Much as credit card companies have charged exorbitant interest rates in the period leading up to the passage and enactment of reform, so too have prescription drug companies added more cost to their already prohibitively expensive products. Afraid that health care regulatory legislation will cut too heavily into their soaring profits, the industry feels no shame, nor any compulsion to give heavily burdened consumers much of a break. This is a side of the debate that has not gotten the same attention as other areas and one that I have tried to bring to light quite frequently, being that I myself stand to lose quite a bit if out-of-control price increases are not sharply curtailed. I do not deceive myself into thinking that I am the only one who stands to lose. Though I do not mind invoking personal experience if it facilitates greater understanding and urgency, I wish it didn't take the anecdotes of the chronically ill to impress upon a skeptical public the importance of health care reform.
On the subject of psychotropic medication, something of which I am an amateur expert, I have closely monitored new classes, types, and formulations of prescription drugs in a desire to find the best way possible to treat my condition. For every new medication that breaks new ground, wins approval by the FDA, and is then prescribed by GPs and psychiatrists across the country, it is a never-ending source of frustration for me to observe the three new offerings which are merely slightly different formulations of existing medications. This is a covetous process undertaken mainly to reap maximum profit when older scripts are on the verge of losing patent status and thus being offered as generics. For example, the anti-depressant which is the most recent addition to a family of medications known as SSNRIs has been marketed under the name Pristiq. Pristiq has a very similar chemical structure and as a result works only slightly differently from an existing drug in the same school, Effexor, that has been around for over ten years. Sometimes, however, even generics occasionally have limitations. Though a lower-cost equivalent to Effexor exists, the less-expensive form has been reported to work not nearly as effectively as the name brand formulation.
An article in today's New York Times reports on Big Pharma's side of the story.
But drug companies say they are having to raise prices to maintain the profits necessary to invest in research and development of new drugs as the patents on many of their most popular drugs are set to expire over the next few years.
That may be, but before one gets misty-eyed listening to the woe-is-us violin, rest assured that the pharmaceutical industry isn't exactly hurting for business. Conveniently they don't mention the larger picture. Another example of this kind of infuriating slight-of-hand is the sleep aid Ambien, which has had a sufficient generic alternative for a while. A relatively new formulation dubbed Ambien CR produces an only a slightly different reaction, mainly by time-releasing the absorption of the drug into the blood stream. The drug is the same, but the gimmick is different. Returning to psychiatry, it is either a testament to how little we know about the function of the brain or how unwilling we are to risk radical change that the medications used to treat depression, anxiety, bipolar disorder, and schizophrenia have broken only relatively limited ground in decades. The best treatment for depression are still a class of powerful anti-depressant known as a MAOI inhibitors, which are close to fifty years old. They are rarely prescribed, however, because taking them requires strict dietary restrictions that, if not adhered to, can result in serious damage to the body and, in extreme cases, even death. In treating bipolar disorder, some patients still respond best to Lithium, which has been used in treatment for over a century, but extensively since the Fifties.
Newer medication often cut down side effects and make the period of adjustment less painful, but do little to increasing the stated objectives of the drug, namely to drag people out of depressive episodes and set them on a course towards health and functionality. Experimental trials are often plodding affairs proceeding at the pace of a snail, targeting a relatively limited area of the brain, and unwilling to take any unnecessary chances. Despite this, some medications do pass muster and do end up being taken by who are suffering in the hopes of providing relief. Even so, the drug makers and those who formulate them sometimes fail to take into account such crucial details as major side effects in a rush to get out the next big thing. SSNRIs like Effexor, for example, are infamous for producing absolutely awful issues when someone stops taking it. Though not strictly classified as such, one might even say that such drugs are addictive because the brain acts violently when the medication is discontinued. These serious matters somehow never find their way onto the commercials on television or the ads inside glossy magazines.
The difference in cost between name brand and generic drugs is quite vast. Often it is a matter of several hundred dollars for a one month supply, though it can be as high as a thousand dollars or more. As one might expect, those with employer-based or individual plans paid for out of pocket have to pay substantially higher co-pays for name brand drugs. When I had private insurance, the co-pay for generic medications was $10 and for name-brand drugs, it was $60. Sometimes I had no choice but to take a name-brand medication, which are often treated by insurance companies as something bordering on cosmetic and not essential, when the fact of the matter is that they are highly necessary and highly unavoidable at times.
Those who don't have the luxury of private insurance, of course, have it rougher. Those who have to rely on Medicaid find that they have no choice but to settle for generic medications when a name-brand drug would be a much better fit and work much more effectively. Medicaid programs vary, but in the state of Alabama, the most expensive medications are only covered if a doctor or specialist one can provide proof that at least two lower-cost alternatives have failed or been insufficient to treat the condition. Not only must they have failed, one must also work within the confines of a 90 day coverage window. If a claim to cover a more expensive medication is not filed within 90 days of failing the requisite two medications, then coverage is not granted. This is ridiculous in lots of ways, mainly that few medications used to treat mental illness work quickly, and many take weeks upon weeks before any psychiatrist or doctor can make a judgment either way. It's also ridiculous because it uses a broad brush of convenience, painting all illnesses as basically the same and all treatment regimens as similar. Some name-brand medications, regardless of the need are not covered at all, since whomever set up the system decided that covering it would unnecessarily drain the General Fund and that it was an unnecessary prescription in the first place.
Returning to the Times column,
But the drug makers have been proudly citing the agreement they reached with the White House and the Senate Finance Committee chairman to trim $8 billion a year — $80 billion over 10 years — from the nation’s drug bill by giving rebates to older Americans and the government. That provision is likely to be part of the legislation that will reach the Senate floor in coming weeks.
But this year’s price increases would effectively cancel out the savings from at least the first year of the Senate Finance agreement. And some critics say the surge in drug prices could change the dynamics of the entire 10-year deal.
Those who trust Big Pharma do so at their own peril.
Additionally, The news broke today that, quite unsurprisingly, much misinformation exists surrounding the Public Option™. As Politico points out,
The debate has placed disproportionate emphasis on the creation of a government insurance plan, raising the expectation that everyone could ditch their employer-provided coverage and enroll in the public option.
But that won’t happen, at least not at the start. The reality is that only about 30 million Americans — 10 percent of the population — would even be eligible.
It could be accessed only through a new insurance marketplace known as an exchange, where consumers would shop for plans. Only certain categories of people could use the exchange: the self-employed, small businesses, lower-income people who qualify for tax credits to purchase insurance and those who are otherwise unable to find affordable private coverage.
This might deflate the hopes of supporters and pacify opponents, but since so much of this debate has been a three-ring-circus based on raw emotion and faulty logic, I sincerely doubt it. However, as proposed, it is interesting to note that the Public Option™ would be more like Medicaid than anything else. My hope is that we do not make the same mistakes with the current bill as we do with existing systems it seeks to augment or replace, particularly those in red states who likely would opt-out altogether if provided the opportunity to do so. Though at least red state residents would presumably have the fall-back of Medicaid, provided they could qualify, the framework is based on ignorance and tunnel-vision of an almost incomprehensible degree. One cannot simplify the complexities of humanity, nor its diseases, which are as multifarious as its people.
Returning to the treatment of mental illness, what is often not cited is the disconcerting fact that often African-Americans and Latinos respond much less favorably to medications used to treat the condition. This is a contentious topic with lots of disagreement, but the argument some advance is that cultural stigma factors in to a very large degree. If minorities feel shamed or guilty about seeking help for psychiatric needs, they are much less likely to engage in medical research. Furthermore, many believe that therapy is a more viable option than medication. Often it is difficult to make any kind of pronouncement when the truth is obscured by so many different interrelated factors. And though one can easily make a case for mental illness, one could also make a case that minority and low-income residents might be less inclined to visit a doctor for a more run-of-the-mill ailments as well.
The lifetime prevalence of major depression in the United States is estimated to be 16.2 percent, with considerable social and role impairment evident in the majority of patients. Previous studies found only minor differences in depression rates among African Americans, Latinos and whites. But various studies have found patients from lower social economic groups often have less access to mental health care, are less likely to be prescribed and to fill prescriptions for new antidepressants and are less likely to receive care beyond medications when compared to whites.
This fear and anxiety so many have that resembles to these eyes a case of St. Vitus Dance may not have any basis in reality. Doesn't matter how good the system is if no one uses it. God forbid everyone in this country have a high standard of living and good health. As the article points out, minorities and low-income citizens often have the highest need for quality care and are apt to put off seeking help until the pain becomes intolerable. That these are the people most likely to be eligible for enrollment in the government-run (gasp) option, those now building it from the ground up would do well to consider its target audience. We speak out of our own privilege when we assume that somehow the Public Option™ will directly affect us for better or for worse, when the poor and less fortunate will be the ones who either reap its rewards or suffer from its limitations. While it is true that middle class individuals and the reasonably affluent have struggled under the yoke of skyrocketing health care costs, I recall going in that I assumed the changes needed and intended were meant to appeal to our tired, our poor, our huddled masses yearning to breathe free. Somewhere along the way this became all about us.