Insulin/diabetes situation in Belgium (Team meeting notes 26.04.2017)

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Notes from the gathering on 26.04.2017. We had the pleasure to meet Guido ( @GLS9000 ), who produces scientific content at the Diabetes Liga.

Guido: Insulin is very well organized in EU. Belgium is 14th (out of 30) in the European index. The medicine doesn’t cost much here. Pumps, sensors etc. come with the package patients get from convention centers. The Diabetes Liga sells some stuff like glucometers, sensors, strips. It doesn’t make sense to sell other stuff, since they get it cheaply from convention centers. The convention centers are an intermediary between hospitals and the government health services.

Maria (@mboto ): it’s the same in Spain, it’s almost free.

Guido: The problem is clearly different in the US vs. here. In the US the price is a problem. Here the problem is more type 2 diabetes, specifically the prevention, as it’s a lifestyle diseases. Many organizations work on that. Diabetes still costs the government way too much money because of it: checkups, dietary stuff, … Type 2 diabetes here is also tied to poverty. The best way to reach these poorer people is the doctor, but they usually have no time.

Maria: it would be best to focus on this type, because it’s an actual problem here. It’s hard to reach these poor groups, we could help there. An art project would be a good medium in general to spread awareness to the public.

Through the non-profit Ekoli, we do come into contact with poorer and vulnerable groups of children in Belgium. This ties in with the idea of @NiekD  for educational outreach. It would be a way to assist with the pressing matters here.

Vincent: someone is paying for the insulin here. Probably tax payers. Guido: yes, there are intermediaries that gain a lot from the government. In the US that is much more. There was a scandal not too long ago: big companies were making deals. Walmart is now also bringing back an old version of insulin to sell it cheaper. People here are spoiled though: they are always asking for faster, better insulin. They wouldn’t settle anymore for older types.

Other info around the Diabetes Liga. They have about 80.000 patient members and 2.000 professionals. The members determine what the organisation does, and cheaper insulin simply isn’t a policy point here. Guido mentioned the Open Insulin project at the office, but it was not a priority at all.

Pieter will design some infographics that can be used for communicating about the issues surrounding diabetes/insulin. The International Diabetes Foundation has some good ones already, these can be used as well or serve as a starting point.

Thanks a lot Guido for the interesting input! I’m interested to hear what others think. How can we shape the project so that it also meets the needs of the Belgium situation?

The next gathering is in two weeks: Wednesday 10 May at 8pm @ ReaGent
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Belgian diabetes care models

For people (with type 1 or type 2 diabetes) that have to take insulin injection (more than 2/day), there are diabetes convetion all across Belgium, for more info see (in Dutch): https://www.diabetes.be/diabetesconventie

For people with type 2 diabetes that get up to 2 insulin injections/day there are the care paths, see (in Dutch): https://www.diabetes.be/zorgtraject-diabetes-type-2   There are only two diseases that require ‘care paths’ (treatment and  follow-up of chronic diseases) in Belgium, more specifically diabetes type 2 and chronic kidney disease (by the way, this is also a possible diabetes complication).

The third group of diabetics, are the people that were just diagnosed with diabetes type 2 and who do not require insuline injections:  https://www.diabetes.be/zorgmodel-opvolging-van-een-patient-met-type-2-diabetes  The main treatment here are metformin ( and statins against high cholesterol if necessary) and life style changes: https://www.diabetes.be/zorgmodel-opvolging-van-een-patient-met-type-2-diabetes

You can also check the RIZIV website: http://www.inami.fgov.be/nl/themas/kost-terugbetaling/ziekten/endocriene-metabole/Paginas/diabetes-tegemoetkoming-kosten-begeleiding-volwassenen-gespecialiseerd-centrum.aspx#.WQXy5_nyiUk

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“Someone is paying for the insulin” – but how much?

Thanks everyone, especially @GLS9000 for the detailed information.

As an economist, I resonate with Vincent’s point: there is no free lunch, so someone has to pay for the insulin. It is very affordable to patients, but that does not mean it is cheap. Cheap insulin is resilient: even if the health care system were to undergo a financing crisis (not all that unlikely), it it’s cheap it is probably going to stay, and even if its costs are passed over to patients… it’s cheap. Expensive insulin, even if cheap or free at the point of delivery, is not resilient at all. It means diabetic patients are at the mercy of the political/financial cycle. Generic, open-sourced drugs are always  a good thing.

Guido (and everybody), which one is it in Belgium? Is it really cheap or is it cheap to patients? How good is the Belgian state at negotiating down the price of pharmaceuticals sold in the Kingdom?

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Someone is paying for the insulin" – but how much?

Hi @Alberto, thx!

The price setting method for medicin/drugs differs completely between Europe and the US. In Europe (EU) the price setting method for prescription drugs is strictly regulated (and it’s within this framework that the EU-members can negotiate the prices), while in the US they follow the free market principle which leaves room for misuse and pricing agreements (which happens in the US for insulin) between the pharmaceutical companies. I

The coming years, the much cheaper,  biosimilars for some types of insulin will hit the market (one already this year in Belgium), so the insulin producing companies would like to cash in on the insulin while they can. See this article for some background: http://www.diabetesforecast.org/2016/mar-apr/rising-costs-insulin.html?referrer=https://www.google.be/

In Belgium insulin is considered as a A-class or essential drug, therefore the patient pays nothing for it (this is the case in most EU-countries). The yearly cost/patient using insulin in Belgium: 1414€ for the insulin and 5175€ for the care (in 2012). Mind you, this is for a patient without any complications. In general, cost of a person with diabetes was between 5.650 – 10.737 €.

I would like to quote from the article which I linked above:

“So, where are these generic forms of insulin? Currently, there are no generic insulin products in the US, and the reason why is complicated. For one, insulin is considered a biologic rather than small-molecule drug because it’s made from living cells, and all generic forms of biologics, called biosimilars, are subject to more stringent approval standards than small-molecule generics. So it’s much more expensive, more complex, and more difficult to achieve a “copy” of the original.

Because of the larger financial burden of manufacturing biosimilars, they would likely not lead to the same 90% price reduction seen with other generic meds. Experts estimate that it would be more like a 20 to 40%, though most are leaning toward the low end of that range. Still, that should bring down the price of some of the most costly insulin.

How soon until we see a biosimilar hit U.S. markets? Abasaglar, a pen-based version of insulin glargine manufactured by Eli Lilly and Boehringer Ingelheim, is approved as a biosimilar in Europe and as a follow-on medication called Basaglar (a drug similar to an already approved product) in the United States. The launch date is currently December 2016.”

I think the real challenge lies in the transformation from a curative healthcare to a preventive healthcare, which implies a more durable solution for this healthcare problem/burden. Education, information & awareness, prevention remain important.

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Great numbers

Thanks again, Guido. So, by making open insulin, we’d be saving maybe 500 EUR per year per patient. 80,000 is the number of diabetics in Belgium, or that of members of the Diabetes Liga? In the former case, 40 million – a lot of money, but still less than 0.1% of Belgium’s total health care costs.

I totally agree on preventative, by the way. This is a clear indication of the whole OpenCare project. How would you translate that into activities for Open Insulin?

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Some more numbers

I do think that Open insulin could play a role in enhancing the protocol for the production of insulin biosimilars, because that seems to be the major problem for putting out cheaper insulins.

The Diabetes liga has about 18.000 members (patients) and 1600 professional members (endocrinologists, dieticians, GPs,…).

The prevalence of diabetes (diagnosed + undiagnosed people) is estimated to be 5,4- 6,3% in Belgium (on a population of 11 million people) of which about 40.000 are type 1 diabetes patients. Or, more concrete, about 570.000 people bought glucose lowering drugs (metformin) in 2015. So the numbers are much higher :wink: According to the International Diabetes Federation, about 7,4% of the Belgian healthcare budget goes to diabetes care. Globally it is estimated that about 12% of the healtcare budget goes to diabetes.

In fact the biggest cost are the diabetes complications. Type 2 diabetes is a sneaky disease, because in the beginning it does not affect your life that much, you’ll be less inclined to watch your diet and your life style in general, which in turn enhances the chances for complications. These complications are very costly. For instance foot amputations (cost 25-60k), cardiovascular diseases, terminal kidney disease, blindness,… Complications can be delayed or even avoided by life style changes.

While we’re on the statistics, when comparing people with a lower socioeconomic status (SES) with people with a higher SES, at  the ages of 29-44, we see that people with a lower SES have a 3x higher chance of getting diabetes. There are also numbers about Moroccans and Turks in Belgium, the have 2 to 4 more chance of getting diabetes than autochthonous Belgians. Women have it worst, about 11,5%  of Moroccan women and 18,5 of Turkish women have diabetes.

So (culture sensitive) education is very important, especially in the lower SES portion of the population, but the Diabetes Liga, the government, has problems reaching these people. I really think that Ekoli could do some valuable work in this area.

People need reliable and understandble health information and there is a lot of garbage on the internet. Applying life style changes is not easy, but some studies show that introducing green areas in city districts, has a positive effect on the health of its inhabitants (now that’s preventive healtcare :wink: ).

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Thanks Guido @GLS9000 for the insights. Preventative medicine is indeed the logical path forward. This ties in with @Alberto 's post on Amish communities I only recently discovered.

A 20-40% decrease in cost is still pretty big at this scale, I didn’t stop to think about the absolute numbers.