CLINICAL DIABETES These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly. Letters to the Editor Disputing the Costs of Diabetes Drugs To the editor: Furthermore, to list glimepiride in the same cost category as repaglinide, metformin, and acarbose is grossly inaccurate. The latter analysis, which listed the 30-day cost of glimepiride at $7.06, indicated the costs of these agents to be $67.12, $48.38, and $41.05, respectively. Cost is an increasingly important consideration to primary care physicians (and all health care providers) when choosing medications for their patients. Therefore, we appreciate this opportunity to set the record straight. Romana Slavik, PharmD The authors' response: We did have some reservations about presenting cost information on the card. Cost to the patient may vary given a number of factors, such as geographic location and pharmacy benefits. Our patients have a variety of different pharmacy benefits ranging from none or co-pays to full coverage of cost. In addition, cost may depend on whether you are talking about the AWP, what the patient pays at the pharmacy, or the cost to a health plan. For this reason we cautioned the users of the pocket card (as designated by ** in the Cost column) about what the number of "$" symbols reflects. Our footnote states "Relative Cost to PSGHP. Actual cost may vary by region and health plan." The Cost column reflects the cost to our Penn State Geisinger Health Plan. The cost to our health plan is different from the cost to pharmacists or the AWP. This raises an interesting problem for primary care physicians, especially those who provide care for a number of health plans. The cost of medications and formularies vary from plan to plan. This makes it very difficult for primary care physicians to really know the true cost of medications. While we can consult sources such as those you gave in your letter, we have no idea what kind of discount a health plan may be able to negotiate or what a pharmacy will charge. Alan M. Adelman, MD, MS To the editor: Dr. Leichter states that "the cost of a product to retail customers may be up to two or three times higher than the AWP [average wholesale price]." While this is his opinion, I feel this is totally inaccurate. For instance, the AWP for 100 Becton-Dickinson insulin syringes is $23.93. This product is obtainable in most states without a prescription and retails for $22.49 to $25.99. (This certainly is an average in competing markets.) Lancets, packed either in 100s or 200s, typically are marked up only15–20%. Products in the diabetes care arena have low profit margins due to the highly competitive nature of the marketplace. Prescription-only products have their profit margins determined by each pharmacy benefits manager. Again, we deal with low reimbursement rates, as you do in your practice. Contrary to Dr. Leichter's statement, the retail prices of diabetes care products are not two or more times their AWP. Secondly, Dr. Leichter mentions that companies may engage some specialists as "thought leaders." Nowhere do I see mentioned that some of these thought leaders may also be receiving speaking fees along with hotel accommodations, etc. I am not suggesting that a thought leader be that because he or she is receiving a fee for being a guest speaker and advocates the use of a product or drug on that basis. Many times drug companies provide thought leaders with the necessary means to do research and unlock many mysteries, and I fully support that. But I feel that the author failed to mention some of the perks when one becomes a thought leader. I really enjoyed this article, and Dr. Leichter was right on the money concerning the selling approaches that companies use. As a community pharmacist and diabetes specialist, I hear all of the great selling lines each day. If I were to believe each one, my pharmacy would not have the physical space to stock every product. Andrew Meyers, RPh The author's response: Mr. Meyers asserts that the retail markup of diabetes products is not, as I contended, two to three times AWP, and he is correct, but only in regard to certain products. Pharmacies often keep the markup on diabetes supplies, such as insulin syringes and lancets, surprisingly low, as Mr. Meyers notes. Often, this is done out of concern for their diabetic customers and also because diabetic people represent very important clientele to pharmacies, based on their use of products. Diabetic supplies may be used as a "loss leader" to bring customers into the pharmacy. In that case, the prices would be kept low to attract diabetic people to the pharmacy, as opposed to competing stores. On the other hand, the markup with regard to many drugs and other supplies is by no means as low as Mr. Meyers represents. Drugs or some items may be marked up as much as I note or more. In addition, pharmaceutical representatives often tell physicians about the cost of their drugs in terms of AWP. This leads the doctors to incorrectly believe that this price is what their patients will pay for the product. We have learned to price products directly from the retail pharmacy because the AWP may not be a valid reflection of product price in the community. When we have presented the retail prices in our community to specific pharmaceutical representatives, they have expressed great surprise at the difference between their claimed AWP and the retail price. Mr. Meyers is also on the mark with his statements about the "perks" drug companies provide their speakers. These perks do include speaking honoraria and hotel and other accommodations. To the degree that these benefits reflect reasonable compensation for the speakers' time, they are, of course, acceptable. My concern grows when the perks or compensation rises substantially above the usual rates. In those cases, one must wonder about whether the dedication to the product is related to the scientific view of the speaker or to the benefits being provided. Steven B. Leichter, MD, FACP,
FACE Clarification Requested on Diabetic Foot Care To the editor: I am writing to express my concern after reading your patient information handout called "Taking Care of Your Feet" (Clinical Diabetes 17:42, 1999). In the handout, you recommend that patients cut their toenails to follow the curve of the toe. This information goes against everything I have ever read or learned concerning cutting toenails. Most articles I have read and my clinical experience have shown me that cutting toenails straight across should help resolve the possibility of ingrown toenails. Cutting toenails to follow the curve of the toe has been shown to increase the likelihood of developing an ingrown toenail. Could you please check this for me and send me any information that you may have concerning cutting your toenails to follow the curve of your toe if this is a recent change in taking care of the diabetic foot? John A. Peterson, PA-C The author's response: Obviously, no one should be digging into the corner of the nail bed, which leads to ingrown nails. Only a slight rounding at the corners is recommended. The article should have made this point clear. Thank you for taking the time to point this out. Steven V. Edelman, MD Copyright © 1999 American Diabetes
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