Tag Archive | donut hole

How Big Pharma Controls Medication Costs and Availability

Big Pharma Calls the Shots in MedicineBig Pharma has more control over how medicine is practiced in the United States than most of us probably realize. The big pharmaceutical companies have deep pockets – filled by American consumers – and big muscles to exert extreme influence over what gets manufactured (patented or generic medications), how much those medications cost, and how often those medications get prescribed.

Big Pharma has also found back channel ways to keep generic forms, which are less costly, of their patented medications off the market longer and to keep the high prices of those patented medications.

As the end of the exclusive right to be the sole manufacturer of patented medication with no competition nears – 12 years in the United States – on popular medications, pharmaceutical companies begin the race to create generic prescription versions of those medications. The cost to make generic prescription drugs is much less, because the formula is already available and there is no investment cost to develop the medication.

Eventually, many generic prescription medications transition to being available over the counter without a prescription.

There is a lot of money being made, no matter how the medications end up being sold, but the most money can be made on patented prescription medications.

Because of that, the pharmaceutical companies can – and do – charge whatever they want for the medications they hold patents for and the consumer often ends up bearing the brunt of the cost as insurance companies refuse to pay the full cost, or as in the case with Medicare Part D, they don’t pay anything at all while senior citizens are in the “donut hole.”

One of the angles that Big Pharma is using to make more money is that they are creating new, patented medications that combine generic and/or over-the-counter (OTC) medications, which if purchased in their separate generic and/or over-the-counter forms wouldn’t cost very much (compared to the patented medication cost).

An example is Horizon Pharma’s patented pain relief medication, Duexis. Duexis combines two older generic forms of Motrin and Pepcid.

The cost for buying the generic forms of Motrin and Pepcid (over-the-counter) separately for a month would probably be less than $50. Duexis, on the other hand, is $1500 for a month’s prescription.

Since there are generic, over-the-counter forms of Motrin and Pepsid (which insurance doesn’t have to pay for), insurance companies, understandably, don’t want to pay for Duexin.

Paradoxically, though, the sales of Duexin are accelerating rapidly.

How and why?

It turns out Horizon Pharma has joined the trend among pharmaceutical companies to partner with a mail-order specialty pharmacy to ostensibly make filling prescriptions easier for everyone.

Doctors are encouraged (they get reimbursed when they prescribe Duexis or any other patented medication) to submit prescriptions directly to the specialty pharmacy instead of sending the patient to the corner drug store with the prescription.

The pharmacy reimburses doctors and mails the medication to the patient and it deals with getting paid by the insurance companies, most of the time very successfully.

The problem for patients who use Duexis – and any other patented medications – is that their insurance costs and deductibles will increase because of the high cost of Duexis (in many parts of the United States, $1500 is in the higher range of a monthly mortgage payment), so the patients end up paying more on the back end.

Under the table deals between pharmaceutical companiesAnother way that pharmaceutical companies are controlling the price and the availability of prescription medications is to pay competitors – known as reverse settlement payments or pay-to-delay deals – to not create generic versions of their patented medications when the company’s 12-year exclusive rights to manufacture the medication ends.

This has become a common practice in the pharmaceutical industry, where everybody winks and turns a blind eye to the practice, and the courts seem to be unable to find anything illegal about the monopolistic effect of this for consumers who have no options but the original patented medication and who end up paying whatever the pharmaceutical company wants to charge for it.

A third way that pharmaceutical companies control what kinds of prescription medications are available as well as the prices is by both generating a consumer demand for the prescription big-pharma-pay-medical-providers-to-prescribe-medicationsmedications (prescription medications rival cars in paid advertising in all form of media) and by giving incentives – monetary and non-monetary – to medical providers to prescribe their medications.

Essentially, this amounts to the pharmaceutical companies creating the market from both sides of the equation for their medications. Not only is this also illegal, but, once again, consumers – you and me – end up carrying the financial brunt of this well-entrenched system in American healthcare.

Most profoundly affected – and what makes the injustice of this burn inside me – by these practices are are also the most vulnerable, healthwise, in our society: the elderly (with and without dementias) and the chronically-ill (diabetes, hypertension, and many neurological and autoimmune diseases).

These two groups of people, then, are often left with the black and white choice of whether to go broke (and lose everything, in some cases) to treat their health problems or to forego treatment altogether to try to stay financially solvent and hang on to what little they have.

This is pure greed, which is why these pharmaceutical companies are in business. They don’t care about the health of anyone. All they care about is a nice, fat bottom line and big payouts to their shareholders and to their executives.

And they have the control, so they can do whatever they want and you and I, either for ourselves or for our loved ones, have to make the choice to dance with them or not.


Help is Available to Pay for the Medications Our Loved Ones With Dementias and Alzheimer’s Disease Need

Financial Assistance to Help Pay For Prescriptions is AvailableOn top of the devastating neurological, physical, and emotional toll that dementias and Alzheimer’s Disease have on our loved ones, the cost of care – hospital equipment, adaptive devices, supplies, and medications – even when we as caregivers are carrying a fair share of that burden is often financially overwhelming.

Most costly, especially for our loved ones who depend on Medicare (and, hopefully, a Part B supplemental policy and a prescription plan), are the prescription medications used to help manage symptoms and behaviors associated with dementias and Alzheimer’s Disease.

Very few of these medications have generic equivalents, so there is no other option but to buy the Big Pharma patented – and outrageously expensive – medications.

When our loved ones with dementias and Alzheimer’s Disease who are covered by Medicare hit the “donut hole” of coverage, the prescription costs go through the roof because they are billed at full price.

However, there are options available for assistance with paying for these medications all year round. 

I’ll summarize the options here:

  1. Do your homework before filling the prescriptions. Big-box retail stores like WalMart and Sam’s Club (Costco and BJ’s as well) have more affordable prices than stores that are specifically geared around selling medication (CVS, Walgreen’s, etc.). Independent pharmacies may be able to give a better price as well.
  2. If the PCP prescribes a medication that the insurance plan doesn’t cover, you can appeal for coverage.
    1. The insurance plan will send a letter of denial.
    2. Make sure that the PCP provides documentation that the medication is medically necessary.
    3. Contact your state’s regulator to ask for a free independent medical review.
  3. Financial assistance may be available.
    1. NeedyMeds is a national non-profit organization that helps connect people with financial assistance.
    2. Other non-profits who may be able to help with financial assistance for prescription medication are: Partnership for Prescription Assistance, Patient Services, Inc., and Patient Advocate Foundation’s National Financial Resource Directory.
    3. Financial assistance – and sometimes free medications – is also available from pharmaceutical companies for medications that are still patented (there are no generic equivalents).

A note from my own experience will save you a lot of time, aggravation, and trouble. Having a PCP or a geriatric psychiatrist deal with the pharmaceutical companies for assistance with patented medications will get the fastest and best results.

The pharmaceutical companies have applications for assistance that the PCP or geriatric psychiatrist will provide. You will have to provide income statements, Medicare expenses already paid, and other expenses related to care. Include everything!

The PCP or geriatric psychiatrist will submit the paperwork and if it is approved, the medication will be sent to them and dispensed from them. The good news is that once you’re in, you don’t have to redo the paperwork again.

Another thing to be aware of is that these programs are not designed just to assist the most economically-disadvantaged members of our society.

The middle-class, which is the largest segment of American society, is feeling the financial squeeze on all fronts more than any other group (and if we are taking prescription medication, we can use some of these resources too for financial assistance to help pay for them). Even though our loved ones with dementia and Alzheimer’s Disease may have pensions, Social Security, and Medicare coverage, the costs of living – and dying – are far outpacing what they have coming in each month.

So this is a potential lifeboat to keep them as financially solvent as possible, while ensuring that they have the medication they need.

The Layperson’s Guide to Vascular Dementia, Multi-Infarct Dementia, Small Vessel Ischemia, and TIA’s

There are many kinds of dementia. In the next few posts, we’ll take a look at a few of them, along with Alzheimer’s Disease, which is a distinct neurological diagnosis from dementias.

Before we start, it is important to note that our loved ones can suffer from only Alzheimer’s Disease or only one kind of dementia. Or they may suffer from Alzheimer’s Disease and multiple kinds of dementia. That distinction is important to loving caregiving, which includes medical advocacy for our loved ones, because each brain disease is distinct, affects the brain differently, and has specific characteristics and symptoms and treatment.

I will admit here that one of my pet peeves while caring for my mom was hearing some people who have no real knowledge of these diseases lump everyone who suffers from them under Alzheimer’s Disease and giving advice on how to deal with that, not realizing the complexity of the situation posed by the presence of both dementias and Alzheimer’s Disease.

So, for non-caregivers or those who are unfamiliar and inexperienced with these diseases who may be reading this, please don’t assume because you’ve seen or read The Notebook that you’re an expert on the subject and please don’t offer medical diagnoses and advice.

The best gift you can give is to just listen and offer non-medical support. Most caregivers get so deep into the details and all the aspects of these diseases because they need to be able to take care of their loved ones in so many ways that if there were such a thing as a non-M.D. expert on them, most caregivers would qualify.

This post will discuss vascular (multi-infarct) dementia. The cause of this dementia is small vessel ischemia in the brain, which presents itself as chronic transient ischemic attacks (TIA’s). TIA’s are sometimes also referred to as mini-strokes.

TIA’s can occur when the small vessels in the brain get temporarily blocked, cutting off the blood supply and oxygen to that part of the brain. The cumulative affect of these is what causes the damage that is present in vascular dementia. Multi-infarct dementia just means that there are many areas in the brain where this vascular damage has occurred and accrued.

Although high blood pressure is a culprit, high levels of stress and a history of migraines are also players in these kind of TIA’s.

In my mom’s case, all three were factors, but high levels of stress were what brought on the majority of her TIA’s. I suspect she started having these as a small child, because there were times that she just couldn’t remember what happened in a specific instance but she’d referred to it as “blacking out.”

She never lost consciousness with them that I witnessed, but she used the same expression to describes times when we kids were all babies and she was under a lot of stress and she couldn’t remember certain instances of things.

Her TIA’s were common as we grew up, and although we never got over the shock of the suddenness of symptoms and the helplessness we had to do anything about it, we all got pretty good at taking care of her when she had one, and that lasted for Daddy until his death, and for me into adulthood until Mama’s death.

Her TIA’s always presented the same way. They were sudden. Her face would lose all color and her lips would get very pursed as she seemed to salivate more. There was a sort of paralysis except for her right hand. She would start rubbing her thumb across the first two fingers and that would last until the episode was over. I suspect there was a sense of unreality associated with the TIA, so the feeling of her fingers rubbing together was the only reality for her in those episodes.

I’d always hold Mama’s left hand and kind of stroke it so she knew I was there and she wasn’t alone. When the TIA was over, she’d immediately try to talk and everything came out totally garbled. That would last about thirty minutes and then she’d be okay.

And she never remembered them happening. I remember the first time I was giving her medical history as her POA at an ER (and this was way before the dementias and Alzheimer’s Disease) and I named TIA’s as part of her medical history and she disagreed with me and said she didn’t remember ever having those. I laughed at the time and told her that not remembering them was part of the symptom of having them.

small-vessel-ischemia-brain-mriOver time, though, as small vessel ischemia recurs, eventually clusters of damage occur in the brain. This disrupts the normal neurological pathways of how information is learned and communicated. One of the most clear indicators of vascular dementia is difficulty in communication. One of these difficulties is misnaming things.

For example, the brain knows that a pencil is a pencil. Someone suffering from vascular dementia knows a pencil is a pencil. But because of the damaged pathways, there is often a break in the connection between knowledge and speech, so someone with vascular dementia is just as likely to call a pencil an apple.

Another clear indicator of vascular dementia is slower processing time. A brain with vascular dementia will fight to reroute stored information to speech. However, because of the extensive damage, it has to take a much more convoluted and lengthier route to do that conversion.

A third clear indicator of vascular dementia is that it occurs in sudden, steep steps of decline (brought on by recurrent TIA’s and new clustered areas of damage in the brain). These can occur in a very short period of time, as they did in my mom’s case.

In addition to these definitive indicators, vascular dementia also has features in common with other dementias, including difficulty learning anything new, cognitive impairment, problems with short-term memory, extreme emotional swings, and confusion.

There are no specific treatments for vascular dementia. Unlike any other organ in the body, once the brain has sustained damage, that damage is permanent.

However, there are medications that can address the symptoms of vascular dementia. The two most likely to help are cognitive enhancers: Excelon (although this comes in oral form, the 24-hour patch is best, if there’s no allergic reaction, to get the continual effect of medication that comes in a starting dose of 4.6 mg, a stabilizing dose of 9.5 mg, and a high dose at 13.3 mg)  and Namenda (given in 5 mg increments, two to three times a day).

When I discuss the medications in later posts, I will give some practical experience and advice on these two medications, especially with regard to Medicare, the “donut hole,” and working with your loved one’s psychiatrist to get the medication at either no charge or a reduced rate during the “donut hole” period. Both of these are patented, so there’s no cheaper generic version. And paying full price for them will break the bank.

In the next post, we’ll take a look at Lewy Body dementia: what is is, how it’s diagnosed, what it looks like, and effective treatments for the symptoms.