I KNOW THIS SOUNDS CRAZY, but I just bought a $3000 facial cream. Actually, it's a bit more complicated, but this story demonstrates the brokenness of our healthcare system.
IN SEARCH OF A CURE
The saga began yesterday when my dermatologist prescribed a skin cream that I've used occasionally. This time, however, before Costco’s pharmacy filled the prescription, the pharmacist took me aside and said, “Mr. Rogers, I’m not sure if you are aware, but this medicine costs $3000.”
My jaw dropped for several reasons.
First, I’ve used the cream, which is called Carac™, on two other occasions, and the price was never this high. Back in 2012, which was the last time I used it, I paid somewhere around $75. It turns out that the price of Carac (0.5% fluorouracil cream) has gone up nearly 1,400 times since then. 1,400 times! I have nearly the same insurance as I did five years ago (still Blue Cross), but even with my insurance discount, I would be paying $1,400 out-of-pocket.
Secondly, it’s not in short supply. In fact, the USPTO patent for the underlying chemical was issued in 2003, and it’s been sold to the general public for over ten years.
Thirdly, and this is the real insanity, it treats a common pre-cancer skin condition called actinic keratosis, which are those seemingly harmless scaly patches of skin that often develop on your face after years of sun exposure. I prefer to think of them as battle scars, earned after years working in the video game industry, but the fact is, I am a freckly-faced Irish man. Actinic keratosis is common among my tribe, especially those of us raised in Southern California where suntan lotion, not sunscreen, was advertised on Coppertone® billboards.
THE PHARMACEUTICAL MAZE
Before I left the dermatologist's office on this mad adventure, the nurse gave me a perplexed look and told me that my Carac was a bit expensive. Until then, expensive, at least in my mind, was somewhere around $100, and I figured Costco might offer it cheaper, so I requested she send the prescription there.
As I was leaving, the nurse handed me a discount card and said, “This might help.”
Little did I know about the maze I about to enter.
COSTCO - $1400
The price for Carac at Costco was $1400 and change, with my insurance discount. When I asked the pharmacist to confirm the price, she looked incredibly embarrassed, informed me that the list price was $3,000, and told me that my out-of-pocket would be $1400. When I asked her for the price of a generic alternative, she said, " $1200 and change." Then she suggested I ask my doctor for samples.
Since I pay roughly $1300 a month for insurance, this struck me as odd that I would have to settle for opening tiny packages of medicine and smearing them on my face because I couldn’t afford the full tube. Nevertheless, I called my doctor again.
I spoke to my doctor’s insurance specialist because, as it turns out, all doctors need a dedicated insurance liaison these days because of the complexity of insurance and to help people like me navigate our way around the Big-Pharma wolves. The specialist apologized, saying that they didn’t have samples, but suggested we send the prescription to Walgreens, where my one-time discount card would be honored.
WALGREENS - $1450 OR $1250 OR $855
So, I then drove across town to the nearest Walgreens. Thirty minutes later and after frantically punching at unseen computer screens and dialogue boxes, the pleasant pharmacy assistant looked up from her screen and said, "It’s pretty expensive, Mr. Rogers.”
“How expensive?” I asked.
“Wow. That is expensive.
“How much is the generic?”
“Ah… Okay. Let me call my doctor and see what’s going on. She told me that it shouldn’t be any more than $75.”
“Well, the list price is $3000, if that makes a difference.”
“It doesn’t,” I answered. With that, I called my doctor’s office again. A little while later, my insurance specialist got on the phone with the pharmacist assistant, and ten minutes later they emerged with a new price.
“Eight fifty-five,” the pharmacist assistant said with a smile.
I was relieved. Finally, I thought. Still, I asked for confirmation: “Eight dollars and fifty-five cents, right?”
Frown. “Eight hundred and fifty-five dollars. I’m so sorry.”
Sadly, I sat down on a fake-leather chair next to the coin-op blood pressure booth and called my doctor again.
“I can’t pay eight hundred and fifty-five dollars for this medicine," I admitted. "I’ll have to go without it.”
My insurance specialist was apologetic but firm. “They can’t charge you more than $100, Dan. Did you use the discount card?”
“I… think they did.”
“Did they run it through your insurance?”
“I don’t know. Lemme ask.” A moment later, I had the answer: "Yes. She ran it through the insurance.”
“Well, she's not supposed to do that. Tell her to look at the back of the card, where it says, “$100.” That’s as much as Walgreens can charge you.”
I immediately thought about the folks who are not lawyers like me or who don't have someone nearly as nice helping them. They would have paid Costco $1400 or Walgreens $1450 and then gone without heating or air conditioning or food for a month.
Back at the pharmacy counter, I showed the pharmacist assistant the back of the discount card and explained that she should run it without going through my insurance. I confidently assured her that the price on her magic screen would come out at $100. Or maybe $75. I wasn’t sure.
This was new territory for my pharmacist assistant. After all, how could a medicine listing at $3000 only cost $100? She quickly determined that it was above her pay grade, so she got the second in command involved.
After Ms. Second In-Command skeptically inspected my discount card, she commanded the pharmacist assistant, “Run it through the insurance again and see what happens.”
“No!” I nearly shouted. “Just run the discount card as if I came in off the street like a hobo. Pretend I’m not insured and just scan the card.”
With Second In-Command looking over her shoulder, a tired looking pharmacist assistant attempted to run the discount card through my insurance again, breathing in deeply with each keystroke, as if typing in a nuclear launch code. Five minutes later she looked at Second In-Command and said, "It's still $1450."
Second In-Command would have none of this. She scooted in front of the monitor and tried it herself. After another five minutes and who knows how many screens and dialogue boxes she navigated, she peered around the computer screen and said, “$1450.”
“Run the card by itself," I pleaded. "Pretend that you never saw me before."
Distant, blank eyes stared back at me.
"Please," I asked.
Second In-Command looked at the pharmacy assistant skeptically, waived her diamond-ringed hand, and said, "Run it by itself," as if it was bound to be a complete waste of time.
The pharmacy assistant dug into the new task with renewed energy, and wah-la, the price came out to $100 for a $3000 face cream. Everyone was amazed. In shock. Instead of realizing that I was about to pay $100 for six ounces of medical cream, I was running through the Walgreens aisles as if I'd won the lottery.
Then horror struck. My pharmacy assistant exited from behind the counter and informed me that was taking her mandatory break. I’d been there nearly two hours, and she was going to leave me alone with Second In-Command.
“Please," I begged. "Can't you wait?”
She shook her head and assured me that I was in good hands with Second In-Command, who is still looking at me like I'd committed fraud. Thankfully, twenty-minutes later, my medicine was ready. I'm still not sure why it took twenty minutes to put a toothpaste tube of $3000 medicine into a paper bag, but I wasn't going to complain. Instead, I left with a smile on my face and a $100 charge on my credit card.
It turns out that 58 million Americans have actinic keratosis, and it’s is highly treatable, provided you see your dermatologist regularly. Not doing so, however, can be deadly, since approximately 10% of AKs have a nasty habit of turning into squamous cell carcinoma (SCC), which is the second most common skin cancer. People die of skin cancer. Even freckle-faced, Irish video game lawyers.
You'd also think that the medical industry would be motivated in treating my pre-cancerous condition inexpensively before it turns into something more serious and expensive. As it turns out, my doctor seems interested in this. So too does my insurance company—at least to some degree. The bad-guy is Big-Pharma, which has grown into an uncontrollable and merciless monster.
NO, OBAMA-CARE ISN’T THE PROBLEM
It's popular these days to blame the Affordable Care Act on anything health related, and while certainly not blameless, it isn’t the problem in this instance. It’s much less complex.
Pharmaceutical-industry greed, to be precise.
It’s the voracious appetite of a for-profit industry that has been allowed to metastasize in the void of self-serving lobbyists and inattentive or compromised government officials. Unfortunately, it's now to the point that innocent people are being hurt.
While far from perfect, the Affordable Care Act, which went into effect in 2010, is the only thing keeping people like me from being denied insurance. It's only fair, given that I've been paying health insurance since I was in my early twenties, right? Additionally, insurance companies can no longer set lifetime benefit limits, which helps people with severe and costly conditions from spending all their cash reserves on medical treatments and then forcing them into bankruptcy. The problem is that the ACA doesn't address predatory drug pricing, which has been on the rise since for nearly two decades.
Big-Pharma has gotten a free ride for too long. They raise their prices with little oversight, and doctors and insurance companies and people like you and me are left to deal with the consequences. As for doctors, including my own, they are forced to take evasive action. They avoid prescribing effective medicines, like Carac, in favor of less effective but cheaper alternatives. In my case, it's liquid nitrogen, which is applied selectively to areas of my face instead of treating the entire area at once. Let me remind you that Carac isn’t an exotic drug. It's been around for years and is used by thousands of patients. However, my doctor has been reticent to prescribe it because of its cost, which is artificially inflated.
OPERATING WITHOUT A CONSCIOUS
While drug prices have been on the rise for years, only recently has it gotten to the point of ridiculousness. Today, insurance companies are forced to create long lists of drugs they won’t insure because of the cost, and doctors are navigating their patients through complex mazes of discounts, alternative drugs, generic drugs, and treatments because no one will stand up to Big-Pharma. Whether you’re talking EpiPens or, in my case, Carac, drug companies are running our health in the ground, and they don’t care. They have no conscious.
Consider Martin Shkreli, who happens to be the poster-child of Big-Pharma humanity. Shkreli is the 34-year-old former hedge fund manager who founded Turing Pharmaceuticals. When Turing purchased an existing drug called Daraprim--which has been around since the 1950s and is now used by AIDS and cancer patients—, they immediately raised the price per pill from $13 to $750, a 4000% increase. Shkreli’s company didn't invent Daraprim, but his predatory price-gouging has made him one of America's most despised individuals. But, he doesn't seem to care. His response after a recent criminal trial for securities fraud is downright scary: “I’m one of the richest New Yorkers there is, and after today’s outcome it’s going to stay that way.”
Then there’s Valeant Pharmaceuticals, the company that sells my facial cream, Carac. Valeant is the same company that purchased a heart medicine from Marathon Pharmaceuticals in 2015 and subsequently raised the price 720%, from $214 to $880. It's the same company that generates nearly ten billion dollars annually. It's the same company that has raised their prices on 147 drugs by an average of 76%. In 2016, Valeant became the subject of a federal criminal investigation into its drug pricing, but that hasn’t stopped them from continuing to overcharge Americans badly in need of their products.
TRUMP-CARE WON'T SAVE US
While our current president, Donald Trump, has expressed concern over drug prices, in June of 2017, he wrote a draft executive order which, supposedly, addresses predatory drug prices. Unfortunately, it appears to do the opposite. It grants Big-Pharma more power to charge higher prices overseas by extending the exclusivity period before generic alternatives can be made available, enables drug companies to give fewer discounts to hospitals and the poor, and fails to allow Medicare to negotiate drug prices directly, which could result in lower drug prices for their customers.
If that isn’t enough, Mr. Trump has repeatedly expressed a desire to let the ACA fail entirely. He's even willing to defund it to bring about this carnage. For anyone who has a pre-existing condition, as is my case, this would be disastrous. It would allow my insurance company to drop me from their plan or cap it in the event I developed skin cancer. In either case, I could lose my home, savings, and health. Already, 26% of all Americans say that medical expenses have taken a serious toll on their finances, and it's only getting worse. Until Congress and the President reign them in—Big-Pharma is going to be exploiting the American public for as long as they can.
Not only was my experience complex, horror-filled, and needless, but I was to the point of not getting my medicine, which, as it turns out, is what many folks are doing these days. Instead of getting the preventive care they need, they are leaving their prescriptions unfilled because they can't afford them. The question is how many of them will end up with a nasty and more serious condition as a result?
AH... MEXICO. I REALLY WANNA GO
When I got home, I put my $3000 Carac cream in the bathroom vanity drawer, although a part me thought it might be safer in our fireproof safe. Then I started investigating.
Carac costs a little over $9.00 in Mexico. That’s nine dollars, not nine-hundred dollars. At Walgreens, I had joked with the assistant pharmacist that it might be cheaper for me to fly to Mexico, spend three days at a nice resort, see a top-dermatologist, and buy my facial medicine there.
It turns out I was right. In fact, I can book a flight to Puerto Vallarta next month, spend three nights at a four and a half star resort, see a well-qualified dermatologist, get a prescription for Carac, and fly home for $1200.
THE ROAD AHEAD
As we grapple with our American healthcare crisis, let’s hope our political representatives—on both sides of the aisle—don't forget that those without the fortitude to do what I did, those without the money to buy their way through this crisis, are on the front lines of this moral war. Moreover, they’re dying because of injuries and ailments that can easily be treated.
Dan Lee Rogers has been a leading figure in the video game industry for over two decades and is the author of the Amazon best-selling novel, Ghosting (https://goo.gl/5RBAEU). A practicing attorney and interactive media law professor, Dan is credited on dozens of best-selling video game titles and recognized worldwide as an expert on the video game industry and computer technology. He lives with his wife outside of Yosemite National Park in California. thing about yourself. No need to be fancy, just an overview.