Tomorrow is yesterday

So this is what my life has come to. Well, my career anyway. The assignment was so depressing it took me several weeks to get it done. Not only was the research difficult—no one has ever done this before, so I’m on uncharted ground—but I had to deal with alternating waves of depression and rage.

It’s not easy being the Harbinger of Death.

I suppose I should consider it an honor that I was chosen for the task. It shows that the powers-that-be have great faith in my abilities. But still…

It’s not like anyone is ever going to see it, but I felt that the document needed a preamble. A declaration of sorts. That’s not something that you typically include on medical standing orders.

I wrote: With worsening economic conditions and growing numbers of un-insured who do not qualify for assistance—as well as under-insured or financially strained patients who can no longer afford co-pays on frontline meds—a reverse protocol is required for moving diabetes patients off of frontline therapies into older, less effective, but more economical therapies. The Medical Team acknowledges that many of these therapies are both riskier and/or less effective than the preferred medications in our decision trees, but that in the spirit of harm reduction it is necessary to make compromises…

Well… now that I re-read it here, it doesn’t seem as eloquent as I was making it out to be in my head. Thomas Jefferson definitely has me beat hands down.

So, yeah, my assignment was to create a “Poverty Protocol,” a medicine decision tree to move people backwards in time. To figure out how to reverse engineer Lantus back to NPH. Novolog back to “R.” To figure out how to best replace meds that are working, but can’t be afforded anymore, with ones that are generally considered to be in the dust bin of diabetes history.

How big a difference can this make, really? Well, it can absolutely help the pocketbook. Take Levemir for instance. The average retail price if you don’t have insurance is $136 per vial. If you’re a type 2, you could very well need five vials in a month. That’s $680. If you just lost your job and your insurance how can you afford that? Or maybe you still have your job. But your spouse just lost hers and the family budget just took a hit. Or maybe you wake up one day and discover that your health plan has just created a new Tier 4 copay on your insulin that requires you to pay 30% of the retail cost.

Me to the “rescue.” Our clinic can buy vials of NPH for less than $1 per vial. Money. That I can save you. But what will it do to your health? Lord only knows. We won’t know for a few years.

NPH is erratic. It’s short lived. It has a nasty peak. Basically, it’s the angry mule of insulin, and I’m surprised in this world of Lantus and Levemir that it’s even still made at all. But thank God it is. Better angry mule insulin than no insulin at all.

And the problem is not just limited to insulin. Thirty days’ worth of Merck’s best-selling pill Januvia costs $216 dollars. That’s $7.20 per pill. The nasty pancreas-breaking pills called sulfonylureas, that wring the type 2 pancreas out like a sponge to get every drop of insulin possible out of the failing organ, only cost a penny each.

So that was my new Third World toolkit. NPH. R. Mix. And cheap pills I regard as poison—use those damn things for very long and you’ll need the NPH and the R.

Once upon a time there must have been protocols for moving people from NPH to Lantus. You know, back when it was first approved twelve years ago. But that was back before the internet was the fountain of info it is today. I couldn’t find any guidelines at first, and I’d long since thrown mine away. Who needed them? Everyone had already been moved off of NPH. I called Endos and CDEs in my “pack,” but no one could remember what they did back then. Finally, I found an archived prescriber’s newsletter from 2009 that had guidelines for how to upgrade people from that nasty ol’ NPH to Lantus and Levemir. I was able to reverse-engineer those as a starting point.

But there were other considerations. It isn’t as simple as “here’s your new vial, and your new dose is ___.” For one thing, most of our people use pens. No NPH pen. Patient, meet syringe. Syringe, meet patient. No trauma there. And back when we all took NPH we understood the peaks. At least I did after NPH landed me in the ER. Going from an insulin with a peak to one that is peakless, or nearly so, is a breeze. Think about what it will be like for patients who have always had peakless insulin to adapt to an insulin that acts differently two hours after you take it. And differently again in four hours. And differently yet again in six hours. And still differently again in eight hours…

And I had to think not only about what to do for people who were in control and can’t afford their meds, but also about those who are out of control and can’t afford their meds. How do I upgrade their therapy and downgrade their cost at the same time?

My proposed “decision tree” sketch began to look like the organizational chart of the Pentagon.

And I’m in the same leaky boat myself, although I recognize that I have it waaaaaaaay better than most. First, I lost my battle to get my beloved iBG Star covered and have had to stop using it. Then I had to go from using a pen to using syringes for my fast-acting. I was paying for the Humalog out of pocket, but now the price has gone up on me. My health plan won’t cover the Humalog cartridges my half-unit pen requires. Their opinion: Use a half unit syringe and a vial of Novolog. It saves them a few pennies a month. So that is what I had to do. By the way, do you know how hard it is to draw up a half-unit of insulin in a syringe? I had to pick up a syringe magnifier. Then I accidently sprayed insulin into my left eye when trying to clear bubbles from one of those fucking syringes. It wasn’t as painful as you’d think, but it just goes to show the kind of week I’m having.

I get bitter and angry because I’m working 80 hours a week to help people be healthier and I can’t even get the tools I need for my own care. I get angrier still when I think how many millions of dollars I’m saving the health plans via my work, and they fight me over every penny, both for myself and for my patients.

Several weeks ago I was at the 2012 DiabetesMine Innovation Summit at Stanford. There were all these amazing people with great visions of tools that can help us rise above the challenges diabetes places in our way. Patients, clinicians, inventors, investors, and industry were at the table together. Even the FDA was there talking frankly and openly about their desire to advance the safe use of technology.

But the 800 pound gorilla was missing. The health plans left their seats at the table empty. What good will the best gear do if no one can afford it? How do we make them understand that healthy us makes wealthy them? I just don’t understand it. I suppose it comes down to the quick buck. The myopic vision of Wall Street. Live for today with no thought for tomorrow.

There’s a lot of talk about the fiscal cliff in Washington. But I’m more worried about the brick wall. The one we are careening towards at 100 miles per hour. In 1980, we spent $256 billion on health care. In 2010 we spent $2.6 trillion. That’s 17.9% of GDP. How much more can we spend? Are we going to spend half of every dollar in the country on health?

So between my own losing battles, writing the Poverty Protocol, and being charged $9.30 by my bank for not having enough money in my account for them to invest, I’m pretty depressed about where we’re headed as a society. Especially when it comes to where we’re headed when it comes to health “care.”

Sometimes I feel the money men are building themselves fancy new buildings using our tombstones for bricks. And in my darkest moments, I wish a plague of diabetes on their houses. Of course, even if that should happen, they’d be fine. They’d still be getting the Levemir, the Januvia, the pens, and the iBG Stars.

They’d never experience my Poverty Protocol.