The Deal About Rebate Reform

Will rebate reform policy save chronic illness sufferers like us from financial doom?

Managing diabetes is already difficult and exhausting to maintain on a daily basis. But what if you are one of 34 million people with diabetes also struggling with increasing medicine costs?

You find yourself having unsuccessfully heated conversations with your doctor and insurance company because that $432.61 Lantus medication that your doctor prescribed is not covered by your insurer. To make matters worse, there’s no generic alternative for Lantus.

Or let’s say that your insurer does cover Lantus. You go to pick up your medication from the pharmacy only to find out that you’re paying more out of pocket, placing a financial burden on you.

In fact, this is actually how the current drug distribution and payment system is designed.

And the end result: we are footing the bill.

According to the Diabetic Leadership Council, a patient advocacy organization for diabetes:

“The substantial costs of living with a chronic illness are compounded year over year, penalizing and marginalizing high risk patients, perpetuating medical inequity. According to the CDC, chronic diseases are the leading causes of death and disability, driving $3.8 trillion in annual health care costs (18% of the GDP). Ultimately, people living with chronic diseases not only bear the burden of daily illness management but also predatory medical costs. Those living with diabetes perpetually pay higher costs to live, $9,600 annually, exacerbated by inflated prescription drug costs due to grossly unfair rebate practices.”

This is the foundation of rebate reform. In order to understand why this is being considered, you have to understand the key players involved; how drug rebates currently work and how this is financially burdening so many of us.

Patients Rising Now, another advocacy organization, created a great infographic showing how prescription drug distribution and payment works:

Key players in the drug distribution and payment process involves the following:

  • Drug Manufacturer
  • Wholesaler
  • Pharmacy Benefit Manager (PBMs)
  • Pharmacy
  • Health Plan (Insurers)
  • Patient (Us)

We will focus on the flow of rebate. The flow of rebate is represented by the orange line.

The key players involved in this flow are:

  • Drug manufacturer
  • Pharmacy Benefit Manager (PBMs)
  • Health plan (Insurers)
  • Patient (Us)

How Do Drug Rebates Work?

Rebates are discounts paid by drug manufacturers after the prescription has been dispensed to insurers, pharmacy benefit managers and pharmacies. These are cash payments that are sent to PBMs, which then shared with the plan sponsor (insurer) that they serve. The insurer generally uses the savings to lower the premium for the patients, rather than passing the discount to them at the point of sale.

This concept has been around for years. At first, drug manufacturers paid rebates for every brand name drug on the market. However, drug manufacturers started to consolidate the rebates into fewer products to maximize their share. Currently, rebates are attached to more expensive brand drugs and specialty medications. The more expensive brand drugs and specialty medications gives insurers and pharmacy benefit managers an incentive to include a drug on their formulary, which is a list of medications that may be prescribed that are covered by the insurer.

PBMs negotiate contracts with the drug manufacturers on behalf of the insurers. It determines the placement of drugs to specific tiers. These tiers determine how much a patient owes out-of-pocket for a prescription drug. Preferred drugs are typically have lower co-pays. The details of the contracts between PBMs and drug manufacturers are kept confidential.

The PBMs financially benefit from the rebates by encouraging fast-growing list prices for the drug. The insurers financially benefit by having us, patients, pay our share of the list price of the drug (the original price of the drug) instead of the net price (the total cost of the drug after rebate). This places a major financial burden on us, especially if we are relying on expensive medication.

Organizations like the Diabetes Leadership Council believe that patients should never have to pay more for medical products and services than their health plan pays. This is why advocacy programs are targeting congress to pass non-partisan rebate reform policies to help reduce patient costs. A rebate reform would require PBMs and insurers to pass savings to the patient, making it easier to afford to access to the medicine that they need.

Currently, there are talks in Congress surrounding rising prescription drug costs, including two hearings on the issue. My hope is this will be the traction that we need to be able to get some meaningful reform passed so we don’t have to suffer from anymore additional stress because of medical costs.

We should not be forced to choose between taking care of family or medicine we need that will allow us to do so.

It’s past time to change the narrative.

Until Next Time,

The Genetic Diabetic

No U-Turns

Setbacks await for those who return to old habits

It’s been said that once we are in remission from type 2 diabetes, or if you’re a pre-diabetic who has reversed their chances of being diagnosed with type 2 diabetes means that the journey is over. Most of us are unaware that a dose of reality is about to hit us head on.

Remission and reversal doesn’t mean dismissal. 

It doesn’t mean that we return to our prior health and nutrition habits before our diagnosis. Diabetes is considered progressive for a reason. The more that we indulge in foods that we know are not healthy and stop the habits that helped us get to the point of remission or reversal, the faster Diabetes will further progress in our bodies, causing us to regress and erase all of the strides we’ve made. This is why type 2 diabetes is a lifelong chronic illness that we will always have to keep in check. 

Friends, this is reality. 

There are many of us who will continue these habits because we know that it works and we know the consequences when we don’t do it. This is the attitude that we need to adopt and live by EVERYDAY! 

But for those who have backslidden and stopped implementing the very habits that have helped achieve remission and reversal in the first place: there’s no turning back! 

There are no U-turns on this diabetes journey. 

The constant grazing of unhealthy foods throughout the day, late eating patterns, the lack of sleep, the lack of intentional exercise and remaining in stressful and toxic environments are no longer options for us and should not be accepted as our normal. We have to ask ourselves, “Why do we even want to return to this life in the first place?”

Is it because we get to eat all of the foods that we’ve missed? 

I get it. There are plenty of days when I have to battle those same feelings, especially while on a strict way of eating where you can’t eat a banana. Not all foods are bad, but for some, something like a banana can do more harm than good. Are you willing to risk eating something that you know will harm you just because you miss it? 

Or is it because you just want to feel normal again…

I completely understand. I’ve mentioned this on several occasions on this blog and on some of the diabetes community platforms that the day I was diagnosed was the day that life that I knew it ended. Changing my eating habits, becoming more active, setting boundaries and staying consistent was the new normal for me. Even though there are difficult days, I know that this new normal is better in the long run. I’ve witnessed the benefits from the daily sacrifice of dying to self and taking a risk that many would find extremely difficult to do. If it wasn’t for diabetes, I would not have the knowledge of what I’ve gleaned from this journey. Why return to a chaotic life filled with inconsistent habits and ignorance? 

Is it just something you had to do and now that you’re done, you don’t have to deal with this again.

“Yes”, I’ve said to myself five years after having my last child.

Dealing with a second bout of gestational diabetes really took a toll on me, causing me to give birth three weeks early. My final A1c check after delivery was 5.3. I was done. I was finally able to get on with my life and not have to deal with anything that had the word diabetes in it and if that was the case then it was not God’s will for my life. Even though I thought I was doing well because I was eating what I believed was a low carb diet (AKA: not eating much, but eating foods that caused insulin resistance.) and being active (AKA: staying busy, team no sleep, no intentional exercise), diabetes still found its way into my life. I did what I was instructed to do just to be free. That attitude brought me here.

Take a page from my book: if you return on the path that you were on prior to diagnosis, then you will find yourself head to head with diabetes at a high rate of speed and inevitably crashing.

Do you know the difference between a trip and a journey? A trip is an act of traveling to another place for a short time and then returning. A journey is when you travel a long distance from one place to another.

Diabetes is not a short trip where you can just make a U-turn, return and revert back to your old ways. Instead, think of diabetes as a long and continuous journey, discovering new ways of becoming healthier, feeling so much better than you ever had that you’ll never want to return to the way things were. Instead you’ll return with a new outlook and mindset, an unrecognizable you, who’s been inspired and forever impacted by this experience called diabetes.

Until Next Time,

The Genetic Diabetic