Feb 13, 2020

Axios Vitals

By Caitlin Owens
Caitlin Owens

Good morning, again from San Francisco. My apologies to my loving parents, who found out at the same time as the rest of you that I'm here, and who would like to be kept more informed. Shoutout to them for being such Vitals fans!

Today's word count is a quick 737, or a 3-minute read.

1 big thing: The boom times of insulin sales
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Data: Company documents; Chart: Andrew Witherspoon/Axios

The three drug companies that control the insulin market have seen their net sales climb over the past 12 years even as they have had to agree to bigger discounts, according to an Axios analysis of insulin types sold by Eli Lilly, Novo Nordisk and Sanofi.

The big picture: Drug manufacturers have largely blamed the broken insulin market — where many people with diabetes are rationing their medication — on other actors within the supply chain.

  • But insulin makers have still been able to collect more money overall and retain their power over the market, Axios' Bob Herman reports.

By the numbers: Net global insulin sales, after accounting for rebates, rose by at least 80% from 2008 through 2019 for each of the big three companies.

Between the lines: Revenue is a function of price and quantity, and both have risen.

  • Insulin's list prices have gone up drastically over the past two decades. List prices matter a lot for the uninsured and people with less generous health plans.
  • Net prices have not increased as much, and for some insulin types they have dropped, because pharmacy benefit managers have extracted higher discounts, called rebates, in exchange for giving certain insulins preferred coverage status.
  • The growing prevalence of diabetes has led to higher insulin use, but outside data shows total prescriptions and daily insulin use have grown modestly over the past several years.

The intrigue: Insulin sales are rising even though many of the drugs' patents have expired.

The bottom line: Discounts and price negotiations have inconvenienced, not fundamentally hurt, insulin makers. And patients, along with the public, are footing the bills.

Go deeper.

2. How doctors have shaped surprise billing fight

Kaiser Health News' Rachana Pradhan has an excellent deep dive into doctors' extensive lobbying on surprise medical bills, which is partly to blame for Congress' inaction.

Why it matters: "As Congress begins its 2020 legislative session, there is evidence the doctors' message has been received: The bills with the most momentum are making more and more concessions to physicians," Rachana writes.

The big picture: Many of the doctors involved in the surprise billing fight are employed by private equity-backed companies.

  • Doctors' voices have a distinct power compared to other industry lobbyists, as they're the ones providing care to patients.
  • Their message to lawmakers, one doctor told Rachana, is that "we just want to be paid a fair amount for the services rendered."

Reality check: Study after study has shown that the doctors that tend to send the most surprise bills also get paid more than other specialties.

  • One study found that four specialties that are often out-of-network raise employer insurance spending by 3.4%.
  • These other specialties — the ones that don't tend to be paid private insurance rates multiple times the amount that Medicare pays — somehow manage to get by.
  • And the relationship to high payment rates and surprise billing isn't random. Researchers say that the potential of surprise bills gives doctors greater negotiating leverage against insurers. One major physician staffing firm admitted as much to lawmakers last year.
3. Tobacco marketing works

Exposure to vaping products — through friends, endorsements on social media or branded merchandise — makes students much more likely to vape, according to a study published in JAMA on Wednesday.

Driving the news: The study was published the same day Massachusetts Attorney General Maura Healey sued Juul, saying its early marketing campaign targeted teenagers with celebrity endorsements and ads on popular sites, Axios' Marisa Fernandez reports.

Between the lines: The JAMA study, which polled more than 4,000 students in New Jersey, confirmed that Juul is especially popular with teens.

  • Nearly 90% of high school e-cigarette users said they had used a Juul product in the past 30 days.

Go deeper: Juul's very bad, no good rotten year

4. Employers struggle to handle mental illness

Illustration: Aïda Amer/Axios

Reported mental illnesses are more common among young people than other generations, and employers are struggling to figure out how to accommodate their young employees' mental health issues, the Wall Street Journal reports.

Between the lines: These young workers grew up receiving accommodations in school that helped them manage their mental health, but the laws — and pressures — around employment are different.

Details: Mental illnesses covered by the Americans with Disabilities Act often have vague or invisible symptoms, which can make accommodations more difficult for employers than those for physical health issues.

  • But workers are making more requests for such accommodations, WSJ reports, and more are alleging that they're experiencing discrimination because of their mental health conditions.
  • The number of discrimination charges filed with the Equal Employment Opportunity Commission that cited anxiety disorders rose from 65 in 2006 to 371 in 2019.

Go deeper:

Caitlin Owens