Many medications have drastically increased in price in recent years. Share on Pinterest Some people with diabetes have been reportedly rationing the life-saving medication. Getty Images Insulin in the United States isn’t free — in fact, it’s remarkably expensive, with some of today’s newest varieties costing over $500 for a box of five pens, according to GoodRx. And its cost is still rising. List prices of insulin have nearly tripled from 2002 to 2013, according to a report from a working group at the American Diabetes Association. Some patients are also reportedly rationing their insulin because taking too little is better than having none to take at all. The result is people with diabetes living with dangerously high blood glucose levels, putting their health and even their lives in danger. But the questions of who is to blame for skyrocketing prices and what can be done about it don’t have simple answers. The reality is that people with diabetes are part of a very large, complicated system, often caught between insurance companies, pharmaceutical companies, and medical providers. While there may be some lifelines for those looking for affordable insulin, the core of the problem may be difficult to change.

Skyrocketing prices As the price of insulin has nearly tripled over the last decade, people who take it want to know why. founder of David Kliff,of Diabetic Investor , told Healthline it isn’t fair or accurate to say that Big Pharma has raised the price of insulin out of greed, but instead to compensate for the amount that’s taken by the negotiators in the middle: the payers. “They keep raising prices to keep the net effective price in an acceptable range,” explains Kliff. Kliff has lived with type 1 diabetes for over 20 years. A former money management and investment advisor, today Kliff is well- known throughout the diabetes industry as one of the leading experts in all things regarding diabetes business and finance. Kliff says he finds it hypocritical to “complain about ‘BigPharma’ making billions of dollars from drugs like insulin.” “That’s their job, by the way,” added Kliff, “to make billions. That’s how it works in America. Kliff pointed out that many people who complain that they want insulin to cost less are often the same people who complain that they want new drugs and better drugs, and better insulin. In order to develop those newer, better drugs, the pharmaceutical company has to spend money on research and development. Insulin, emphasizes Kliff, is a commodity, like coffee or a pair of sneakers, and commodities cost money. Innovation, even in the world of helping people live longer, better lives with a chronic illness, is expensive. “The bottom line is: if I’m Dave Ricks, and I’m the CEO of Eli Lilly, my first responsibility is to my stakeholders, and they didn’t invest in Eli Lilly so I could give insulin away,” said Kliff. “He has a fiduciary responsibility to his stakeholders, and that responsibility is to make money.”

Blame game While Dave Ricks, the CEO of Eli Lilly, says their net pricing has been flat since 2009, patient advocacy groups say prices are still being raised on patients. Christel Aprigliano, CEO of the Diabetes Patient Advocacy Coalition (DPAC), argues that the list prices are being raised in part due to middlemen. “List prices are being raised in order to offset the [pharmacy benefit manager] PBM demands for higher rebates,” Aprigliano told Healthline. Pharmacy benefit managers act as middlemen between the pharmaceutical companies and pharmacies. “If the list price isn’t raised to meet the PBM’s demands, the PBM won’t include the drug on its formulary, or its list of drugs covered by the insurance plan,” Aprigliano explains. “So, PBMs get all this rebate money, and there’s no telling how they use it.” and manufacturers. The ADA working group report on insulin pricing concluded there were a variety of reasons the medication prices have increased. They also reported the rising costs were the result of “multiple opaque” transactions among wholesalers, pharmacies,manufacturers. Aprigliano added that PBMs claim that dollars earned in rebates are passed on to employers in order to help them lower their premiums. But patients are still seeing sharp increases in high-deductible health plans (HDHP), and are then forced to pay the extremely high list prices before their insurance coverage kicks in through copays or coinsurance. “Moreover,” said Aprigliano, “uninsured patients who need insulin are penalized; they are forced to pay the list price that was created for a system of rebates in which no one should ever be paying the list price.” The current system is broken, said Aprigliano. The question still remains: How can it be fixed? “It’s time for a change in the system,” said Eli Lilly CEO Dave Ricks in a June 2018 interview on CNBC. “They’ve put together many proposals, but clearly [the Trump administration] is moving the market in that direction.” Ricks added that they’ve developed programs with companies like BlinkHealth and InsideRX to offer “any American a 40 percent discount on insulin at the point of sale.” Research conducted at the time of publication on both of these sites found that insulin discount programs were either still in development and not yet available, or prices were still listed as costing hundreds of dollars for a box of five insulin pens. Additionally, people with healthcare from government-funded programs won’t be eligible for these discounts. Other experts within the industry are weighing in on pricing claims. “Net pricing is really hard to define and should not be equated to net profit,” argue d Vermont-based pharmacist, Christopher Sexton. “Pharma lobbying is one of the most powerful in this country by far. Ricks does play the ‘middlemen are part of this equation’ card, but does anybody seriously think PBMs (pharmacy benefit managers) or drug wholesalers or insurance companies are getting huge windfall profits when the price of an insulin quadruples in a couple of years?” Sexton believes the world’s three largest pharmaceutical companies — Eli Lilly, Sanofi, and Novo Nordisk — could easily cut these middle negotiators out of the equation if they wanted to, and sell drugs like insulin at a much cheaper price directly to insurance companies. “Interviews like [the 2018 CNBC interview with Ricks] are usually set up to be friendly, with no surprises, no follow-up questions or any pushback from interviewer ,” add ed Sexton. Additionally, people with healthcare from government-funded programs won’t be eligible for these discounts. Other experts within the industry are weighing in on pricing claims. “Net pricing is really hard to define and should not be equated to net profit,” argued Vermont-based pharmacist, Christopher Sexton. “Pharma lobbying is one of the most powerful in this country by far. Ricks does play the ‘middlemen are part of this equation’ card, but does anybody seriously think PBMs (pharmacy benefit managers) or drug wholesalers or insurance companies are getting huge windfall profits when the price of an insulin quadruples in a couple of years?” Sexton believes the world’s three largest pharmaceutical companies — Eli Lilly, Sanofi, and Novo Nordisk — could easily cut these middle negotiators out of the equation if they wanted to, and sell drugs like insulin at a much cheaper price directly to insurance companies. “Interviews like [the 2018 CNBC interview with Ricks] are usually set up to be friendly, with no surprises, no follow-up questions or any pushback from interviewer ,” added Sexton.

