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Post by agedhippie on Mar 16, 2023 17:36:15 GMT -5
Afrezza was locked out of some PBMs' drug list because Novo/Lilly made agreements of exclusivity, in exchange for rebates. Now that they won't be rebating the PBMs, there will be no incentive for the PBMs to lock other competing drugs out. So, Afrezza will now have a level playing field. Novo/Lilly can use the other drugs they sell. Give us exclusivity on our insulin (and other drugs) and we will give you a better rebate on Ozempic/Trulicity... The PBM will be looking at the big picture and not single drugs.
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Post by agedhippie on Mar 16, 2023 17:31:00 GMT -5
Medicaid and Medicare are different although both run by the CMS. The last available data was from 2021 which was $1.94M for Medicare Part D. For context Humalog was $594.5M. Aged, are the pharmacy purchasing managers going to care about script numbers for Humalog or Novalog any more? Yes because they want the other drugs NVO or LLY make. Look at Ozempic which bounces between the the fifth and sixth highest revenue drug, or Trulicity which is a couple of positions lower. If you are not taking their insulin you aren't getting their best price on those juicy high value drugs. These things get negotiated as a basket, not individually.
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Post by agedhippie on Mar 16, 2023 17:06:27 GMT -5
How does this apply to MNKD? Your link is for MedicAID and not Medicare. Are they the same??? I would think MNKD has close to $0 sales for Medicaid. I don't know what Lilly and NVO MedicAID sales are. Medicare on the other hand I would think is significant. I also see Medicare as the place MNKD can make a foothold in the T2 world with Medicare and the CGM effort underway. I do know is on the last four public calls MNKDs CEO has mentioned afrezza and Medicare and this being a big deal. Medicaid and Medicare are different although both run by the CMS. The last available data was from 2021 which was $1.94M for Medicare Part D. For context Humalog was $594.5M.
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Post by agedhippie on Mar 15, 2023 22:08:42 GMT -5
Yes, the PBMs are the big losers because they cannot show a big reduction in cost to the insurer so they have to go back to what they are paid for - managing pharmacy benefits.
With Medicaid the pharma pays the rebate, today that is the whole cost of the drug (208 + 234 which is capped at 100% of cost so $274. Next year that cap is removed so they would have been rebating $442 on a $274 drug. Hence they have to reduce their prices to avoid that fate, and as a bonus they actually get to make money for once. The obvious question is why didn't they do this years ago? The answer (I think) is that the old price was very beneficial from the POV of tying in the commercial PBMs, plus Medicaid generated a $650M cashflow and that's effectively an interest free loan.
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Post by agedhippie on Mar 15, 2023 17:14:40 GMT -5
Paywall? I can't see it... By dropping the cost of its Humalog and Humulin insulins, Lilly could sidestep $430 million per year in new Medicaid rebates and make more than $85 million in new annual profit, according to an analysis by Spencer Perlman, the director of health-care research at Veda Partners.10 hours ago That's correct. A slightly longer explanation from the research paper ( here) is that a drug company has to rebate the greater of 23% or the difference between the list price and the best price a PBM pays, plus an addition for the amount the price rises above inflation to CMS on Medicaid revenue. Currently that is capped at 100% of the list price and the big three insulin manufacturers all hit that cap. As of the start of next year that cap is removed and so they will be rebating a fair bit more than the list price of the drug. The example the chose in the paper was Humalog. The list price is $274, and the best price is about $66 (all these numbers are approximate, but the reasoning is sound). That gives a rebate of 274-66 = $208 plus an inflation rebate of $234 for a total rebate of $442. The current cap limits that to 100% of the list price and so while Lilly make no profit they avoid the full $442, but that changes next year when their rebate cost would jump from $234 to $442. How can they avoid this? By reducing the price to $66 they now pay the 23% rebate, since that is the greater, which is $15 and the inflation rebate drops to $26 for a total rebate of $41 which gives a margin of $25, or 37%. After the price reduction the revenue next year will be $156M so they jump from a revenue after rebate of $0 to $56M. Novo Nordisk and Sanofi are in the same position which is why Novo Nordisk reduced their prices, and Sanofi will reduce their prices at some point before next year.
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Post by agedhippie on Mar 12, 2023 10:47:13 GMT -5
People get given premix to simplify the number of drugs and doses because it's not thought that group cannot cope with MDI so this is not a natural fit for Afrezza. I think there is mileage in combining AID pumps with Afrezza. Shawn, who used to post here, talked about how he periodically did what you were proposing - taking RAA and Afrezza at the same time and got good results. It don't think you would get large scale adoption of the model (it's more work) but there is definitely a group who would be receptive I feel. Shawn used regular insulin and ate no carb. Shawn had a program. shawnonafrezza That will teach me to go from memory Yes, he used human insulin because the peak is late so it is spiking as Afrezza is exiting so there is solid cover. Thanks for that link to his posts. I went and reread a lot of them. There is good stuff there.
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Post by agedhippie on Mar 12, 2023 10:42:00 GMT -5
OK - for some reason I think I must have hit a sore spot. You seem to really be shaken the CMS is now providing CGM payment for "insulin treated" seniors. For Robert Ford to gets those words in the policy was a surprise but a very pleasant surprise. Funny, I was thinking the same thing. Remember this? You could be right but first they have to get Medicare approval. Do you think Merck, Nova Nordisk, Lilly and the rest want T2s using a CGM showing PPG excursions without the cover of a mealtime insulin??? They think they are getting approval by July and the NICE study is what they are banking on but this is the only study I see and its for T1s. www.nice.org.uk/guidance/ng17/evidence/b-continuous-glucose-monitoring-in-adults-with-type-1-diabetes-pdf-11013435182.
I was right. I told you it would get approved. Remember this? You ask how long will the doctor keep prescribing the CGM? As long as he keeps prescribing afrezza and that's as long as the rep keeps coming with that big lunch buffet and other goodies.
Sorry, but that is fraud and there is no way that Abbott would countenance that approach. The really stupid thing about the idea is the conclusion that this CMS change allows Afrezza users to get CGMs where they couldn't before. Afrezza counts as MDI and as such you can already get a CGM from Medicare if you use Afrezza. And yet somehow we don't have reps proposing defrauding Medicare (" Neither the GP nor the Abbott rep really care if the PWD ever uses afrezza") to doctors currently. Anyway, if you want to believe Abbott will do have at it! I have explained why it's silly and you are free to ignore it. The truth is that we will see from the Afrezza prescription sales if you are right.
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Post by agedhippie on Mar 12, 2023 10:16:26 GMT -5
Welcome to being a doctor š. These are considerations I make with each patient. There are never any absolutes in medicine. It is all risk/benefit analysis. Weāre playing the same waiting game with Afrezza, at least all of us but say hey. Medicine will never advance if weāre too afraid to take the first step. The only way we now know afrezza is *probably* safe is because we can look backwards and see that it is. Weāll do the same with GLP-1s. Sometimes we get it wrong. When that happens, you adjust. Itās why the first step for me when I treat diabetes is to address the underlying cause first. I stress diet and exercise changes, because THAT is the safest and best first line treatment for diabetes. Then we go from thereā¦ Stevil - what is the underlying cause of T2 diabetes? What have autopsies of the pancreas of obese non-diabetic people shown us? How about recent Covid T2 diabetics? There is probably a Nobel prize waiting for the person who can answer that question. The problem is that Type 2 is a classification (antibody negative diabetes) rather than a single disease so there are a lot of variants.
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Post by agedhippie on Mar 12, 2023 10:12:00 GMT -5
In those cases where BG starts to stubbornly rise again, Afrezza in combination with a longer-acting insulin might be a helpful combination and potentially preferable to stacking puffs of Afrezza a couple of hours apart. The reasons for using mixes of the so-called ārapid actingā and long-acting forms are the same basis for using them in combination with Afrezza. I donāt know how helpful it would be to use the pre-mix combinations with Afrezza but I assume they might be just the ticket for some PWDs. Just more tools in the toolbox as it were. People get given premix to simplify the number of drugs and doses because it's not thought that group cannot cope with MDI so this is not a natural fit for Afrezza. I think there is mileage in combining AID pumps with Afrezza. Shawn, who used to post here, talked about how he periodically did what you were proposing - taking RAA and Afrezza at the same time and got good results. It don't think you would get large scale adoption of the model (it's more work) but there is definitely a group who would be receptive I feel.
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Post by agedhippie on Mar 12, 2023 9:45:16 GMT -5
No because premix is a combination of basal and mealtime insulin. It's an invention of the devil and should be shunned by all right thinking people.
It's problem is that if you need more insulin for a meal you are also getting more basal and vice versa. Unless your meal more or less aligns with the ideal dose, and you always eat the same thing it is very hard to get good numbers.
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Post by agedhippie on Mar 11, 2023 21:52:54 GMT -5
I know I noticed it was pretty old and there was a place you can click for updates so I did and it said there werenāt any at this time. i believe that's corrections to the article usually rather than updates to the topic itself.
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Post by agedhippie on Mar 11, 2023 15:51:08 GMT -5
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Post by agedhippie on Mar 11, 2023 15:30:07 GMT -5
Aged, I truly appreciate your posts, you claim to not have the time to work with a product like Afrezza. You say, "a busy diabetic just wants simplicity". You are the diabetic that researches everything related to this disease, that is admirable. You've seen the positive results Afrezza users are discussing. You, with a quick prescription, could share with us the results you experience. I'm not proposing you as a guinea pig, we are far past those days. Afrezza could be a valuable (or not) tool in your tool kit. I truly doubt cost is your barrier, if it is, I'll pay for it. You seem to have countless hours available to dispute every positive aspect of Afrezza as a viable treatment for this disease (I know, you say it really doesn't take much time) but let's take a quick look at Sayhey and your debate, plus the additional 5000 or so posts....the research you do must take a team, or maybe you truly do have that much time to dedicate to research? I suppose you will just continue to join in this conversation regarding a very positive advance in treating diabetes (both adult and pediatric) with your negative slant. I guess it all pays the same. . Although at some point, integrity may come into play? Oh yeah, Ozempic...throw it on Technosphere. I think that Afrezza has a lot of positive aspects, I just don't think it is a magic bullet. Oddly if I went on a pump I would probably use Afrezza at meal times because I could let the pump handle what would have been the second dose. I feel that always taking a 12u cartridge for the meal would work well. Predictable absorption is another benefit. The negatives are the need for follow-on doses, the size of doses (I want bigger doses), and the cough maybe but I suspect that passes as I think it's technique. Usually where I object is when people make assumptions (all diabetics will want this), assign it unproven properties (this cures T2, but we can't prove it just trust us), or treat theories as fact and expect you to take it on faith (magical thinking). My work revolves around risk and that is highly data driven, if there is no data it's unquantifiable, so when claims are made without evidence it stands out to me. The other side of my work is that I enjoy researching and I know how to do it efficiently. So when someone makes a claim I will check it. The flip side is that I don't make claims unless I have evidence to support them because I assume people will fact check. If you look you will see that periodically I jump on people making negative comments when they are wrong as well. It's just that there are a lot more positive stories to examine than negative on this board so it looks like I am anti-Afrezza which is not the case. Ozempic on TS would be interesting, but the tricky bit would be making it last a week.
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Post by agedhippie on Mar 11, 2023 10:06:03 GMT -5
What did Al Mann tell us? The medically correct way to treat the T2 diabetic is to treat the "post prandial glucose excursions". As I told Stevil I don't make this up. You can argue Al Mann was wrong but I would say don't go there. TIR is needed with T1s because of the sleeping hours and how things can go sideways. T2s don't have that issue. TIR is a T1 thing. I am not going to "Get Doctors" and neither is Mike nor MNKD. Robert Ford is on a mission to sell CGMs to the T2 market. He needs to get T2s on insulin ASAP. He could careless what insulin. That is counter to the SoC. I will happily say that Al Mann was wrong since it's theory and not fact. There is no data to support this. If you think T2 diabetics do not have night time issues you have obviously never heard of dawn phenomenon. You will find the 62% number on Mannkind's web site (actually 62.5%.) I would certainly hope Robert Ford wants to sell CGMs. However, the target is $10B over the next 5 years (so 2028) as discussed that at the J.P. Morgan Healthcare Conference. That's 15% CAGR which given a global product is an easy reach. The $25B number by 2025 for Libre is fantasy. And the elephant in the room. There is no way Abbott direct their sales people to defraud Medicare which is what you are proposing. That's even assuming you could get the prescription past the insurer given that a lot of coverage requires prior approval or step therapy. This idea is a flight of fantasy, but by all means invest based on it. At this point I think we are arguing in circles; I go by the data and you go by faith in your ideas. Those cannot be reconciled so I am going to drop this. Going back to the point of this thread - the risk of SBO with GLP-1. Just like amyloid deposits this is so rare that nobody cares, it does make a good headline though (Daily Mail - you do know their reputation don't you?). The clear benefits outweigh the risk and that's how medicine works.
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Post by agedhippie on Mar 10, 2023 20:02:31 GMT -5
So it's agreed then that GLP-1 is good for TIR? We can stop now because that's the measure. You can invent other ones, but TIR and HbA1c are the only two the medical world cares about because their impact has been quantified. Doctors will absolutely take a 91% TIR number for a weekly shot to treat a T2, especially when you add weight loss and the cardiorenal benefits. It's hard to justify putting insulin in front of that unless the patient explicitly asks for it. Aged - going forward - remember afrezza together with the CGM is "forward looking radar" - going forward for T2s it will be less about the SoC and less about time in range and more about the Abbott sales rep getting the Medicare PWD on insulin. The idea that you are going to get doctors to ignore the SoC because a rep asks nicely is a fantasy, but who am I to deprive people of their fantasies? Let's be realistic, 91% TIR is amazing. Under similar circumstances Afrezza managed 62% TIR. The trials for the cardiorenal benefits are adjusted for the improved BG numbers and other factors, you would know that if you read the source material before you speculated. As to block intestines; it's right up there with amyloid deposits from injection sites - it's so rare nobody cares.
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