A Hobson's Choice?

When a choice isn't really a choice

When offered a choice between the last chocolate chip cookie in the case or nothing at all that is still a choice (1). But when that cookie is swapped out for your lifesaving devices and medicines is that a choice we can live with?

Sadly, our choices are dwindling. As a person with diabetes who has lived over a half a century I want to raise the issue of a looming crisis. It's the matter of dwindling choices which patients with diabetes and their families are experiencing in regards to diabetes devices and medications. The phenomenon driving this is known as commoditization. It's hardly a new concept and inhabits many other facets of our lives. For example, we're quite comfortable with price being the primary reason we purchase many food products, fuel, phone service, and utilities. With commodity items, price generally drives demand. Everyone wants cheaper gas, water and electrical power since the products are considered largely equal regardless of provider. Quality is "assumed". In the world of diabetes supplies, where patient access to devices and medications has an intermediary, the pharmacy benefit manager, the people making the decisions are not the patients, but rather the insurers and their agents. Over the last several years, more diabetes supplies and technologies have moved into the commodity category. Insulin, insulin pumps, and glucose meters lead the list. This is in contrast to retail items which must compete for buyers and doctors to prescribe them. Blood sugar meters and test strips (aka BGM) were once very pricey items. That all changed when the government capped what would be paid for test strips. This gutted the profit incentive for BGM producers. A gradual erosion of BGM products began while many companies exited the market altogether. Insulin pumps are in the process of falling into the commodity category, too. While I realize that the companies and many of their users will argue with me on this claim, the rapid move of insulin pumps into treatment as a commodity is largely due to the fact they all do 'pretty much' the same thing. Why would a profit driven corporate employee agree to spend more for pump A when pump B performs the same functions and costs less? Never mind how pump B looks or customer service for pump A is better than pump B. The decision maker (not the patient) is concerned solely about the price. As the number of pump companies diminish, the few that remain are now effectively an oligopoly. Insulin seems to be the outlier as far as cost goes. The prices of insulin have skyrocketed over the last few years (2). Heartbreaking stories abound of how families risk bankruptcy just to get access to insulin. Ironically it's a drug which can be produced in limitless supply. But here too, price dictates access.

So how does this all work in the USA? This involves a person or small team of people inside of a company referred to as a Pharmacy Benefit Manager (PBM). These individuals have become the gatekeepers of access to medi