$38,398 for a single shot of a very old cancer drug

Dr. Josie Tenor and Paul Hinds met through a mutual friend in 2017 and hadn’t been going out long when she laid down the law: He had to have a physical.

“I don’t date people who don’t take care of their health,” says Tenor, who practices cosmetic dermatology and functional medicine in suburban 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 prostate cancer.

There aren’t many comfortable options for treating prostate cancer, which usually progresses as long as testosterone levels remain high. Marijuana seems to lower testosterone levels, so after his diagnosis, Paul dosed himself with a liquid form of marijuana for several weeks. It cut his PSA in half, but Hinds, a cybersecurity expert who likes yoga and cycling, “was stoned out of his mind and couldn’t function,” recalls Tenor.

With Tenor directing her decisions, Hinds next tried a procedure called high-frequency ultrasound treatment, but it was unsuccessful. And in the summer of 2019, doctors removed his prostate gland. Still, PSA levels rose again, and doctors assessed that the cancer had metastasized. The only option was to drastically reduce Hinds’ testosterone levels – either through surgery or drugs that block all testosterone. In May 2021, Paul received his first intramuscular shot of Lupron Depot, a brand name for leuprolide, designed to suppress hormone secretion from the prostate gland for three months. That August, he got his second shot.

And then came the bill.

Patient: Paul Hinds, now 60, is covered by UnitedHealthcare through a COBRA plan from his former employer.

Medical Services: Two to three monthly 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 two shots ($35,414 for first, $38,398 for second), including lab work and physician charges. UnitedHealthcare’s negotiated rate for the two shots and associated fees was $27,568, of which the insurer paid $19,567. After Hinds wrangled with the hospital and insurer for more than a year, her portion of the bill was determined to be about $7,000.

Last hour: The first problem is the unbridled increase in prices of older drugs that remain branded as manufacturers find ways to maintain sales by extending patents and marketing for decades.

Although Lupron was discovered in 1973, its manufacturer received a patent extension in 1989 offering a slow-release version. Drug manufacturers usually use this strategy to extend their exclusive right to sell a product.

The development of Lupron Depot as an intramuscular shot that suppresses testosterone over several months improved patient compliance and enabled its maker, Abbott Laboratories, and its Japanese partner, Takeda, to extend the drug’s patent in the 2000s, Dr. Gerald Weisberg, a former Abbott scientist who has criticized the company’s pricing policy.

In the years that followed, Abbott and Takeda, in a joint venture called TAP Pharmaceuticals, consistently priced their slow-release products. In 2000, the average wholesale US price of a three-month shot was $1,245; Currently that figure is $5,866. (It is now manufactured in the US by AbbVie.)

As his girlfriend and advocate, Dr. Josie Tenor helps Paul Hinds navigate the financial maze of health care during his prostate cancer treatment. Tenor practices cosmetic dermatology and functional medicine in suburban Chicago. (Taylor Glassock for KHN)

In the United Kingdom, where health care is generally free and Takeda sells the drug under the name Prostap, all doctors can buy a three-month dose for about $260.

Perhaps Chicago medicine, where Hinds got his shot, offered something closer to the British price. That’s because the health system’s hospitals on Chicago’s South Side participate in a federal program called 340B, which allows hospitals serving 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 do charge exorbitantly for such services to boost revenue, said Morgan Henderson, chief 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 US drugmakers may be happy with their drug prices, TAP has been in trouble in the past for its Lupron sales policy. In 2001, after a Justice Department investigation, it awarded an $875 million settlement to urologists for illegally stimulating drug sales by offering free and discounted vials and enabling them to charge full price to Medicare.

Since then, many other drugs aimed at lowering testosterone levels have entered the market, including a pill, Relugolix (Orgovix). So why wouldn’t a patient use them?

Lupron Depot is long-acting, easy to prepare and store, and employs a smaller needle, which some patients prefer, says Dr. Brian McNeil, chief of urology at Brooklyn University Hospital. Orgovyx is convenient, but “a patient has to be very compliant. They have to take it at the same time every day,” he said. “Some people just forget.”

But there’s another important factor that may well explain Lupron Depot’s ongoing popularity among medical providers: Doctors and hospitals can make hundreds of thousands of dollars by marking up the cost of each visit and administrative fees — as they did with Hinds. If they only write a prescription for a drug that can be taken at home, they earn nothing.

Asked about these higher patient charges and the possibility of using options, United spokeswoman Maria Gordon Shaidlow said payments are “based on hospital contracts and member benefit plans as appropriate,” adding that the insurer encourages customers to shop around for the best quality and value. . .

After seeing her first bill for the Lupron shot, Dr. Josie Tenor told her partner, Paul Hinds, that she should ask her doctor if there was a less expensive drug that was easier to take. (Taylor Glassock for KHN)

What’s behind the $38,398 price tag for a single shot of an old drug to treat prostate cancer? A mix of unbridled drug price increases and hospital system consolidation. (Taylor Glassock for KHN)

Resolution: Besides leaving Hinds listless, the Lupron Depot shots were, quite literally, a pain in the rear end. “Every time he was miserable for two weeks,” Tenor said. After seeing her first bill for the Lupron shot, Tenor told Hinds she should ask her doctor if there was a less expensive drug that was easier to take.

After the second shot, in August 2021, a pharmacist told her she could take pills instead. Her doctor prescribed Hinds last November three months’ worth of Orgovyx, for which she paid $216 and the insurer paid more than $6,000. The list price of the drug is about $2,700 a month. There is evidence that Orgovix works slightly better than leuprolide.

Orgovix was a “no-brainer,” Hinds said. “Why would you want a sore ass for two weeks when you can take a pill that kicks in faster, works the same way, and clears your body of testosterone faster?”

Although Orgovix is ​​increasingly being used for prostate cancer, Lupron and other injections generally remain the standard of care, hospital spokeswoman Ashley Heher said. Clinicians “work with patients to determine which treatments are most clinically effective and, when necessary, to find reasonable alternatives that may be less financially burdensome due to insurance coverage limitations,” he said.

Hinds was surprised by the size of the charge. After months of phone calls and emails, the hospital reversed and then reapplied some of the charges and then agreed to a $666.34 monthly payment plan in July. After Hinds made the two payments, however, the hospital announced on August 29 that it was canceling the contract and sending the remainder of its bills to a collection agency. Two weeks later, the hospital reinstated the payment plan — after KHN asked about the cancellation.

As for Hinds, he stays active, though his bike rides have been cut from 50 or 60 miles to about 30, he said.

She is grateful to have Tenor as a free consultant and empathetic to those who lack a knowledgeable guide through the financial maze of disease and health care.

“I found Dr. Josey to be a lawyer who knows the system,” Hinds said.

Paul Hinds, a cybersecurity expert who likes yoga and cycling, was diagnosed with prostate cancer about five years ago. He tried multiple treatments before switching to intramuscular shots of Lupron Depot to suppress testosterone. The two shots, each lasting three months, came with a price tag of $73,812, including lab work and physician charges. (Taylor Glassock for KHN)

Takeaway: Tip One: If you are given an infusion or injection, ask your doctor if there are cheaper oral medications to treat your condition. Also, many drugs that are given by injection—those given “subcutaneously” rather than intramuscularly—can be administered by a patient at home, avoiding hefty administration fees. Medicines such as Dupixent for eczema fall into this category.

Remember that where you get treatment can make a big difference in your charges: One study found that leading US cancer centers charge huge markups to private insurers for drug injections or infusions. Another study found that hospital systems charge an average of 86% more for cancer drugs than private clinics. And the percentage of cancer infusions in hospital-run clinics rose from 6% in 2004 to 43% in 2014 and has been rising ever since.

Under a law that takes effect in 2021, hospitals will have to list their charges, though they currently do so in a way that is not user-friendly. But it’s worth looking at the price list — the hospital’s chargemaster — to try to understand the cost and markup of your drugs. If you’re going to have an injection, infusion, or procedure done in a hospital system, ask ahead of time for an estimate of what you’ll owe.

Dan Weissman contributed audio portraits with this story.

Bill of the Month is a crowdsourced investigation by KHN and NPR that breaks down and explains medical bills. Have an interesting medical bill you want to share with us? Tell us about it!

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