There’s so much waste in U.S. cancer care that any pet issue represents but a drop in the proverbial bucket, but here’s one of mine: physicians don’t push self-administration of GSCFs like Neulasta because they can bill the in-office delivery of the drug as an outpatient procedure. So instead of faxing a prescription to a specialty pharmacy to have a box of pre-filled syringes delivered to the patient’s house, which would be charged exclusively under the patient’s pharmacy benefits, the physician/center will have the patient return for a separate appointment after chemo to have a simple subcutaneous injection billed as a medical benefit. Even medical staff aren’t consistently aware that home administration is an option; a nurse once asked after a dose of Abraxane if I had an appointment for Neulasta for the next day, and I told her I’d be giving it myself at home. She raised her eyebrows and said, “Do you have someone at your house that can give injections?”
It’s a subcutaneous injection. You cannot do it wrong. And yes, my doctor at the time and her staff gave me a ton of crap about getting the prescription, but in the end they relented, because on what basis could they resist? Amgen designed the syringe to be patient-friendly; it’s pre-filled and has about sixteen times the plastic of a regular insulin syringe. It looks like this:
That needle cap has foam in it; the little blue shield slides down and locks over the needle, so no one gets stuck. There is an incredibly detailed package insert that makes it very clear that you’re not supposed to re-enact the Pulp Fiction epinephrine scene, but you can stick the needle pretty much anywhere else. Orange danger stickers remind you to store it in the refrigerator. Nothing can go wrong at any stage in this process. Amgen thought of everything – including how to ensure sales of their property post-patent expiry at the expense of patients, in terms of both convenience and in actual healthcare spend.
So yesterday, a Neulasta commercial came on. It opened with, The day after chemo, you could be home. And I lit up, because I really and naively thought this was some kind of patient education campaign. (Who would pay for that, I have no idea.) You don’t have to drive back to your doctor’s office for no reason! Don’t be a sheep! Be an adult with pharmacy benefits!
Yeah, wrong. This is the ad.
This is Onpro, the post-patent device that is supposed to compete with Neulasta biosimilars by requiring a medical professional to load that beeper-looking plastic thing with Neulasta, affix it to the patient’s arm, and send them home. The Neulasta administers itself the next day. I can’t believe the size of it, that this is a serious solution. (This is the only thing I can really fault Amgen for; I guess the product would degrade as a regular drug patch, but this is as low-profile as they could make it?) Significantly, I don’t know how much more difficult it’s going to become to activate the option of self-administered Neulasta, or even if Amgen plans to keep their individual pre-filled syringes alive once Sandoz gets their biosimilar approved, now that the center’s sales angle is You don’t have to come back tomorrow! You’re welcome!
To be clear, we never needed these space-shuttle-looking blue syringes. There’s no reason you can’t send patients a couple ampules of Neulasta and have them draw it up themselves into an insulin syringe, but the excess of the Amgen product seemed like a small price to pay for an opportunity to make one tiny corner of cancer care easier and cheaper. And if patients really don’t want to deal with needles, fine, let them come in for the injection (though I believe more patients would do it themselves if they were aware of the option); it’s the lack of transparency and awareness that’s infuriating, like the hospital is doing patients a favor. It’s not a favor; it’s business. Why are we so quick to accept that drug companies and payers are blindly cash-motivated, but trust the hospital as a pure and benevolent entity? We’re all complicit in these unsustainable patterns of healthcare spend. Drug pricing can’t be the only villain when hospitals serve as the gatekeepers for the options and flexibility patients do have.