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Tuesday Nov 26, 2019

How Much Will This Cost, Doc?

About six months ago I got a flyer in the mail for continuing medical education from a local medical society. The two-day conference covered numerous subjects I wanted -- needed -- to know more about as a primary care physician. Osteoporosis management. Rheumatoid arthritis. Inflammatory bowel disease. Skin cancer.

[woman using smartphone with flying money]

I showed up and slipped from the bright, sunlit hallways into the dark of the large, windowless conference room. There were rows and rows of empty tables in the front where everyone else had declined to sit. People dispersed themselves just far enough apart so as to not really interact with anyone else, which was fine. I was there to learn.

I found my island of a spot, pulled out my laptop and opened the slide deck -- New Technologies in Diabetes Care -- and downloaded it to take notes. We meandered through the history of insulin and the pharmacotherapy and clinical effects of each of the different insulin formulations -- which was great because insulin degludec was released just as I was finishing residency (gulp!) and I hadn't yet sat down to do a deep dive on the basic pharmacology behind the formulation.

The lecturer shifted to talk about continuous glucose monitors and I started to feel my pulse quicken. The devices had been around since 1999, I learned, with the biggest improvements in the patient experience and data collection coming in the last 10 years or so. The current models have been on the market for the last three to four years.

By this point, I was getting antsy in my seat: I had never prescribed a CGM before. Hell, I didn't even know how to prescribe one. And I had no idea how much they cost, but my guess was that they weren't cheap.

The lecturer flipped to his next slide, and up popped a table comparing clinical characteristics of several CGMs.(academic.oup.com) Across the top, it listed the different CGMs on the market. Running down the first column, each row highlighted different attributes: whether calibration is required, warm-up time, alarms and alerts, duration of wear, ability to transmit, acetaminophen interference and pediatric approval.

Nowhere on this chart was cost mentioned. There wasn't a row labeled "value" where a physician (or patient) could make the call as to whether or not a device was affordable, changed outcomes or resulted in a better experience.

(Full disclosure: I'm a direct primary care doctor. I own and operate a primary care clinic where we practice the same medicine practiced by any board-certified, residency-trained family physician, but we're focused on providing transparently priced, affordable primary care.  To achieve this aim, we eschew insurance billing and care for our patients via a flat, fixed monthly payment paid by the patient. Taking the intermediaries out of the relationship allows the economic incentives to realign and for us to be responsive to our patients' needs. Almost as importantly, we -- along with our fellow DPC docs in the area -- use our leverage as health care entities to negotiate for lower drug, lab, radiology and subspecialist pricing. So, in short, I care about prices because my patients care about prices.)

I was immediately down a rabbit hole: How much do these things cost?

I clicked around the CGM manufacturers' websites to see if I could get a better idea of the direct-to-consumer price, but I couldn't find anything. I started to fill out an order form just to see how far I could get without insurance, but I was stopped pretty quickly. In the insurance drop-down menu, uninsured or self-pay wasn't even an option.

I landed at the GoodRx website and found that the Freestyle Libre sensors(www.goodrx.com) were more than $100 a month and the Dexcom sensors(www.goodrx.com) were more than $300 a month. But I still didn't know the cost of the devices themselves.

Resorting to a general search outside the manufacturers' websites, I found a 2018 Managed Care article(www.managedcaremag.com) that estimated annual direct-pay prices for three devices on the market at that time and sensors (when used as directed) were $1,300, $3,556, and $4,800.

I snapped my laptop shut and returned to the reality in front of me

With my mind a bit refocused from my foray into the cost of CGMs, I realized 10 minutes had passed and the lecturer had moved on. He was now discussing troubleshooting insulin pump failures. And as soon as I realized he was talking about a different device, my mind started to wander into the cost of insulin pumps.

Although there is evidence that the CGMs are cost effective(www.ajmc.com) -- at least for patients who have type 1 diabetes -- I realized that this lecture was a little bit of a preview of what I would be experiencing for the rest of the day.

And the next.

I spent two days in lectures learning about all the amazing new science that was almost completely unaffordable and inapplicable to my patients with sparse pharmaceutical coverage, high deductibles or -- simply put -- no insurance.

It's not that they wouldn't have benefitted from the technology or new treatments; it was that there was no way they could afford them.

I left the two-day CME conference frustrated, angry and (I'll admit) a little bit smarter. But I still don't have any idea how to best help my patients.

At my clinic, we cobble together solutions using generics, samples and devices whose patents have expired, like albuterol via nebulizer rather than inhaler. We gratefully accept samples for novel diabetes agents and inhalers for COPD and severe asthma. We talk about how to order medicines and devices from Canada or how to make the most of a trip to Mexico.

But if continuing medical education is supposed to help us help our patients, is it fair to ask that the mission of CME evolves to include figuring out how to help our patients afford the amazing treatments we learn about?

Allison Edwards, M.D., founded and cares for patients at Kansas City Direct Primary Care;(www.kansascitydirectprimarycare.com ) provides locums coverage at rural hospitals in Missouri, Kansas and Colorado with Docs Who Care; and is volunteer faculty at both the University of Colorado and the University of Kansas. You can follow her on Twitter @Dr_A_Edwards.(twitter.com)

Read other Fresh Perspectives posts by this blogger.

Posted at 11:50AM Nov 26, 2019 by Allison Edwards, M.D.

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