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Post by stevil on Feb 6, 2023 11:43:38 GMT -5
You would likely get way more prescriptions for Afrezza by proving no meaningful hypoglycemic events than you would with improved outcomes.
It would likely take a shift in understanding to halt disease progression - as well as years and years of retrospective data to prove- than it would with simply showing the safety of Afrezza. I can’t imagine too many doctors that wouldn’t reach for an insulin that eliminates the number one fear with insulin. But you also need to couple that with efficacy, otherwise you run the risk of the notion it’s weak or doesn’t work.
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Post by stevil on Jan 30, 2023 19:55:42 GMT -5
Ha, yes. He buys me lunch. I wouldn’t meet with him otherwise 🤪 I’m just joking, but, then again, maybe I wouldn’t see him much otherwise.
Thanks for the offer. I actually believe what you are telling me is true. I haven’t had any issue with the reps. I think they’ve been great. It takes character to play against a stacked deck.
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Post by stevil on Jan 30, 2023 19:12:16 GMT -5
They very well might be bringing food. I don’t know for sure. The doctors before me at my practice vetoed reps so I’m not even able to have them come to my office. I’ve requested a rep both times. I initiated the contact.
I may have misunderstood the answer when I asked it. My rep says he drives around and essentially cold calls offices and just shows up to see if he can get face time.
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Post by stevil on Jan 30, 2023 18:29:02 GMT -5
@sayhey I was initially talking to prc who said we need a more persistent and better sales team. Doctors aren’t unlike anyone else. Who likes having door to door salespeople show up at their house all the time? Or telemarketers blowing up your phone? The only reason we tolerate them at all (the vast majority of the time, if not completely) is because of the quid pro quo food they bring. They take care of our office staff with goodies, I give you an ear for a few minutes. We’re too busy during the daytime to entertain company. I barely talk to my wife during the day. Why would I spend that time with a stranger? I agree the issue is with leadership. You also can’t legally say anything that’s not in the literature. You can point to individual studies, but again, this stuff takes a long time, which is why we’re handed printed materials. To keep things concise and highlight the key memorable points when the salespeople are gone. You misunderstood. I was not saying they need to be more persistent. I was saying they would benefit from sayhey24's unquenchable enthusiasm, his knowledge and passion. I think its amusing that you "tolerate" drug reps. So very generous of you. New reps that present a new product you don’t care about? Absolutely. This is why relationships matter so much in sales. Unless you are a rep or watch the QVC channel all day long, I think the vast majority of people can relate. Doctors, based on the experience I have had (and I have been through more than a handful of offices in my training) don’t really want to sit and chat with drug reps unless they already know and like them or if they have a particularly interesting product to sell. You have a schedule to keep, you’re frequently running behind, and you just want a few quiet moments in your day to enjoy a peaceful meal. There were a couple amazing physicians I worked with, older and on their way out, that we’re great with relationships. They’d take time to sit and talk to the reps. Generally, if you’re not busy enough to have enough time to waste chit chatting, you’re not working hard enough. Doctors aren’t going to want to give up time they could be getting paid to sit and have a meal with a stranger. All that to say, having an established relationship as a rep might give you an honest chance to have an attentive ear, but then you hand out information that has an n of 24 and expect to be taken seriously? You might get one or two tries at prescribing if you’re a liked rep, but then you realize there are no dosing instructions, and the ones you do have lead to inferior results. It’s just not a recipe for success. MNKD is handing their reps a pool noodle then sending them into a gun fight.
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Post by stevil on Jan 30, 2023 13:54:58 GMT -5
@sayhey
I was initially talking to prc who said we need a more persistent and better sales team. Doctors aren’t unlike anyone else. Who likes having door to door salespeople show up at their house all the time? Or telemarketers blowing up your phone? The only reason we tolerate them at all (the vast majority of the time, if not completely) is because of the quid pro quo food they bring. They take care of our office staff with goodies, I give you an ear for a few minutes. We’re too busy during the daytime to entertain company. I barely talk to my wife during the day. Why would I spend that time with a stranger?
I agree the issue is with leadership. You also can’t legally say anything that’s not in the literature. You can point to individual studies, but again, this stuff takes a long time, which is why we’re handed printed materials. To keep things concise and highlight the key memorable points when the salespeople are gone.
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Post by stevil on Jan 30, 2023 10:41:05 GMT -5
Side effects fall under exceptional data 😁 Very, very few non responders.
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Post by stevil on Jan 30, 2023 9:57:42 GMT -5
You didn’t read my post carefully.
It’s not the fault of the sales team.
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Post by stevil on Jan 29, 2023 13:56:35 GMT -5
The other issue that people aren’t (fully) taking into account, ar least as it pertains to MNKDs failed efforts with Afrezza is the access to physicians to sell as well as a convincing argument to prescribe.
A lot of reps are having trouble breaking through offices to get a face to face with a physician. A lot of offices have stopped seeing reps after COVID- for reasons I can’t imagine other than just wanting an excuse to say no. On top of that, and I should probably verify with my rep because I haven’t asked explicitly, but I don’t think they buy lunch for office staffs because that gets really expensive really quickly. My rep said he’ll get his foot in the door and talk to staff, they’ll be kind to him, act like they like the product, and then never prescribe it. Happens often with reps because people are either too “polite” or cowardly to be honest.
I’ve lived in 2 densely populated areas now that have been key targets for MNKDs sales team. Both times, you can sense the discouragement and almost lack of confidence in the reps. By that, I mean you can see they get rejected so many times and have so much difficulty selling the product that it weighs on them. It’s like they expect things to go wrong… probably because everything does. Outside of sayhey, I don’t know of a single human being that can run into a brick wall countless times and get back up for more. It’s hard to find those types, and even if we had them, I don’t think they’d be anymore successful- the barriers aren’t at their level to overcome.
It’s a really hard sell to walk into a doctors office with a novel product (and one that carries baggage from a botched Exubera) and change minds. It’s different because you inhale it. That was ultimately the angle the first rep I worked with used. It was almost embarrassing the data they bring with them from the stat study to show superiority with an n of 24 for study participants. Then, if they do get a few prescriptions written, prescribers will give up once they inevitably run into countless prior authorizations and appeals in an office already inundated by frivolous paperwork. No one wants the hassle. To be honest, there’s no way I’d think twice about prescribing Afrezza based on what the reps have said and shown to me. If I didn’t do all the research myself, I wouldnt believe in the product enough to waste my time.
Food for thought. I’m on the fence regarding if I want MNKD to go it alone or have a sales team. It depends on how good the results are. Anyone and their grandmother could sell Viagra. Doesn’t take talent to sell something with exceptional data and coverage. It’s more just a matter of getting boots on the ground and bringing food.
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Post by stevil on Jan 28, 2023 14:11:22 GMT -5
I don’t think we need a SoC change until data supports one.
What we do need is better insurance coverage for Afrezza. Shouldn’t need to get a PA for every insulin dependent diabetic.
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Post by stevil on Jan 28, 2023 10:36:43 GMT -5
It is still non formulary but it got approved with PA. I don’t know the copay amount yet, just got the email it was approved.
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Post by stevil on Jan 28, 2023 0:47:04 GMT -5
Already have 1 denial from one Humana MAP, nonformulary. This new Afrezza Assist group is way better than the previous. I’ve learned how to document better to get Afrezza approved but they must be doing something different because this one got approved. I was expecting it to because the guy is struggling to get control with novolog and is hypoglycemic often overnight but his A1c was 6.7 so I thought might deny it simply because his diabetes is technically “well controlled”. Maybe there is hope for humanity after all.
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Post by stevil on Jan 27, 2023 9:48:05 GMT -5
Already have 1 denial from one Humana MAP, nonformulary. Did you engage MNKD's help desk after the denial? What did they say? Honestly, I don’t even waste time sending stuff to pharmacies. I send all my prescriptions through Afrezza Assist because the initial denial rate is 100%. Every new Rx needs a PA. It’s currently being appealed
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Post by stevil on Jan 26, 2023 20:54:33 GMT -5
Already have 1 denial from one Humana MAP, nonformulary.
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Post by stevil on Jan 25, 2023 21:55:53 GMT -5
Stevil if you don’t mine me asking , how did you come to prescribe Afrezza / were did you learn of it ..(marketing question ) I became interested in MNKD right before I started my medical journey. I think it was either a Yahoo article or Motley Stool that led to my demise. Actually, it looks like perfect timing since I didn’t have a whole lot saved in my Roth account until shares became dirt cheap.
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Post by stevil on Jan 25, 2023 15:18:34 GMT -5
The exchange between stevil and sayhey this morning is awesome. Sadly, this is the first time I correlated the diabetes Standard of Care (SoC) with insurance coverage. It is and should have been obvious, but I didn't get it. And it 1. explains much about why Afrezza is not better positioned. The 2. A DA is underwritten by big pharma sponsors. Those who are responsible for updating the SoC 3. will not be inclined to improve the SoC unless they can point to evidence such as they have for the other treatments. And insurance providers are playing it "safe" by underwriting what is in the ADA SoC. And producing the quantity and quality of evidence required to persuade early use of Afrezza isn't cheaply or easily/quickly available. That's why Dr. Kendall moved on. The pediatric trials that underpin the Mannkind "T1 Strategy" now make a ton of sense. Data (and cash) is king. It takes money to make money is the old saying. Taking aim at the T2s is going to be a long-haul but it also needs a strategy. A Mounjaro + Afrezza trial is the most appealing thing I've seen suggested (by sayhey). Not sure if there is an opportunity to beneficially refinance debt to fund such a trial or whether Mannkind must raise money "the old-fashioned way - they earn it". Interesting. Interesting. Thank you again stevil and sayhey. 1. This is why Afrezza needs clinical data to support moving up in the SOC. They're not going to move until payors have a reason to decrease their bottom line. This has been hashed/rehashed/hashed/rehashed and hashed again. I think people get it. 2. Don't think I agree that this is why, although it could certainly be. Reason being, insulin was never first line. Kinda weakens the "insulin cabal" argument for me. Orals have always been first line. Injectable insulin won't get covered if I prescribe it before orals, either. 3. This is true of medicine in general, and honestly, the way you would want it. Evidence-based medicine is the best medicine. What irks me is when the insurance tells me I can't practice medicine the way I want to. It makes sense why they do within reason. Their job is to cut costs. I don't have a problem with Afrezza nearly as much as I do other chronic diseases. I can't even get normal albuterol inhalers covered anymore with prior authorizations. It's getting ridiculous. Regarding mounjaro vs Afrezza: As much of a fan as I am for Afrezza, I still remain skeptical that Afrezza is the answer we've all been looking for. Bill and VDEX have done a great job, at the very least, explaining the "why and how". I'm still waiting for the "that". For instance, it has been known for a long time that early intensive insulin and/or diet and exercise can reverse diabetes. I still think there may be some selection bias (through no fault of VDEX at all... it's not a bad thing) regarding their results. It sounds like they start with the easier and less severe diabetics and get great results. They also get the patients that are motivated enough to care about their health and their disease to seek special care at a specialty clinic like VDEX. Then, it sounds like they have a lot of resources to offer the patients to get them to do all the right things and are able to check in on them frequently to make sure they're meeting their goals. First, forget about mounjaro vs Afrezza. I don't really care that much about Mounjaro unless either it or Afrezza can slow/stop progression of diabetes over the long term. In a controlled environment, Afrezza should win every time or the examiners need their cognitive ability assessed. Nothing will ever be more efficient than insulin at decreasing blood glucose. What I want to know is if that has any meaningful impact on patient safety and long-term outcomes. I don't think anyone, doctors and insurers included, are going to care if Afrezza beats Mounjaro in a head-to-head short term study. It's like asking me to beat Usain Bolt in a 100m dash. I'd like to see 3 arms of a study within a setting like VDEX. 1. SOC 2. other insulins 3. Afrezza only. Again, this is no knock at all on VDEX and I'm not trying to discredit their results at all. I really would like to be convinced at least part of their success isn't from selection bias as well as taking and having the necessary time to coach and follow up with their patients. I think that's probably the biggest cause for worsening diabetes over time. It's a misunderstanding of the role of diet in the disease as well as the personalized coaching needed to hit attainable goals. In short, if anything, I'm actually praising VDEX itself more than Afrezza. I don't think there's anything special about the "secret sauce" of Afrezza that would reverse diabetes other than providing a consistent environment with proper glucose maintenance. We see this often in ketogenic/low/no carb diets. Insulin sensitivity often improves within just a month or so. I have had many patients decrease the amount of insulin they use over time if they change lifestyle habits or if we get their sugar under control early on. Is that the effect of insulin, diet/exercise, or both? I think it's some, I think it's all. Now, does Afrezza do a better job at restoring a healthy glucose metabolism than anything else? Probably. It should. Does that have any meaningful effect on long-term outcomes? I'd be willing to bet it does, but how much of a difference really needs to be quantified, especially for insurance companies. They need to be shown that starting Afrezza on day 1 will halt the progression of the disease in all people in order for them to consider changing the order of treatment. If anyone has seen studies that shows any of this stuff, I'm happy to review it.
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