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(单词翻译:双击或拖选)
It cost $38,398 for a single shot of a very old cancer drug
Dr. Josie Tenore and Paul Hinds2 were introduced by a mutual3 friend in 2017 and hadn't been going out long when she laid down the law: He had to get a physical.
"I don't date people who don't take care of their health," said Tenore, who practices cosmetic4 dermatology and functional5 medicine in suburban6 Chicago.
One of Hinds' blood tests that summer came back with an alarming result: His prostate-specific antigen, or PSA, level was very high. A biopsy confirmed he had advanced prostate cancer.
There aren't a lot of comfortable alternatives for treating prostate cancer, which generally progresses as long as testosterone levels remain high. Marijuana appears to lower testosterone levels, so after his diagnosis7, Paul dosed a liquid form of cannabis for several weeks. That cut his PSA in half, but Hinds, a cybersecurity expert who likes yoga and bicycling, "was stoned out of his mind and couldn't function," Tenore recalled.
With Tenore guiding his decisions, Hinds next tried a procedure called high-frequency ultrasound treatment, but it failed, and in summer 2019 doctors removed his prostate gland8. Still, the PSA levels climbed again, and doctors assessed that the cancer had metastasized. Now the only alternative was to drastically lower Hinds' testosterone levels — either via surgery or drugs that block all testosterone.
In May 2021, Paul got his first intramuscular shot of Lupron Depot10, a brand name for leuprolide, designed to suppress the body's release of the hormone11 for three months. That August he got his second shot.
And then the bills came.
The patient: Paul Hinds, now 60, is covered by United Healthcare through a COBRA plan from his former employer.
Medical service: Two three-month Lupron Depot injections for metastatic prostate cancer.
Service provider: University of Chicago Medicine, a 900-physician nonprofit system that includes an 811-bed medical center, a suburban hospital, the Pritzker School of Medicine, and outpatient clinics and physician offices throughout the Chicago area.
Total bill: $73,812 for the two shots ($35,414 for the first, $38,398 for the second), including lab work and physician charges. United Healthcare's negotiated rate for the two shots plus associated fees was $27,568, of which the insurer paid $19,567. After more than a year of haggling12 with the hospital and insurer, Hinds share of the bills for the shots was determined13 to be nearly $7,000.
What gives: The first issue is unrelenting price increases on old drugs that have remained branded, as manufacturers find ways to extend patents for decades and maintain sales through marketing14.
Though Lupron was invented in 1973, its manufacturer got patent extensions in 1989 by offering a slow-release version. Drugmakers commonly use this tactic16 to extend their exclusive rights to sell a product.
The development of Lupron Depot as an intramuscular shot that suppressed testosterone for months at a time improved patient compliance17 and also enabled its maker15, Abbott Laboratories, and its Japanese partner, Takeda, to extend their patents on the drug into the 2000s, said Dr. Gerald Weisberg, a former Abbott scientist who has been critical of the company's pricing policies.
In subsequent years, Abbott and Takeda, in a joint18 venture called TAP Pharmaceuticals19, steadily20 marked up the price of their slow-release product. In 2000, the average wholesale21 U.S. price for a three-month shot was $1,245; currently that figure is $5,866. (It is manufactured in the U.S. by AbbVie now.)
In the United Kingdom, where health care is generally free and Takeda sells the drug under the name Prostap, all physicians can purchase a three-month dose for about $260.
It's likely that Chicago Medicine, where Hinds got his shots, paid something close to the British price. That's because the health system's hospital on Chicago's South Side participates in a federal program called 340B, which allows hospitals that serve low-income populations to purchase drugs at deep discounts.
Lupron Depot is given as a simple injection into the muscle. It takes minutes for a nurse or doctor to administer. Yet hospital systems like Chicago Medicine can and typically do charge lavishly22 for such services, to enhance revenue, said Morgan Henderson, principal data scientist at the Hilltop Institute at the University of Maryland, Baltimore County. Chicago Medicine declined to say what it paid for the drug.
While U.S. drugmakers can price their drugs however they please, TAP has gotten into trouble for its Lupron sales policies in the past. In 2001, after a Justice Department probe, it paid an $875 million settlement for illegally stimulating23 sales by giving urologists free and discounted vials of the drug while enabling them to charge Medicare full price.
Since then, many other drugs aimed at lowering testosterone levels have entered the market, including a pill, relugolix (Orgovyx). So why wouldn't a patient use them?
Lupron Depot is long-acting, is easy to prepare and store, and employs a small needle, which some patients prefer, said Dr. Brian McNeil, chief of urology at University Hospital of Brooklyn. Orgovyx is convenient, but "a patient has to be very compliant24. They have to take it every day around the same time," he said. "Some people just forget."
But there is another important factor that may well explain Lupron Depot's ongoing25 popularity among medical providers: Doctors and hospitals can earn tens of thousands of dollars each visit by marking up its price and administration fees — as they did with Hinds. If they merely write a prescription26 for a drug that can be taken at home, they earn nothing.
Asked about this high patient charge and the possibility of using alternatives, United spokesperson Maria Gordon Shydlo said payment was "appropriately based on the hospital's contract and the member's benefit plan," adding that the insurer encourages customers to shop around for the best quality and price.
Resolution: In addition to leaving Hinds listless, the Lupron Depot shots were, literally27, a pain in the rear end. "Each time he was miserable28 for two weeks," said Tenore. After looking over his first bill for the Lupron shot, Tenore told Hinds he should ask his doctor if there was a less expensive drug that was easier to take.
After the second shot in August 2021, a pharmacist told Hinds he could instead receive the pill. The doctor prescribed Hinds three months' worth of Orgovyx last November, for which he paid $216 and the insurer paid over $6,000. The drug's list price is about $2,700 a month. There is evidence that Orgovyx works a little better than leuprolide.
Orgovyx was a "no-brainer," Hinds said. "Why would you want a sore ass9 for two weeks when you can take a pill that kicks in sooner, functions the same way, and clears your body of testosterone faster?"
While Orgovyx is increasingly used for prostate cancer, Lupron and other injections usually remain the standard of care, said hospital spokesperson Ashley Heher. Clinicians "work with patients to determine what treatments are the most medically effective and, when necessary, to find reasonable alternatives that may be less financially burdensome due to insurance coverage29 limitations," she said.
Hinds was baffled by the size of the charges. During months of phone calls and emails, the hospital reversed and then reapplied part of the charge, and then in July agreed to a $666.34 monthly payment plan. After Hinds had made two payments, however, the hospital announced Aug. 29 it was canceling the agreement and sending the remainder of his bill to a collection agency. Two weeks later, the hospital reinstated the payment plan — after KHN asked about the cancellation30.
As for Hinds, he remains31 active, though his bike rides have been shortened from 50 or 60 miles to about 30, he said.
He's grateful to have Tenore as a free consultant32, and empathizes with those who lack a knowledgeable33 guide through their disease and health care's financial maze34.
"I've got Dr. Josie as an advocate who knows the system," Hinds said.
The takeaway: First tip: If you are prescribed an infusion35 or injection, ask your physician if there are cheaper oral medications to treat your condition. Also, many drugs that are given by injection — ones that are given "subcutaneously," rather than into a muscle — can be administered by a patient at home, avoiding hefty administration fees. Drugs like Dupixent for eczema fall into this category.
Keep in mind that where you get treatment could make a big difference in your charges: A study found that leading U.S. cancer centers charge enormous markups to private insurers for drug injections or infusions37. Another study found that hospital systems charge an average of 86% more than private clinics for cancer drug infusions. And the percentage of cancer infusions done in hospital-operated clinics increased from 6% in 2004 to 43% in 2014, and has grown since.
Under a law that took effect in 2021, hospitals are required to list their charges, though they currently do so in a way that is not user friendly. But it's worth taking a look at the price list — the hospital chargemaster — to try to decipher the pricing and markup36 for your medicine. If you're about to get an injection, infusion, or procedure done in a hospital system, ask ahead of time for an estimate of what you will owe.
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| n.抄本，誊本，副本，肄业证书 | |
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hinds
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| n.（常指动物腿）后面的( hind的名词复数 )；在后的；（通常与can或could连用）唠叨不停；滔滔不绝 | |
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mutual
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| adj.相互的，彼此的；共同的，共有的 | |
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cosmetic
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| n.化妆品；adj.化妆用的；装门面的；装饰性的 | |
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functional
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| adj.为实用而设计的，具备功能的，起作用的 | |
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suburban
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| adj.城郊的，在郊区的 | |
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diagnosis
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| n.诊断，诊断结果，调查分析，判断 | |
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gland
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| n.腺体，(机)密封压盖，填料盖 | |
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ass
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| n.驴；傻瓜，蠢笨的人 | |
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depot
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| n.仓库，储藏处；公共汽车站；火车站 | |
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hormone
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| n.荷尔蒙，激素，内分泌 | |
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haggling
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| v.讨价还价( haggle的现在分词 ) | |
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determined
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| adj.坚定的；有决心的 | |
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marketing
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| n.行销，在市场的买卖，买东西 | |
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maker
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| n.制造者，制造商 | |
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tactic
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| n.战略，策略；adj.战术的，有策略的 | |
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compliance
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| n.顺从；服从；附和；屈从 | |
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joint
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| adj.联合的，共同的；n.关节，接合处；v.连接，贴合 | |
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pharmaceuticals
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| n.医药品；药物( pharmaceutical的名词复数 ) | |
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steadily
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| adv.稳定地；不变地；持续地 | |
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wholesale
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| n.批发；adv.以批发方式；vt.批发，成批出售 | |
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lavishly
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| adv.慷慨地，大方地 | |
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stimulating
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| adj.有启发性的，能激发人思考的 | |
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compliant
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| adj.服从的，顺从的 | |
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ongoing
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| adj.进行中的，前进的 | |
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prescription
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| n.处方，开药；指示，规定 | |
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literally
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| adv.照字面意义，逐字地；确实 | |
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miserable
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| adj.悲惨的，痛苦的；可怜的，糟糕的 | |
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coverage
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| n.报导，保险范围，保险额，范围，覆盖 | |
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cancellation
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| n.删除，取消 | |
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remains
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| n.剩余物，残留物；遗体，遗迹 | |
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consultant
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| n.顾问；会诊医师，专科医生 | |
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knowledgeable
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| adj.知识渊博的；有见识的 | |
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maze
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| n.迷宫，八阵图，混乱，迷惑 | |
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infusion
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| n.灌输 | |
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markup
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| n.加价，涨价，利润 | |
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infusions
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| n.沏或泡成的浸液（如茶等）( infusion的名词复数 )；注入，注入物 | |
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