Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Sunday musings…1/16/2022

1 Obstreperous. Noisy and difficult to control.


2 Emu. Google “horses asshole emu”.

Think obstreperous flightless bird.

3 Rainbow. My very good friend and his family escorted their black lab Gus across the rainbow bridge today. In the last 3 1/2 years the White family has lost 2 dogs and 2 horses. It never gets any easier. Saying goodbye to our pets guts me every time.

Grace and peace to my friend Rob and his family. Gus was a very good boy.

4 Somebody. “The grains of sand that pass through the funnel of life’s hourglass are only dry and colorless if they are observed from afar; up close each one is as colorful as any rainbow, as full of energy as any thunderstorm. Poetry is there for the asking.” DEW 1/16/2017.

While everyone isn’t necessarily “A” somebody, everyone is somebody who matters. My Dad was heroic in this regard. He remembered everyone. The lower on the economic food chain someone may have been, the more he remembered them. Janitors, waitresses/waiters, maintenance workers…he knew all of their names. He’d ask you about your story, ask you to describe the grains of sand in your hourglass, and if you told him he remembered. Dad would be dumbfounded by the denigration of these and other physical jobs so prevalent on mainstream media and other outlets.

Dad had a way with frontline workers. It was natural, a gift for sure, but he obviously worked at it, too. Did you have a problem getting THAT gift this year? Turns out, that’s not a new phenomenon caused by “COVID-related supply chain issues.” My Dad had a coronary artery bypass graft surgery (CABG) in 1985 at the peak of the Cabbage Patch Doll craze. Somehow he found a Cabbage Patch Doll for every nurse in the Coronary ICU to thank them for their care.

So what’s the point? It shouldn’t take a pandemic that interrupts every aspect of everyday life for us to notice the folks who aren’t anywhere near the top of the economic food chain. CEO’s saved the world in the early parts of the pandemic (Sunday NYT)? Bullshit. Company X allowed the economy to survive because it made “stay at home” work possible? Yeah, that’s bullshit, too. The person who answers the phone in my office or the person driving the garbage trucks had just as much impact as that self-satisfied CEO who’s biggest sacrifice was skipping Davos this year.

There’s no such thing as a small life. Each life is full, vibrant, colorful, and important. Each little grain of sand flowing through the hourglass is as meaningful as the next.

It’s been years since my Dad died and yet I return to his lessons on a daily basis. I see him talking to the guy who swept the floors in the factory. There his is, sitting down to lunch with a banker. If I close my eyes and just listen to the personal banter it’s hard to figure out which is which. The sands of time that flowed for each looked the same to my Dad. He heard the poetry, saw the beauty. My Dad made every life he touched bigger.

Everyone was a somebody.

5. Cost. Mark Cuban has launched a website/business called “Cost Plus Drugs” (costplusdrugs.com) to much fanfare, especially on Social Media of all sorts (Cuban is a plays SM like Yo Yo Ma plays cello). The concept is quite simple: buy generic drugs at wholesale cost, mark ’em up 15%, add a handling fee of $5 and ship ’em off to a waiting patient. The fanfare part comes in the marketing on the website. Each drug is compared with the retail price of the branded drug from which it was spawned. For example, $41 for a chemo drug compared with $9,600 for the brand. Brilliant, right?

Meh…not so much. First of all, if a super expensive drug is off-patent and there is now a generic equivalent on the market, essentially no one prescribes the branded drug anymore (caveat: equivalent in potency, side effects, etc.). Secondly, there are several options out there already doing a very nice job of this, thank you very much, without the hullabaloo surrounding Mr. Cuban’s offering. GoodRx and Costco come to mind. There’s somebody out there, can’t remember who, offering hundreds of generics for $4.00 a month. To the extent that Cost Plus Drugs continues to pressure the pharmaceutical industry and its high prices I suppose Cuban’s entry is a net positive.

Let’s step back and look at the real issue here, though: groundbreaking, new treatments are too expensive. I’m not talking about the outlandish prices of these branded, patent-protected drugs that people like Mark Cuban bandy about to make the price of their generic look so virtuous. No, I’m talking about the amount of money that comes out of the pockets of the people who need the newer medications for which a generic equivalent is not available (or who for whatever reason cannot take a particular generic). For all of Cuban’s bluster and bravado, the bruises that he is getting from patting himself on the back are all for naught. With very few exceptions people aren’t struggling to pay for generic chemo drugs, they are breaking the bank on the newer, more effective drugs.

In general, new drugs come in one of two varieties: minimally changed versions of existing drugs/”me too” drugs from a competing company in order to be in the market space, or truly innovative and new drugs that are a measurable upgrade in all ways from existing treatments. Yes, to be sure, there are some newcomers into a therapeutic space that have a similar mechanism of action as legacy drugs but really do work better in that treatment pathway, but they are a small minority; most are the same drug with a slightly different concentration or secondary delivery ingredients, patented and priced as if they were groundbreaking, new developments.

Where we need someone of Mark Cuban’s intellect, entrepreneurial zeal and all-around chutzpah is when the very best treatments, standard of care treatments, are not available as generics. Here the unholy triumvirate of manufacturer/pharmacy benefit manager (PBM) and insurance company put profit before patient (and healthcare worker) welfare. New, innovative treatments are priced so that the manufacturer can give a handsome rebate (kickback) to the PBM. A patient is then charged a co-pay which is a percentage of that artificially elevated price. This co-pay reduces the financial obligation of the insurance company to pay for the medication. If you’ve ever wondered why a medicine which was priced at $100 ten years ago is now $1,000, this is it.

If the Mark Cubans of the world want to have a real impact on the healthcare costs that matter, the costs to the patient themself, let them turn their attention here. It does us no good to have another do-gooding middleman saving patients a few dollars on widely available generic medications. This is the equivalent of hitting a single when you’re down 10 runs in the ninth. In eye care we don’t need someone to shave off a couple of bucks from the cost of Avastin as the first-line treatment for the devastating, sight-stealing disease macular degeneration; it’s like $50, so patients drop 10 bucks in the bucket on the way out. At big places like the Cleveland Clinic they pay more to park.

No, what we need is someone to step in and figure out how regular folks can afford Eylea or Lucentis, the branded medications that a majority of these patients end up needing when the Avastin stops working (as it almost always does). At $2000 a pop that 20% co-pay can run into thousands of dollars each year for folks who need injections every few weeks, sometimes forever. Cancer treatments that cost $40,000 per dose or truly revolutionary, life-saving drugs like the hepatitis C drugs that came out a few years ago that are now “only” $10-15,000. 20% of that is meaningful to most folks. Step up to the plate and take a swing at these, Mr. Cuban. Figure out how people who have terrible diseases that aren’t really all that rare can afford their medicine. You’re not a singles hitter. Figuring this out is the equivalent of hitting a walk-off grand slam in the 7th game of the World Series.

You were made for this, Mark.

I’ll see you next week…

Leave a Reply