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Welcome to the Neuro transmitters, a podcast about everything Neurology with the goal of reducing your neuro phobia. I'm Doctor Michael Ken Trees and I'm joined today by my good friend Dr Praveen Vent Potential. Um And today we're gonna be talking about drug pricing in neurology. High Praveen. How's it going? Hey Michael, how's it going? Good, good. So, so yeah, you, you would come to me with this, this idea for our conversation about the drug pricing and there have been some, some recent articles out about drug pricing in neurology specifically. But, but I understand you've had some uh personal experience with a patient having some issues recently. Exactly. I mean, I remember uh talking to you about this patient's and probably you could talk more on this, but it is obviously a stroke lor um that came through. Um um but the patient has a history of seizures and, and you know, someone who uses visit, it gives you all these uh previous scans uh that were done on this too. So I think she had like about 12 scans in total. And um when you go back in her, it's like, why does she have 12 scans and it seems like she has some placed on her Keppra and Vimpat and um um seems like there was some noncompliance reported in the chart with the Vimpat. And uh I remember calling you up and saying like, hey, you know, I'm, I'm going to give her an impact right now because I think she has a seizure, focus from the left, you know, she, she's the impressive one that has like the postictal aphasia for about a couple days. And I remember this and I put in my note clearly how the profusion was like the reverse of stroke and she's got hyperperfusion. Yeah, and she's having the seizure focus from the left hemisphere. I mean, it's not exact science but, you know, it does help. The CT profusion does help. So, um no, she was within the time window. So I didn't give TBA because, you know, she has a stereotypical history. But I did let you know that, you know, hey, you know, is there something that we can do something for her cheaper? So she doesn't come up, you know, like with more scans and more cost a system. And also, you know, um I had the time to, to go through a chart to, you know, if there was another physician that, that didn't have that time or didn't have the records on file, you know, and that would be an unnecessary TP A. Right. Right. Uh Yeah. So, um and that's where we hit the thing is like, can she not afford it? Is this the reason why, you know, is, is there a copay? And I remember talking to you about it? So I was like, okay, you know, what point do we like, um, address drug pricing as an inpatient or like even as an emergency, you know, you're, you're taking care of acute, an acute physician. Uh, at what point do we address this? So, uh, that, that was on, on my mind and then we came, I came across this, um, article on 46 Brooklyn and I sent it to you. Right. Right. Yeah. And I was like, it's, it's like the next day or the, the other day I think I came across this article from, uh, it's called Rec Fitter A how Medicare part D has hidden the benefits of generic competition for a Blockbuster multiple sclerosis treatment. Yeah. I don't know. Uh, I mean, before we go to the article, I don't know what your experiences on like, you know, more expensive epilepsy medications are and, you know, I thought we could just, yeah, it's, it's definitely a concern. Um, you know, in particular in the epilepsy population, you know, there's, there's a higher incidence of unemployment, uh, just due to like, you know, what their previous occupation was, you know, if there's like heavy machinery or other kind of occupational risk factors that kind of preclude them from that job. But, um, but yeah, a lot of the newer, you know, no surprises, write brand name, medications tend to be more expensive. Uh, I remember when I was in residency in particular, we would try and use on fee. A lot of cloBAZam. And, um, it had been kind of over in Europe for decades, but in the US it got, uh, got a different patent. And so up until just recently, it had been quite expensive for a lot of people to get for epilepsy control. And it's a great man, it works well. But, uh, it would just cost prohibitive and you see that with a number of medications, um, I mean, it's kind of the typical pattern that you see. It's like, oh, I think this medication will work better but they can't afford it. And that's kind of the old saying is like, what is the best medication for this patient? It's the one that they take and if they can't afford it they can't take it. Right. Yeah, I agree in your experience, like, um, other hospitals, like, do the social worker goes through this or is there a way that, you know, um, in the inpatient setting that this could be checked? You know. Um, I mean, they'll, they'll sometimes run an, an insurance check where they can see like how much it would cost running it through different insurance plans and things like that. I don't know that that always happens, uh, in particular with neurology patient's, you know, if they're being discharged to like a nursing facility or something like that, that isn't necessarily as big of a concern until they leave that nursing facility. I should say if or when, um, because a lot of times the nursing facilities kind of have to eat that cost, which then becomes its own thing because if you have like a med list that you're sending to a nursing home that has a bunch of expensive meds on it. It, it's not supposed to, but it may make some facilities less likely to take on a patient uh due to the cost that they're going to be taking on as a burden. All right. Yeah, I mean, that's, uh, that's pretty laid out over there. But, uh, let me ask you this question. So if this patient, um if I didn't have the, I was unfortunate enough to have an epileptologist uh on your hospitals and call and I was the neuro and the neurologist of the neuro hospitalist. And, and this patient comes to me like, um, and uh what would be, um, my choices um that I have in, in the generic space and um, how to go about that, would you say? Well, at that point, right, she's kind of like not really taking anything by mouth. So you're kind of limited to your IV formulations unless they put an NG tube in. And then you can, you know, we don't do it as often. But if they're not in like true, true status epilepticus, you can still give loading doses um of other medications, like for instance, like two pyramids or, you know, Perampanel, there is some limited data using those in some of these situations where you give like a sort of kind of loading dose. Um but it's not the same level of evidence as giving like the IV formulations of levetiracetam, uh valproate, even PHENobarbital or you don't really do that as often anymore. Um It's basically, uh and what I've seen is that every time there's an IV formulation of a drug, uh an anti seizure medication made, eventually you get uh some studies that look at like status epilepticus, non convulsive status epilepticus because you're really just throwing everything at the wall to see what sticks. So you kind of get these uh initially, you know, just like a lot of other things in medicine, you initially get like case reports, then case series and then you get like some, you know, non randomized retrospective type studies. And so, so we do have evidence for lacosamide Vimpat as well as levetiracetam, even brivaracetam, Broviac uh is starting to get the same kind of data behind it in terms of status and things like that. So, so those are all options. Uh mechanistically speaking, right? Lacosamide is kind of an atypical sodium channel uh blocker. So we don't really have anything else that does exactly the same thing although theoretically, you know, like fenny tone might be comparable, but, you know, then you have to worry about other interactions. And if I recall correctly, this lady was on Eliquis. Is that right? No, no, I think she was thinking somebody else then. Yeah, it's kept run and, uh, but she seems to be taking the Capra, it's, uh, the levels seemed to be somewhere around the ballpark. Um, there must be a combination of uh non compliance to it, but, you know, it seems like it's always the Vimpat that runs up based on the, on the right. And then, yeah, Vimpat has also poor to follow up, you know, so if she had to follow up with, with her provider, probably they would have worked with insurance on that too. But. Right. Right. Yeah, it's hard to get that stuff from an inpatient setting squared away without outpatient follow up just from a purely insurance perspective. Yeah, I know. So if uh if you did have to use two agents on this patient and, you know, you know, the Keppra dosage is obviously maxed out and, and what would your second generic choice be? Um, I prefer uh do like uh Zonisamide Zahn A gram. Yeah. And some of the reasons why it's because I feel like it's under utilized drug. It's a very good drug, but it wasn't marketed as well because it just lost it. Uh it became generic in a year since I got on market. So I think the marketing has a lot of, a lot, a lot to play in a neurologist, decision making. So I feel like personally I've had successful, it's honest in my, yeah, I mean, it's, especially if you're worried about adherence issues, it's got a super long half life, uh like 90 plus hours so that it is one that I usually will use in someone who has a long standing history of, of noncompliance. So, yeah, um, it, I agree it is a good medication from what I remember. It was cheap. I was like, you know, 2030 bucks and, uh, you know, even if you pay out of pocket, I think that was what I remember. Um, uh, I got good Rx upright, uh, speaking about good Rx, you know, I wanted to just plug and remember that we talked about this Mark Cuban website. Cost plus drugs, you know, for people without insurance and everything was like $6 or $5. I think it was like, don't quote me on it, but it was like, I have the website up right now. I think it's like, um, Depakote Duyvil products, extended release. Um, that's like very cheap limit dolls cheap on that website. And LaMICtal er, is like less than 10 bucks and then you can get kept the Levetiracetam, the generic Keppra for, for cheap. And then you have the, er, formulation, if you want to use the, er, formulation for cheap too. So along with, of course, Topamax, which is like a few dollars, I think. Yeah, you know, 2 to $3 or less than $10 I think. You know. Yeah. Which is crazy cause I'm looking at good Rx for, for Vimpat and it's over $1000 at all the pharmacies. Which, yeah, it's higher than I remember it being, I don't know, something's changed recently with it but um, it's the inflation, it might be, man, you know, uh the economy is not being kind to a lot of different sectors right now. But, but yeah, so, you know, neurology is kind of notorious for, for having expensive drugs unfortunately. And a lot of that, you know, kind of ties into the fact that, you know, 40 50 years ago, there weren't a huge number of treatments for a lot of things. And then probably since like the nineties, we start getting a lot of these MS drugs and then over the last, you know, 10, 20 years, we're getting more biologics and now a lot of like monoclonal antibodies and kind of these more designer uh type drugs coming out in the MS sphere, but we're not really seeing that improvement in price that you would normally see with increased competition in the market. And that usually speaks to some sort of distortion in the market, whether on the supply side or on the regulation side. Exactly. Yeah. And, you know, it's always fascinated me, you know, I think I was interested in like autoimmune and um an MS and since like we had that mogut patient with GFAP positive, I remember that. Yeah. Yeah. So, but then it was interested me that the, the, the expense and then the, the influence of the pharmaceutical company, you know, I'm like, I'm in the world with like international neurology where um you know, stuff are expensive, you know, they consider neuro catheters or neuro catheter is going to be expensive or on your device is going to be expensive. But even with that, you know, we're talking about permanent treatment of an aneurysm, an aneurysm coils like $1200 and, you know, it's a one time cost, it's a one time, hopefully. Yeah, you know, hopefully, you know, if you do it right the first time. But, you know, like, like for example, like an aspiration catheter where you aspirated, um, the clot out and if you just use the, the aspiration cather alone, anywhere between 2500 and 3500 hours, you know, to take a do it thrown back to me. And, you know, historically, we've been um, um, um, you know, required to like, prove the cost effectiveness of a thrown back to me. Is it beneficial? And, you know, an Mrs of two or below? Um, so these are issues that we've always dealt with for, you know, something that's relatively cheap. And uh, I know there was uh the article in the stroke this month that uh from the Mister Clean Data uh that uh suggested like um uh cost benefit. Um um And from the Mister Clean data that, you know, you're actually saving. Um Let me pull this up here if I have it. Sorry. Was this the one where they were saying pre existing dementia, other comorbidities are not a contra indication? Oh yeah, that's the A N uh statement on it. But yeah, it seems like there, it seems like they're still, uh you know, people would not certain, certain individuals would not do or, you know, because of the MRS scale, right? What about the ranks you to like, you know, you're severely dependent so you would probably going up for and then that makes you not a candidate. But, you know, I think about it different. You're at home, you're living with your son or you're living with your daughter, you're living a happy life with your grandkids in the home. And then I just want to, you know, give you the best chance of going home and the best chance of you going home is thrown back to me. So, um you know, I think of it is like it's not a burden on the healthcare system because if I've taken the clot out and I've not been in a nursing home state or even a short term rehab stay. Um uh that's how I've always thought about it as but um I don't think everyone necessarily thinks it um thinks of it that way. That's probably true. That's true. But um I think it was like an average saving of a good outcome of thrown back to me. You save about $18,000 of patient in, in, in the, in the current hospitalization. So boom, patient did well, you know, probably, yeah, like I had one this week that got discharged within 36 hours. So, uh you know, it's, it's great to see those uh those. Uh so if it's a good outcome, you know, were saying about that. And also um it showed the EMR clean $105,869 per additional uh quality of just of life here in favor of EVT because, you know, you don't have the expenses of the rehab and all that stuff and, you know, than medical management. So it seems to be effective in, in, in, in, in a wider range group. And um we've been forced to like prove cost effectiveness over several years even though the Mister Clean trial came out in 2015. And it just surprises me that that on the medicine side of things in neurology, um it's, it's like uh it's like, oh, you know, we don't worry about cost at all and, and a lot of, a lot of people do not worry about cost. Um and it's just, it's surprising that uh you know, we do prefer medication. However, if you think about the number of scans or the the compliance issue due to cost and how much that costs on, on the healthcare system, like, is it like, you know, should we do um try generic stuff first and, and then then go to uh right, like the kind of escalation model that a lot of insurance companies use. Um And I don't know if I told you before. I did do some uh like utilization type review case review type stuff for a little while. In the past couple of years, it was, it was a decent company. They were doing a good job in terms of getting like same specially specialist for review. But I remember like sometimes I would be the second or third neurologist reviewing a case and like one that sticks in my mind was this one with, with multiple sclerosis who had been on one of the interferons? I can't recall exactly which one. And she's been on stable on that for like 20 years. No, no relapses, no flares, nothing. Uh tolerating it. Well, and it had gone off formulary on her insurance carrier. And so they wanted to switch her to one of the other ones and I get, I forget which one it was, it was one of the weekly injections and they were going to switch her to like the three times a week injection. And so, you know, you find, and that's the kind of my argument. You can find a study to support any perspective you want uh in terms of medical decision making. But essentially, like she, you know, she had had two previous neurologist say, like, no, there's no reason to it. But, you know, I dug through the literature is like, hey, here's this one study that shows that if you uh changing people's interference to a quote unquote equivalent doesn't necessarily that there is an increased incidence of uh symptomatic relapse. And so, you know, but it took me probably like, like 30 minutes to an hour to find like a journal article that looked solid that support that position. Um It's much easier to just say there's no evidence to support that and just, you know, sign the case move on to the next one. And that's really why I don't really do uh that those kinds of med reviews anymore. It just became this very disappointing and disheartening task uh to see all these things because, you know, my inclination is to support the treating physician. Like you made a decision, hopefully there's a rationale behind it. Um But the, yeah, the whole system as far as that goes is terribly broken. Unfortunately. Uh It was interesting, what are your thoughts about the, when you came to that? I was like, I know that the A N reviewed the cost effectiveness of the, the new Alzheimer's monoclonal antibody. Uh Yeah, you can. Um ob yeah, I I haven't looked too much into, it is just like looked at it and wasn't impressive in terms of, um, in my world, in the stroke world, the results are very, very impressive. It's not mild or anything of that sort. But, um, but it was not something that I really like thought was very impressive and I can understand why the, um, FDA advisory panel, I think a bunch of them quit. Um, uh, yeah, against the recommendations. But I know that they drop the price and the A N revisited it because they have the price of, of that medication. But I haven't no known so too much about it. What are your thoughts um on like, you know, I give if, if, if someone comes and asks me about that medication. Yeah. So, so my, it's um yeah. Right. It's a very ethically complicated issue. So like the, the I think it was two out of the three initial studies showed radiologic improvement but no clear clinical improvement. And you also had this uh this Aria, right? The uh you can um um related inflammatory uh I forget what the last A stands for, but it's going to bother me, abnormalities, amyloid, related imaging abnormalities. And uh so, yeah, and it's not uncommon either. Uh remember there was an interview on the neurology podcast where they interviewed uh uh a guy who's a neurologist who had Aria uh after one of the infusions. And so that's I think part of the, the approval at this point last I read was that it is contingent upon them continuing to get data and show that there is in fact clinical improvement. But, but yeah, there's a lot of hoops to jump through in terms of the approval process. So you have to have, I believe uh CSF testing uh showing phosphorylase tau and, and or uh Amyloid pet studies. So uh that's just, and a lot of insurance companies again, I haven't looked at in the last month, but uh, a lot of insurance companies were saying that they're not going to cover it regardless. So, so it was initially going to be out of pocket for a lot of people and the initial cost, you know, fact check myself here in real time. Uh I think it was close to $50,000 a year. And so if they cost that or half that, yeah, here we go. Uh, and you're right. It was just in December. They went from $56,000 yearly to basically half 28,028 something like that. Yeah, I remember that because we were talking about, we have a family member with Alzheimer's and, you know, I thought to myself, hey, should we pay out of pocket to, to do it like, you know, like, but, you know, it's like, no, I looked at the, and I was like, uh, you know, she's, it's not that bad. So, you know. Right. And, you know, I wouldn't want her to die from pay out of pocket, go fund me account and then die complication. That would be even worse. And that's, that's the, the, you know, the counter argument. Right. Is that there isn't anything available. So why not let, let them try if they're willing to pay. And from what I've read the, the counter counter argument to that is that, well, let's say that, you know, this gets approved, it goes on the market and that's what people start using. Well, then we're going to be shunting systemic, you know, financial resources into treating with this drug. And maybe it doesn't even work that well, maybe there's something better and there are a few other drugs in the pipeline from what I hear now, a lot of them still are kind of based off of this Amyloid monoclonal theory. So I don't know if there will be significant differences but, um, but it does, you know, kind of that. Uh So the anchoring bias, like this is the first thing that we have. So people want to latch onto it and is it actually going to help that much? Yeah, it's, it's a hard, hard decision to make and I think that it exists in a lot of, a lot of um um, a lot of fields in neurology and, and I think, you know, headache uh is one that I can think of right now is used to be like a field that, where everything was, you know, pretty generic. I would say, you know, back when, back when we were trained before the seizure many years ago. Uh, I think, uh, I think the first one came out around 2017 or so 2017. I, I would, I would imagine there was a slow rollout too but, you know, now it's like this, um, you know, I know there is the, um, have you heard about Icer? Like, um, uh, you know, it's like, it's like this institution that, uh, compares cost of ineffectiveness. And one of the most famous ones are the, uh, the medications, the gene therapies for SM A, um, and it compares like the cost effectiveness and it gives you a price and it gives you a price of range. Um, and I think it was like, it came out like, you know, the Ice a study came out, I think if I remember, right? It was like, it's more cost effective for people who have chronic migraine or the, at the, um, and it would cost like about $6000 I think. So, an additional to the healthcare system per patient to, for a better, uh, quality of life. So, um, but, you know, it seems like the insurance companies from my experience do not cover them cause I do use them on, uh, instead of, um, some of the Triptan is that they used to work on trip tans and then they have some vascular issues. So I, I take them off the Triptan. So like, hey, what else can I use? So they're already on a blood thinner or aspirin, Brilinta or aspirin Plavix. And then we are like, okay, what else can I use? So I think um the c therapies have a reasonable cardiac say data that I have been, you know, trying to use them in my vascular all paid. But I do get a bunch of pushback from insurance. So, um yeah, you have to. So, so again, kind of uh I did review a lot of charts that were for exactly that. Uh And so again, it depended, it was usually like a three tier kind of thing. Again, just based off of my, you know, anecdotal to if you will. But um typically you have to fail one from a BP medicine class, one from an antidepressant class and or one from an anti seizure medication class in terms of if you're talking about prophylactic migraine therapy, and if you had failed those three categories, almost every insurance uh plan criteria would allow you to go to the CGRPS um right to that same kind of escalation theory. Um Or if you document a reason, again, this kind of goes back into, you know, playing the game, right? Uh a reason why you couldn't add another medication, like say they're already on like a beta blocker. I can't add another BP medication or they have like, you know, hard to control hypertension. I can't add like a TC A or, or they're already, they have a history of bipolar. I can't add another antidepressant and risk throwing them into a manic spell or something like that. So, as long as you document very clear cut reasons, um, you can kind of hit those bullet points very, uh, concisely, but a lot of people don't know about that. I don't think. Sure. I think I've, I've had that issue for, uh, when I was a resident and, and we did, um, uh, Botox and, and, and, and I had to do the prior authorization. I think we, we documented those reasons for Botox. So I do document them, um, um, as, as much as I could, they kind of, I think, um, they approved it for a couple of months and then, you know, what happens is then, uh, then I have to fill out more paperwork or, you know, at the end of the year. So, uh, yeah, so it, um, it is, uh, it is, it is a little hard to get those medications mainly, I think because of the cost is an issue. So, what I've been doing is I've been reverting to, you know, the back, um, you know, prophylactics and, you know, trying different ones and it seems to be working as much as possible, um, that I can limit them, you know, the old school Depakote or Topamax or, you know, all that stuff while they're approving in. Um, I think it helps at sometimes and some, some insurances, you know, they, they do review my chart and say like, hey, why can't use the Triptan anymore for the acute abortive CR CGRP S instead? And I don't want to use the Triptan anymore. Um Yeah, so I think those still do exist and when they feel, I think uh preventing them with Botox seems to be like a more stress free uh way. Um, so I send them for, you know, a Botox, uh referral or, you know, you know, injection blocks or something like that. So it seems to be an alternative way of doing stuff is what I've noticed. So, um, yeah, and that comes to where we were talking about, you know, it's how, how are, are long diversion, diversion? I think that's actually a good conversation that we had. And yeah, I mean, I mean, baby biased. But so, yeah, when, when all this is all my thought process raising, do, do I do this or, you know, do you know what do I do in these situations? And, um, I do feel like there's all these cost savings and, and I'm involved in, in all these hospital committee savings of, you know, how can we save a little bit over here? You know, can we standardize what catheters we use or what wires we use or you know, storms and, and, and, and, and stuff like that. And then, um, you know, I always amazed me about how much stuff costs in the multiple sclerosis world. Like how, how expensive, you know, it's always in 46 Brooklyn. I think I have, I read an article from them before. Um, and I have sent that article to you too and I think they did a Copaxone case study. They know that's, that's a beautiful article that they did and this is the most recent one from December. I think we I sent it to you like in January for the title here, Wreck Fidera, which is just excellent, excellent. Uh Do you include links in your in like your description or something like that? I don't know. Uh Yeah, I do, I can do these links in the show notes. We do have to give them a shout out for their article. I think so. But they, they have this um you know, they arranged in chapters in um beautiful organization of how it is. And then you can see uh chapter one tech for us days of exclusivity. They have this graph over there. It is 2013. We're talking about $4500 and this is for a 2 40 mg monthly into it when it first came out 8276 7 years later, seven years later, right? So the price almost doubled over seven years. Uh which is insane. Insane. I know. I mean, and yeah, it's, it's fascinating that uh all right. So that even because I'm trying to use it, Myelin was the generic company who started making Dimethyl fumarate. Um gosh, I'm trying to find the timeline for that. Do do do do do uh but after, after that came out the price dropped but then uh the company started, yeah, you can get a generic as low as uh $900 monthly, you know, um, as of January 2021 as what it says over here for the article and there was 11 total manufacturers of um, of that medication. So that's, we're talking about a 90% say 90% to 90% saving healthcare costs. Uh to put this into perspective. I always think about, think about, you know, the neuro intervention, let's say, you know, like a pin number, a catheter not, I'm not sponsored or I have, have disclosures for any of these companies. Let just, just to be fair, I had to something, I'd say a pin number. Uh Yeah, if you're listening, it's $3000 a catheter, right? Uh Normally what companies would do, they would actually add something, make it much bigger or make it, you know, um uh a much better catheter. So, and then they would jack up the price. So, you know, it would be, yeah, these incremental changes. I don't think that they have jacked up the price by more than 100%. It's the same cats or it's the same thing like, you know, you're using, and let's say, in a 68 you know, I don't think they're like, jacking up the price they would come up with like a, a newer, um, you're a catheter in and, and, you know, there's all the R and D that goes into that catheter and then probably, you know, the price would be marginally increased. I don't not seen it double the price of, of a catheter, but that's how I think about it and it just, it's just mind boggling to me how this is over here. Uh Yeah, and I've had, I've had experiences where I have uh sent people to specialize MS centers after diagnosing it because I don't have the um the capacity to, to, to neuro intervention and then, you know, do all that stuff. But these are friends, these are friends and families and the friends and families that actually want to see me because they, you know, they're like, oh, you know, he's a good neurointerventionalist. So probably you'll be good, good year. It's probably not, not the case because I tell them like, hey, I'm not, not up to date on as, as much as I try to be up to date. I don't, I'm not as up to date as I'd like it to be. Um is what I tell you. I'll probably do all right, but I tell them, I, I'd rather you go to the better, uh, and then it seems like they go straight for the infusion and I understand the reality of going straight for infusions and, and all that stuff and it seems like the, and to me the disease is mild and, you know, sometimes I do think of as like, do you have to run the infusion center? Like you have to keep the doors open for the infusion center? Yeah, that I'm a, I'm a strong believer in uh in basic human psychology, right? You know, if you incentivize something, you're going to get more of it. Um, and not, you know, not every MS doc has as a steak in an infusion center, especially those who are kind of more in academic settings. But depending on how the department is funded, you know, you got to think of. But these things, but that being said, I, I do often, uh in my recommendations lean towards infusions depending on like the disease, you know, the lesion burden or exactly, I, I completely agree to this, this person I was talking about was more of a very milder disease, like very, very mild. Um, and, you know, kind of, again, little uh diversion for a moment. There was a study from, I forget which, where it was published, but it was, it was done in Europe and it was looking at the efficacy and tolerability of this was in the pre uh ocrelizumab days. So it was riTUXimab versus like dimethyl fumarate. Uh your Interferon's Gilenya. Uh Yeah. So, and, and riTUXimab, you know, if we use that as a stand in for say, like ocrelizumab, then it had a significantly higher efficacy and tolerability and you had less people falling off. I, I completely agree with that, that these are more of like, you know, and, you know, no aneurysm correlated an MRI and I found out in one small lesion. So I did an LP and then the Oligoclonal bands are positive. Oh, also very early days. No, no, no deficits at all. That's fair. Uh It's like, I know, I understand it. Uh you know, you know, trying to get pregnant, you know, but it seems like it was uh very, very early day and, and, and stuff like that. It just some weird stuff that I've always experienced personally. So, you know, I don't know. Um But yeah, coming to the article, you know, it goes in chapter three how, how, um, you know, Tecfidera, the brand name just like lighten the, the cost of it. Um And then make sure that the generics as cheap as, as uh like, you know, 3 50. It's like the lowest generic WAC. It's on Patriots like so, uh so, so, uh and they have this chart from Blueberry Pharmacy uh of, of how they charge, you know, how much does the lid cost? How much of the vial cost how much does the technology feed and how much is the actual drug that they imported from, from somewhere probably India and, and, and, and, and, and how much do they cost is how they break it down. Um, you know, and, and, and I think what the article comes up is like, you know, it looked at Medicare party enrollees and I don't think they were even aware of, um, the availability of a generic medication and, you know, it seems like, um, there was, uh, no notification or, um, they were okay. They're going with the brand name stall even after the availability of a significantly cheaper medication that was available. Um, yeah, like more than half of the seniors didn't even know that the generic Tecfidera exist and this would, like, greatly reduce copays across the whole Medicare. Uh, yeah, system. And I, I told you, like, you know, I've had all of a sudden people who are on Medicare, you know, they've, they've had their, their medications for free and now that they're asked to pay like 100 and 100 and $50 copay per requisite zero tow. Some of the patient's on the nature of tribulation has been free and I'm like, wondering what's going on, like, why do they have to, you know? Yeah. Right. You get all these, uh, these rebates from the drug companies. Right. Which you think initially, like, oh, great. I can get my, my patient, you know, free medication. But, uh, what happens when that rug is pulled out from under you, you know, someone is still bearing that cost. And so, you know, it's, is it, the company, is it, is it the insurer? Um, a lot of times it ends up being other patient's, uh, not necessarily the ones who are getting the rebates but the ones who don't have the rebates or who are on a different carrier or, you know, there's, there's all these, again, these market disturbances. So you're not really seeing the, the cream rise to the top if you will in terms of best pricing. Mhm. Yeah, I don't know. But it just, it comes, it breaks it down without, you know, spending too much on someone else's article and their research project that they did. Um, hopefully, you know, the pockets grow that we can actually have someone from, from 46 Brooklyn or, like, you know, I clear it on our podcast, but that would be, that would be very nice someday someday. Yeah. But, yeah, I think the negotiated price is from all these, uh, companies or insurance party. Um, what is the exact term that you use? Uh, large parent organizations, um, uh, or the plan sponsors, um, you know, that they prefer to go with the more expensive medication than the generic when, for other stuff such as headache medications. Uh, right. It is penny pinching on the headache medications. So, that actually works on the patient and I'm afraid to use another one enforcing us to. It's interesting, you know, I, I like this one. we're not asking to switch it to something else. It's, it's, it's, you know, brand name and then generic of the equal. So patient with who is on Keppra, we're just switching to the uterus it and it's worth a try of that. Many people are on that medication, especially elderly people. So I like this one quote near, near the end of uh second half of the article. Um In fact, some of the lowest negotiated price is available in part D for generic tecfidera are being reported by some of the smallest plans. That's the exact opposite dynamic. We were taught in our economics classes and likely also surprising to the government powers that be that signed off on so much health plan integration consolidation in the hopes of driving down costs for Americans. You know, there's a, there's an old saying never ascribe to malevolence, what can be explained by incompetence. Um uh I get a strong vibe of why'd you do that? Uh because it doesn't make sense, right? The insurance company is paying more unless they get these rebates, right? These rebates are passing on the cost, the it's letting it kind of bypass the insurance company. So ultimately, it's, it's the the companies who make these drugs who are using these rebates as a way to still gain profit, right? It just has to be a rebate to bring it down enough that their margin is still enough to produce it and be profitable. Um So, so yeah, there's definitely some uh shenanigans going on here. I would say I do like that. Go down there, have a mem there if you can't trust a car salesman who can you trust? It's like it's like, and then they have this line less than 0.02% of all seniors have access to die, multiple murder and negotiated price is below Nidac is what they say. Yeah. And being a math geeks, we're going around it to 0%. Right. Nobody in Medicare. Yeah. So it's, it's definitely, yeah, it's worrisome. You know, how did this happen? And why is it being allowed to happen? And it could cost, it says chapter nine, you know, you go and about to be $5800 per patient. If they switch to, you know, generics per, on the Medicare part D, this would probably help, you know, the other neurology drugs or the other areas of this thing because, you know, it seems like the burden is, is already high with the MS medications and then you're, you're, you're also, you know, complaining, you know, are also having, you know, um, um all this stuff that's going on. Um, along with it. Um, yeah, you can probably use that $6000 better for another patient that would actually, you know, use it needs it better. It is how I think of it as, but they also have a great, um, a great article on Copaxone. I know that we don't have like, um, uh, time to probably even the flawed design of Medicare Party of Copaxone case study for. Oh, my God. Yeah. You want to talk about the flaws of Medicare, uh, gone into big, uh, not that I'm, you know, I'm not an economist but, uh, yeah. Yeah, but I have eyes to see. Yeah, I don't know. But I, I do think that, you know, it's, um, uh, with, with all that's going, going on, you know, it's always good for residents to be aware of cost. I think this was one of my interests. Yeah, when I was a resident and, you know, I remember you were always talking about, you always knew more than I did when we were both residents. I think that that was more of the epilepsy drugs, you know, that's the choice of the epilepsy drugs was, was, uh, and, and, and once again, I, I know I'm like, I do like, just like expensive medications. It's not like I don't like, I understand, uh, work. Well, for example, I do like Berlin to like, uh, to gargle or is, uh, once again, not sponsored by anyone know, different uh, companies. Well, you know, I've had zero stent thrombosis with Berlin to, I don't like, it's like a miracle drug. Like you know, with the Plavix is a 30% Plavix sources stand, you put it in the stand and I, I obviously put one patient on Plavix and then I put a stent in, in the, as stent thrombosis on that patient. I ended up having to put the patient on, on a GB to be a 2283 in a bitter and then, you know, you know, probably do a successful thrown back to me. But after that, you know, my experiences, um you know, it's like, you know, Berlin test seems like it has none of them. We do the platelet function testing and it seems to be always um efficacious and I'm trying to think that that is a war that I do. Um uh you know, ready to take on because, you know, that it causes a less complication. And um um I think some of our colleagues, my colleagues have done like a cost analysis and then the system and then they found out that, you know, um um if probably that's like just paying for that Berlin test, like cheaper than doing it, thrown back to me or doing a thrown back to me device and then charging for that because it's always think so. It's obviously, I think it's like $600. So my guess is 608 $100 don't quote me on that. But um you know, thrown back to the device and the whole set of thrown back to me. I think I'll be on the 5 to $6000 if you do an aspiration, thrown back to me and the stent retrievers around back to me is around 12 to $13,000 I would expect. Um, well, in inter procedural, so the, the it's, it's probably if you're doing like a flow diverter or for an aneurysm or extent, it's probably, you know, I've come to the conclusion that this is so it actually helps my decision making because I've always thought of it like that way. I thought it's important for people to, to know that and, and, and that being part of, of, of teaching and, and, and residents and medical students of like, hey, you know, you always have to consider this. Well, we'll, we'll doing, um, doing stuff. Yeah. But, um, yeah, I'll include a link to the, uh, 46 Brooklyn Wreck Fidera, uh article and I know it's, it's really good. It's, it's, it is a long read. Um, they have actually some nice recommendations about like more systemic insurance, uh, things that could be changed. And I just love the, the end quote from doctor, uh, Madeline Feldman. At some point, we can't afford all of these savings, which, which is great. But, yeah. Right. So, you know, neurology is we have in our specialty, you know, you alluded to it earlier with SM A, right, like on a semi gene by Parp Avik. If I'm pronouncing that right. Uh, single dose audio and continue on my way and, oh, yeah, you said that word like probably what, 200 times? I, so I, I had to, uh, before I'm gonna, I'm gonna lift the curtain up. I had to track down video of the researchers saying it because it's not written like anywhere online. Oh, yeah, those, uh, some of those chemo, uh, type medications and monoclonals when I'm recording that it does take quite a bit of time. Uh Oh man. Yeah. Uh let's just say that that took a few takes. But, but right, but like a single dose of that is over $2 million. Um, now, granted it, it makes a significant difference in terms of outcomes in these kids. Right. But there are those other sm a drugs that are not one time doses and those are still like 2 50 to $500,000 a dose. So, yeah. Right. And you know, I think it's like you get like to, I want to say it's 2 to 3 times a year, but again, don't quote me on that. So, neurology is definitely with, with so much research going on in the Neurosciences and you know, that translational research into clinical neurology, we're going to continue to have to deal with these questions. Is it effective? First of all? And is it cost effective? And you know, can, can the system bear the costs? Um, and you know, a lot of this research is important. You know, no one likes to really talk about like the money part of it. Um, because we're supposed to be, you know, purely altruistic and focusing and that, that is ultimately the, the aspiration. But, you know, if the patient can't afford the meds, if I can't get them the medication, then we're not any better off than if we didn't have it to begin with, uh, to wind things down. I just wanted to let you know that I can't wait for the neuro ophthalmology. Um continuing to come out because there's a new drug that got approved for labor's heritage, every object neuropathy. And I Yeah, and it's uh I think it was proven to be uh intravitreal gene therapy. So it's proven to be effective, I think. So I pulled it up the name, it's called Lena Do Gene know Parvo vaccine. So I can't wait for that issue to come out. So you can repeat that again and again and again. Yeah. Oh God. Yeah. Those articles are challenging to record. I think this one coming up actually, next end of this month is epilepsy. So that's kind of in my wheelhouse there. So I should be good to go, good to go on that one. Yeah, I mean, probably I should reverse the role here and I can ask you about epilepsy the next time about Yeah. Yeah, absolutely. Uh We should have some, we'll see what some new stuff is there's always new stuff I'm biased. Right. You know, I, I still follow, like, the journal of clinical neurophysiology and epilepsy to, as opposed to some of the other folks and neurology who may not be as into that. I don't know but listen to this, but it may be educational for me and I'm sure you don't mind that. No, no, I could. That's so, that's always easy for me because then I have to less prep work to do. So I don't prepare for the show so well. I mean, I read the articles. Yeah. But yeah, it's, it's, there's, there's not necessarily an outline as you may have been able to tell from the flow of the conversation. There is not. And I think that's a great way. Different shapes that's from the, from the other professional podcast. Right. Right. Right. Yeah. You know, it's casual, casual, just having a conversation. I think we're like, um, like hitting our time probably. Yeah. Yeah, we are getting about there. Uh, any final thoughts, Praveen? No, I just think, I wish, um, these are stuff that I had to, um, learn during the course of several years and, you know, um, discussion with, I think once I went in the field and they're like, you know, that you're using this device and that device and then I kind of like, go back and fighting with insurance companies and all that stuff. Yeah. Yeah. But I think it's, it's, it's really nice if, you know, all this is taught, um, in a structured way in, in, in your residency program. And, um, you know, they, uh, I think that part would be, um, that part would be really, really beneficial of, like, you know, you're choosing this medication. I know it's easy to choose medication but, you know, it's going to have a healthcare system, um, you know, a burden on the healthcare system. I think those are stuff that I wish they would teach a little bit more. Um, because these are stuff that we had to like, or I, I don't know, but you, but I had to, like, personally go about and then you go into a hospital and then you have to sit on these cost committee measures and then you have to go through all that stuff that's from the hospital. Absolutely. Which is, uh, there's a, there's definitely a learning curve there. Exactly. Sure would be nice to be prepped for it. You know, I, I think it's going to exist there and, you know, I do understand that, you know, uh, there has to be, um, uh, you know, uh, there, you know, there has to be a profitable hospital system to, to understand it. But, you know, if, if we're prepared for this advance, I think, um, we would be more comfortable handling this in the real world scenario is also how I would feel. Yeah. Well, that's, that's definitely fair to say. Do you have any comments? No, I, I think we've, we've hit all of our main points today, you know, just uh kind of bemoaning the current state of things. But um but yeah, there are some lobbying groups out there. I know the A N does a lot of lobbying as far as patient advocacy and things like that. So that's, you know, make sure to support and follow their efforts. If you enjoyed listening to this podcast today, please leave us a five star review on Apple itunes or wherever you are listening from today and don't forget to subscribe for future episodes. You can reach me on Twitter at Doctor Ken Trees. That's Kantris. Are you on the Twitter Praveen? Do you want people to find you? Okay. You can also e mails at the Neuro Transmitters podcast at gmail dot com. If you have any show ideas, questions concerns, you want to tell us how wrong we are about everything. Uh Let us know and we can always address that in future recordings. Alright, Praveen. Hey, always a pleasure. Uh We'll have to do this again soon. Thank you for having me again. Anytime buddy, take care.