, insulin products have historically been regulated under the FD&C Act rather than the PHS Act, which governs the FDA approval of most biologics. Biologics are typically isolated from a variety of natural sources – human, animal or microorganism – and may be produced by biotechnology methods and other cutting-edge technologies. Due in part to the complexities of these products, it has been hard to bring a substitutable generic insulin to the market under the FD&C Act.

The transition of insulin from the drug to the biologics pathway will open up these products to biosimilar competition. We’re already seeing robust activity among sponsors seeking to bring forward biosimilar copies of insulin......
So, to answer your question - being off-patent isn't enough, there is also a period you have to wait before you can apply to market a copy product; and the FDA need to reclassify insulins from chemical drugs to biologicals before copy drugs can be authorised. They are doing this now.

OK, so that was long and complicated, but I hope it makes sense and helps. I'm sure there are bits that need further explanation - so treat this as a Mini-AMA: just ask and I'll do my best to explain.

j

Disclaimer - there are many drugs - eg inhalers, ointments - which are outside the scope of this explanation.
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