$38,398 for one shot of a very old cancer drug
Dr Josie Tenore and Paul Hinds were introduced in 2017 by a mutual friend and had not been dating for long before she made a rule: He must have a medical examination.
“I don’t date people who don’t take care of their health,” says Tenore, who practices cosmetic dermatology. functional medicine in the suburbs of Chicago.
One of Hinds’ blood tests that summer gave an alarming result: The level of prostate-specific antigen, or PSA, was very high. A biopsy confirmed he had terminal prostate cancer.
There aren’t many comfortable alternatives to treating prostate cancer, which usually progresses as long as testosterone levels remain high. Cannabis Appears to lower his testosterone levels, so after being diagnosed, Paul took liquid marijuana for several weeks. That halved his PSA, but Hinds, a cybersecurity expert who enjoys yoga and cycling, “was stoned for his mind and couldn’t function,” Tenore recalls .
With Tenore guiding her decisions, Hinds next tried a procedure called high-frequency ultrasound therapy, but it was unsuccessful. And in the summer of 2019, doctors removed his prostate. However, PSA levels rose again and doctors judged that the cancer had metastasized. The only alternative is to drastically reduce Hinds’ testosterone levels – either through surgery or drugs that block all testosterone. In May 2021, Paul gave his first intramuscular injection of Lupron Depot, a brand of leuprolide, designed to stop the prostate from releasing the hormone for three months. That August, he had his second shot.
And then the bills came.
Patient: Paul Hinds, now 60, is covered by United Healthcare through the COBRA program from his former employer.
Health services: Two injections of Lupron Depot over three months to treat metastatic prostate cancer.
Service Provider: University of Chicago Medical School, a non-profit system of 900 physicians that includes an 811-bed medical center, suburban hospital, Pritzker School of Medicine, outpatient clinics, and physician offices throughout the Chicago area .
Invoice total: $73,812 for two injections ($35,414 for the first shot, $38,398 for the second), including lab and physician costs. United Healthcare’s negotiated fee for two shots plus associated fees is $27,568, of which the insurer pays $19,567. After Hinds bargained with the hospital and insurance company for more than a year, his share of the bill was determined to be close to $7,000.
Give what: The first problem is the relentless price increase on older drugs that stay brand-name as manufacturers seek to renew patents for decades and maintain sales through marketing.
Although Lupron was invented in 1973, its manufacturer extended the patent in 1989 by offering a delayed release version. Drugmakers often use this tactic to expand their monopoly on selling their products.
Dr. Gerald Weisberg, a former Abbott scientist who has been critical of the company’s pricing policies.
Over the following years, Abbott and Takeda, in a joint venture called TAP Pharmaceuticals, steadily increased the price of their slow-release product. In 2000, the average US wholesale price for a three-month shoot was $1,245; currently that figure is $5,866. (It is made in the USA by AbbVie now.)
In the UK, where healthcare is generally free and Takeda sells the drug under the name Prostap, all doctors can buy a three-month dose for around $260.
It is likely that Chicago Medicine, where Hinds performed the injections, paid something close to British prices. That’s because the health system hospital on Chicago’s South Side participates in a federal program called 340B, which allows hospitals that serve low-income people to buy drugs at deep discounts.
Lupron Depot is simply injected into a muscle. It takes a few minutes for the nurse or doctor to administer. Morgan Henderson, principal data scientist at the Hilltop Institute at the University of Maryland-Baltimore, said hospital systems like Chicago Medicine can, and often do, charge very high fees for such services, to increase revenue. Chicago Medicine declined to say how much it paid for the drug.
While US drugmakers can price their drugs however they want, TAP has had trouble with its Lupron sales policies in the past. In 2001, after a Justice Department investigation, it paid a settlement of 875 million dollars to illegally stimulate sales by providing urologists with free and discounted vials while allowing them to charge full Medicare prices.
Since then, many other drugs aimed at lowering testosterone levels have come onto the market, including a pill, relugolix (Orgovyx). So why don’t patients use them?
Brian McNeil, chief of urology at Brooklyn University Hospital, says Lupron Depot is long-acting, easy to prepare and store, and uses a small needle that some patients prefer. Orgovyx is convenient, but “patients have to be very compliant. They have to take it every day for the same amount of time,” he said. “Some people just forget.”
But there’s another key factor that could explain Lupron Depot’s continued popularity with medical providers: Doctors and hospitals can make tens of thousands of dollars per visit. disease by raising its price and management fees – as they did with Hinds. If they merely prescribe a drug that can be taken at home, they gain nothing.
When asked about this high patient fee and the possibility of using alternatives, United spokeswoman Maria Gordon Shydlo said payment was “appropriate based on the hospital’s contract and rights plan.” member benefit,” adding that the insurer encourages customers to shop around for the best quality and prices. .
Resolution: In addition to leaving Hinds listless, the photos of Lupron Depot are, literally, a pain in the back of the car. “Each time he was miserable for two weeks,” said Tenore. After going through his first bill for the Lupron shot, Tenore told Hinds he should ask his doctor if there was a cheaper and easier to take medication.
After the second injection, in August 2021, a pharmacist told him he could get an alternative. His doctor prescribed three months’ worth of Orgovyx to Hinds last November, for which he paid $216 and the insurance company paid over $6,000. Drugs of List price around $2,700 one month. There is evidence that Orgovyx works slightly better than leuprolide.
Orgovyx was a “no brainer,” Hinds said. “Why would you want a sore butt in two weeks when you could take a stimulant pill sooner, work the same, and clear your body of testosterone faster?”
While Orgovyx is increasingly commonly used for prostate cancer, Lupron and other injectable drugs often remain the standard of care, hospital spokeswoman Ashley Heher said. Clinicians “work with patients to determine which treatments are most medically effective and, when necessary, to find affordable alternatives that may be less burdensome in terms of finance due to insurance limitations,” she said.
Hinds is hampered by the size of the fees. During months of calls and emails, the hospital reversed and then re-applied part of the fee, and then in July agreed to a $666.34 monthly payment plan. However, after Hinds made two payments, the hospital announced on August 29 that it would cancel the agreement and send the remainder of the bill to a collection agency. Two weeks later, the hospital reinstated the payment plan – after KHN inquired about the cancellation.
As for Hinds, he remains active, although his cycling distance has been shortened from 50 or 60 miles to about 30, he said.
He is grateful to have Tenore as a free consultant and empathizes with those who lack an informed guide about their illness and the financial maze of healthcare.
“I have Dr. Josie as an advocate who understands the system well,” Hinds said.
Carried away: First tip: If you are prescribed an infusion or injection, ask your doctor if there is a cheaper oral medication to treat your condition. In addition, many parenteral medications — those given “under the skin,” rather than into a muscle — can be administered to patients at home, avoiding excessive administration fees. Medicines like Dupixent for eczema fall into this category.
Remember that where you get treatment can make a big difference in your costs: A research found that the top US cancer centers charge huge subsidies to private insurance companies for injections or infusions of drugs. Another study found that hospital systems charge 86% more on average than private clinics to deliver cancer drugs. And the rate of cancer transmissions performed in hospital-run clinics has increased from 6% in 2004 to 43% in 2014and have grew up from.
Under the law coming into effect in 2021, hospitals asked to list their fees, although they are currently doing so in a non-user-friendly manner. But you should look at the price list – the charge manager – to try to decipher the pricing and classification of your drugs. If you are going to have an injection, infusion, or procedure in the hospital system, ask ahead of time to find out how much you will owe.
Dan Weissmann contributed the sound portrait to this story.
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