This is so incredibly wrong - and trying to claim something you know obviously nothing about is hilarious.

The different between NPH (regular insulin) (maybe R too, not sure??) sold by walmart and Fast Acting insulins (Novolog, Humalog, Apidra) is massive.

Fast acting insulins start working at about in about 30 minutes and "peak" at like 2 hours, and may slowly have some effects for another 1-2 hours.

NPH on the other hand, starts working at ~2 hour mark and continues to work slowly until peaking at like 6 hours and slowly degrades away, that means its in your system for something like 9 hours - trying to meal plan around multiple doses of that is unsafe at best.

R is slightly better but still remains and slowly peaks closer to 4 hours.

These are obviously GREAT IF and only IF you dont have access to fast acting. I applaud Walmart for giving access to these, as they are way better than nothing.

source: Type 1 diabetic

I do know what I'm talking about. Also diabetic.

Yes, there are different insulins and Novolin is an intermediate-acting insulin like you describe and available at those prices.

Thanks, sithlord. My wife is a type 1 diabetic and it's even worse than your comment suggests, because the different fast acting insulins have a different curve (when do they start working, when is the peak, how long do they have an effect) and our insurance company keeps making her switch to a different "equivalent" formulation because the price to them is lower this month. This means that there's a learning curve, more highs and lows, when she has to switch.

Humalog's patents have expired, as I understand it, but cartel behavior has kept the price high in the US.

The net price on Humalog has gone down since 2014. The PBMs are the ones who distort list prices.

The PBMs are mostly owned and operated by the managed care organizations (insurance companies). The insurance companies have profit margins of less than 5%.

This is not true and just an industry talking point from the PBMs. They use revenue tricks to hide their profit margin.

See https://www.fiercehealthcare.com/payer/facing-criticism-pbms...

My information is from 10-K filings with SEC, and my statement is referring to net profit margins, which are what they are. Unless there is massive fraud going on, managed care organizations are not earning massive profits. If their PBM divisions are, then they are simply subsidizing the insurance division, but it would make no difference to people. The total expense for premium plus out of pocket expenses would not change, it would just shift from one to the other.

> Unless there is massive fraud going on

That is exactly what is happening, and it's legal. It's very easy to hide profits and move them around.

One big element is that a lot of large companies and non-profits run their insurance programs as self-insured. They pay the direct costs of the medical care of their insureds, and keep the annual premiums the entire employee-base pays. The "insurance companies" are paid a percentage of the total revenue/claims as an administration fee, so they have incentives to push the overall amounts paid up, not down. Self-insuring eliminates the profit overhead of the insurance companies, but screws the incentives.

There are quite a few big insurers (better known as managed care organizations) competing for business, so the incentives are there to limit expenses so they don’t have the most expensive premiums.

Some insurers (looking at you United Health Care) have wholly owned PBMs. Thus, the PBM is an asset in its insurance trust. Any profit the PBM makes will appear as in increase in asset valuation for their insurance trust, or balance sheet in some cases.

However, insurance margins remain unaffected as the money did, in some sense, go out the door and is no longer in control by the insurer directly. It's not fraud. It's just anti-competivie self-dealing. So, no, it's not profits per se, but rather increased valuation via clever financial engineering.

All the big managed care organizations (better word than insurer) have their own PBM. I would need to read more about how an MCO accounts for assets set aside for insurance, but I would be surprised if insurance regulators are allowing it, considering how strict insurance regulators are.

A quick search shows me that on page 73 of Cigna’s 10-K, it clearly does not have its Express Scripts division accounted for in the “Investment Assets” section, based on how low those numbers are.

It just does not pass the smell test to me. The simpler answer, based on all the numbers, is that managed care organizations are squeezing other entities in the healthcare chain, but due to competitive pressure and upper profit margin limits due to ACA, they are not raking in big bucks.

This is probably true - and I am not here to point fingers - but I will say that the insulin manufacturers are at some fault too, they do just enough to keep renewing their rights to their insulins every time they come around.

You cannot renew a patent in the US. They get a new product patented, but anyone is still free to come along and make the older one. However, I bet there is a ton of expertise and cost required with doing that, and that is what is stopping others.

they "renew" by "improving" their existing product enough to make it obsolete, and to get a new patent. Per the article below this has been happening since 1923

https://www.hopkinsmedicine.org/news/media/releases/why_peop...

That is better described as a new patent. The product for the patent that expired is expired, and can be made by others.

Would it be possible to get a limited amount of the fast acting stuff for unpredictable situations and then normally use the "cheap" stuff? I don't know how this works so I would like some info from someone who seems to know.

Possible, sure, but not ideal. The "fun" thing about T1 diabetes is that every meal becomes an unpredictable situation based on exercise, sleep, stress, etc etc.

Slightly exaggerated, but only slightly: Imagine you could only drink water 6 hours before you got thirsty, but if you drank too much you might pass out (at any point 2-6 hours from now) or if you drank too little you're doing major damage to your body.

Really the only way to manage with that kind of insulin is to live a very, very low carb lifestyle. Its doable, but it limits your variety and leaves you prone to other potential issues.

Not likely, also lets not forget - as a Type 1 diabetic, you also take long acting insuling (unless you are on a pump). So, for example, a pump uses only fast acting insulin - and it gives a small amount (known as "basil") every 5 minutes (+/- depending on pump).

Whereas, if you use pens (or from a vial) with direct injection, you also take a long acting insulin (levemir, Lantus, etc) once or twice a day (they are supposed to last 24ish hours but often people find splitting their total daily dose up into morning and night has better results). And these insulins cost even more than the fast-acting stuff.

I thought it was “basal”, not “basil”.

That's mobile autoformatting for ya, you are correct. I would correct, but edit limits...

It's not branding, the newer insulin is significantly different and better for almost every patient. https://diabetesstrong.com/walmart-insulin/

It's likely not what your doctor prescribed, it doesn't last as long, it requires you (or your young children) to eat on a very specific schedule, it can't be used with an insulin pen or insulin pump, it's just all around a worse and less effective treatment.

Seems like everything is working as intended? A corporation invests money to develop a better product, and the government gives them a 20 year monopoly on it so they charge a premium and recoup their investment. As a patient if you want to pay the premium for it, you can get the better product, otherwise you can still stick with whatever walmart's selling. It's worse, but it's not any worse than what you'd had if the company didn't come along and invented the better product.

That's not what is happening. It has nothing to do with a patent monopoly or recouping any investment:

FTA: >In 1996, a vial of Humalog produced by Eli Lilly cost $21. Today, it's priced at $324 despite the cost of production remaining steady.

>Rising costs are nothing new. Insulin prices tripled from 2002 to 2013, and doubled between 2012 and 2016. To put this into perspective, in 1996 a vial of Humalog produced by Eli Lilly cost $21. Today, it's priced at $324 despite the cost of production remaining steady.

If everything is working as intended, it begs the question, what institution intended for patients to die from rationing insulin[0], and why is the USA ok with that institution's intention?

[0]https://www.ontrackdiabetes.com/live-well/diabetes-managemen...

If it was developed in 1996, the patent protection would have expired by now. If the cost of production was "steady", then the question is why is a competitor not jumping in to make and sell something that would earn them a huge profit margin?

Do you doubt it was developed in 1996? Do you have evidence that the cost of production has significantly risen?

Otherwise, you seem to be repeating the old economics joke:

"The young economist looks down and sees a $20 bill on the street and says, “Hey, look a twenty-dollar bill!”

    Without even looking, his older and wiser colleague replies, “Nonsense. If there had been a twenty-dollar lying on the street, someone would have already picked it up by now.”"

When there is a claim that there exists an arbitrage opportunity worth billions of dollars, I would consider it common sense to consider why has no one claimed the arbitrage opportunity yet.

The world has many very smart people spending many hours working very hard to find these opportunities, so the likelihood of it just sitting there like a $20 bill on the street, and not being picked up, seems quite small.

I do not know the answer myself, so I am interested in finding out. reddicky posted this:

https://www.hopkinsmedicine.org/news/media/releases/why_peop...

which sort of answers it:

>Biotech insulin is now the standard in the U.S., the authors say. Patents on the first synthetic insulin expired in 2014, but these newer forms are harder to copy, so the unpatented versions will go through a lengthy Food and Drug Administration approval process and cost more to make. When these insulins come on the market, they may cost just 20 to 40 percent less than the patented versions, Riggs and Greene write.

So it looks like there is some expensive expertise involved and investment into R&D that needs to be done.

Yes there is expertise and capital costs involved, which make it not an arbitrage play. It is more like a cartel, which seems to explain what is going on here, with the 3 insulin producing companies all fixing their prices together (at least in the US)

In theory there is 'nothing' stopping another company from coming along, even a group of Biohackers may try to do something - I wonder if that's been done... :)

The reason no one will pick it up is because there are massive capital investments to get something like that up and running, and the existing manufacturers can just drop their price to compete with you as soon as you get up and running. Now you have to recoup your capital costs in a saturated market, and your competitors can probably make insulin cheaper than you due to pre-existing economies of scale.

I would imagine that even other companies already in the pharma space would be interested. They don't want to play the race to the bottom game with billions of dollars in upfront costs. If anything, it's probably more profitable to make a new form of insulin that you get to patent. Which is how we end up where we are.

Although... I needed to buy a vial of the newest fast insulin in Spain last year without an insurance. One vial was 28 euros, which is much less than people in US have to pay.

The insulin in question is Lyumjev from Eli Lilly.

This is an incredibly stupid comment. Net price in Humalog has decreased since 2014 [0]. The PBMs jack up the list price so they can get their fat rebates.

[0] = https://www.cnbc.com/2019/03/25/eli-lilly-discloses-pricing-....

You are correct. It’s a rebate game. Net price of insulin has been going down.

https://1.bp.blogspot.com/-ZfBANMMU5dQ/XzFtNw93ZCI/AAAAAAAAq...

Eli Lilly's profit margin is double digit, usually around 20%. Managed care organizations (insurance companies), which own the PBMs, have profit margins of ~5% or less.

That is a nonsense talking point from the industry. They use passthrough revenue to distort their profit margin. Express scripts is closer to 15% and CVS is closer to 10%.

See https://www.fiercehealthcare.com/payer/facing-criticism-pbms....

CVS net profit margin is in the 2% to 3% range:

https://www.macrotrends.net/stocks/charts/CVS/cvs-health/pro...

Cigna purchased Express Scripts in Mar 2018, and has profit margins of 3% to 5% over the last couple years.

https://www.macrotrends.net/stocks/charts/CI/cigna/profit-ma...

If these PBMs are making lots of profits, then they are simply subsidizing losses elsewhere in the MCO. The total costs paid for insurance premium plus out of pocket costs by the end user in the US would not be affected.

You are not addressing my main point which is that these MCO's distort their "net margin" stat using accounting tricks. And yes PBM's are INCREDIBLY profitable. Express scripts made 4.5 billion in net income in 2017. They have never produced a drug that has saved a life.

PBMs are important but they should not be able to put a gun to these pharma companies heads because they control the formulary.

CVS net margin includes their retail business. You can't compare AWS's margin to Walmart's e-commerce margin.

I am not addressing it, because I do not see any further evidence of distortion of an MCO's net profit margin other than what this article claims. Nor would it matter to me unless some MCO executives are smuggling cash out of the country or something.

As a customer, it does not affect me.

In the healthcare business, the flow of money is:

Individual -> MCO (insurance company) -> healthcare providers and drug manufacturers

What does it matter to the individual what portion of an MCO is earning what profit if the net profit margin of the whole MCO is 5% or less? They are obviously not left with a lot of money, their employees are not known to be lavishly compensated.

That doesn't seem too strange when you consider that those two types of companies have different operating models. A drug company is in the business of taking relatively cheap goods and converting them to very expensive goods, in other words adding a lot of value. A insurance company/PBM is mostly in the business of skimming a percentage off transactions.

It is not strange, but it also contradicts claims about managed care organizations earning tons of money. It is not a business you go into to get super rich.

LMFAO. Express Scripts (the biggest PBM) was bought for 67 billion! They have never saved a patient life but are bigger than most pharma companies.

That sounds irrelevant to my point that MCOs do not make a lot of profit.

Yes it is working as intended, the argument is that those intentions are inhumane. Can you think of any medical treatments that were developed without the promise of 20 years of limitless profits? I can.

> Can you think of any medical treatments that were developed without the promise of 20 years of limitless profits? I can.

This sounds like it's responding to a strawman. Proponents of the patent system aren't claiming that zero innovation would happen without patents, just that it would be much less. In other words:

No patent system: only inventions from altruistic inventors

Patent system: inventions from altruistic inventors and profit-focused inventors.

Let's say corporations were only promised a 10 year monopoly instead of 20. Do you think their business would collapse, or would they keep trying? If profit-focused inventors could still be motivated by a 10 year horizon, then that extra 10 years only benefits corporate executives and kills patients. So, is the patent system as limited as possible while still encouraging innovation? Obviously not, because pharma companies routinely direct billions of dollars in profit into stock buybacks instead of research or any other actual investment. They can easily afford to make less profit.

>Do you think their business would collapse,

It would depend on the project's margins and/or sunk costs. A project that had very little invested in it or is a breakout success might we able to weather a 50% cut in exclusivity period, but a marginal product might not. Most of the already developed drugs are probably going to be fine, assuming that the financing for them was already secured.

>or would they keep trying?

For the projects at the margins? most certainly. That is not to say all private drug development would, stop. If some sort of unpatented-but-super-cheap-to-perfect-but-still-not-patented drug showed up it might still be developed, but in aggregate I'd expect drug development to drop significantly.

I am arguing that there are no marginal projects at current profit levels, and that's why they can spend billions on stock buybacks. There is a point that lessening patent protections would cause companies to cut back, but we are not at that point.

>I am arguing that there are no marginal projects at current profit levels, and that's why they can spend billions on stock buybacks

How does the act of buybacks imply that there are no marginal projects?

Do you think a gross profit margin of 93% is fair?

Define fair and unfair. If it was so "unfairly" lucrative, I would have to ask why everyone does not invest in pharma? Why are tech companies where much of the VC funds land?

Perhaps it is because there a huge amount of risk involved?

But that does not make for emotion inducing tweets.

When were these newer insulins invented? Are they a recent thing? Was it the case that twenty years ago, "Walmart" insulin was the only insulin?

1996. https://en.wikipedia.org/wiki/Insulin_lispro

Novolin is available as an insulin pen. I use it twice-a-day and it's available at the prices specified.

Type 1 diabetic here. Managing T1D even with the "Gucci" insulins (I use Novolog and have tried Fiasp) is still a huge pain in the butt; you have to give yourself a dose of insulin a fairly precise amount of time before eating, and accurately judge how much you're going to need, which is half science and half wild guesswork. My per-meal dosage requirements vary randomly from month to month -- a dose that would be fine one month is either inadequate or deadly on another month, and the only way to tell if you've got it right is to obsessively monitor your blood sugar.

And that's with the $700/vial insulin... the $25/vial stuff is stone age technology by comparison; you have to take it twice a day, and then eat at two specific times afterwards, or you'll go hypoglycemic (unconscious or maybe dead hypoglycemic, not just the feeling-a-bit-tired kind that people who don't use insulin are familiar with).

The situation right now is that the best and most expensive T1D technology, even the various "artificial pancreas" solutions, still gives you nothing like the experience of a normal pancreas. It would be really nice if the Walmart insulin were a viable long term solution for the cost problem, but unfortunately the negative health effects of older insulin tech are considerable :(

Have you looked into the Warsaw Calculation of calculating insulin? I did it for awhile and pretty interesting. Only real issue is its pretty inconvenient, requires breaking up doses more. But it also takes into account for fats and proteins into the insulin calcuation. I dont remember what, but say your carb ration is 1:10, you would calulate a protein as maybe 1:25 and fat as 1:30 (theres some assigned value is the point iirc - dont use these numbers )

The no-direct-cost PBMs price generic Humalog at $50-$60 now.

Generic Novolog is also ~$55 at Walgreens (more at other places).

Have you tried low-carb eating? I've been doing it for years and it seems to be an easier method then insulin(type2 borderline when I started, so not exactly the same).

When you eat lots of fat and protein as a T1, you just get a slowly rising glucose that needs insulin and is harder to control compared to carbs with less fat.

T1 is really complex even with a low carb diet, if you don't only eat vegetables, but meatier food.

Yeah, T1 is pretty much just a pain whatever you do. Low carb does make it quite a bit easier, and I imagine would pretty much be the only safe way to eat if you were using a non-rapid insulin.

Unfortunately (doctor's orders) I also have to cut back on the cholesterol, which seems to be very high in all my favorite low-carb foods :( It's a constant experiment; it may turn out to make more sense to eat more fat but take statins, but I need to wait a bit longer and see how my lipids look with the current diet.

(BTW I'm actually doing fine -- pretty decent control/A1C -- but I had to rant in response to the Walmart insulin suggestion above!)

Some other things that raise your glucose and you need insulin:

- waking up, liver produces glucagon

- stress at work, hormones going wild… including glucagon

- weather changes, when it is cooler you need more insulin

- you get sick. 2-3x insulin for me

- liver just having a normal glucagon production, that needs insulin without you ever eating anything

Nice that you have your A1c in control. Mine is 5.8% without too many hypos after 26 years of having T1. The tech I need for this costs a fortune without insurance, but at least I can finally live a normal life without nasty surprises every day.

The Regular stuff came out in '82. The Humalog variants came out in '96

The regular stuff is not really stone-age by comparison. They are both old tech.

A friend had insurance problems for years and often had to use Walmart insulin instead. He's now going blind, and his doctors suspect that's why. </anecdote>

The hard part is getting doctors to offer prescriptions for the cheaper brands as an alternative. A lot of doctors will prescribe the most expensive drug simply because they believe or know that it is better in some way without regard to it's cost.

It's changed a lot recently as doctors have become more aware of the cost of these drugs. But you still have to self advocate for less expensive drugs. Less savvy people often have trouble getting transparency into drug costs. Often even the doctors can't get a straight answer on pricing and insurance coverage.

It has been many years since pharmacies have been allowed to substitute brand name medications with generic medications. In fact, doctors have to write "dispense as written" if they want the patient to only get the brand name medication they prescribe.

Additionally, managed care organizations (MCOs, commonly known as insurance companies) do not pay for brand name medications just because a doctor prescribes them. If the MCO is aware of a generic option, then they will only pay for the generic or they will ask the doctor for a "prior authorization" to justify the use of a brand name medicine (such as the generic version not working).

The pediatricians I have visited in recent years even have the MCOs' formulary available for the patient in their systems, so they can see which medicines need a prior authorization and which do not so there is no time wasted on figuring out what the MCO will pay for without prior authorizations.

> A lot of doctors will prescribe the most expensive drug simply because they believe or know that it is better in some way without regard to it's cost.

This is so obnoxiously common across every profession.

People are willing to piss away other people's money on "the best" without even telling them what the options are.

But you don't need a prescription...

True! However doctors often don't know this or simply don't think to mention it. In addition, self medicating with OTC insulin can lead to poor outcomes. With proper training and care it can be a powerful tool for uninsured patients. However, insulin can be extremely dangerous leading to ER visits and insane hospital bills.

Every time I try to wrap my head around this stuff. How to fix the problems with our current system. I keep coming back to socialized or single payer health care.

Sure the current system works okayish for people like me. Insured and employed. But for my friends and the people I meet on the streets or the grocery store it's a nightmare. There is real suffering and death caused by no access to adequate health care. Even basic preventative stuff like diabetes care and checkups is missing.

https://khn.org/news/you-can-buy-insulin-without-a-prescript...

Walmart insulin is not lispro/glargine, it is R/N, which is a different formulation. Treatment of type 1 with R/N is associated with significantly higher mortality, A1C, and complication risk, and, of course, much lower quality of life.

Bear in mind: when you mis-dose insulin, your blood turns into acid.

No endocrinologist would ever recommend treatment with older insulins over the new stuff. The only way it happens is because of cost.

Or, you know, public health care. But I digress.

This is like saying a car and a bicycle are equivalent means of transportation. Sometimes a bike is the right solution for some people and a bike is usually better than nothing but it’s really not fast enough to be a practical solution for most people’s daily needs.

Edit: Perhaps high speed internet vs dial-up would be a better analogy to spare us the comments about how bikes are actually better than cars...

it’s “Gucci”, like the luxury brand

Funnily enough, also a "luxury" brand.

Goodrx shows lispro generic $48.85 per vial. Humalog 'guchi' is $142.55. If you're fortunate enough to have diabetic retinopathy and can't read the tiny print, the larger kwikpens are only $270.28. Lets not even get into the real guchi brands.

this is very true. prices of name brand insulin need to come down, but there is a low cost option available for those that need it

Patient outcomes for the insulin aspart pens and the vials of generic insulin at Walmart are so different that many doctors refuse to prescribe the cheap stuff except as a very last resort.

There's no simply substituting. These are two different brands of a generic statin pill or something. Although it's all insulin, these are very different drugs. The dosages for the same insulin in the same patient can vary, and the calculations or charts for what to take when vary across types of insulins. The handling instructions vary. There's different patient training for a pen vs. a vial and syringe.

There is no substituting but also no easy comparison of how much worse the regular stuff is, since the population using R is often underinsured and unable to afford other elements of prevention and care.

Novolin is available as a pen without prescription. Costs a bit more ($45 for 5 pens).

That fixes the pen issue, but it's still not the same insulin most doctors prescribe and can't be easily substituted without medical consultation. Having it available inexpensively and without a prescription is a compromise, per Novo Nordisk themselves.

https://khn.org/news/you-can-buy-insulin-without-a-prescript...