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Scott Benner 0:00
Hello friends and welcome to Episode 1279 of the juicebox podcast.

On today's episode, Jenny and I, we talk about some stuff that we don't understand. Please don't forget that nothing you hear on the juicebox podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. I know that Facebook has a bad reputation, but please give the private Facebook group for the juicebox podcast, a healthy once over juicebox podcast, type one diabetes. If you're newly diagnosed, check out the bold beginnings series. Find it at juicebox podcast.com, up in the menu in the feature tab of the private Facebook group. Or go into the audio app you're listening in right now and search for juicebox podcast. Bold beginnings, this series is perfect for newly diagnosed people. When you place your first order for ag one, with my link, you'll get five free travel packs and a free year supply of vitamin D drink. Ag one.com/juice, box. You music.

This episode of The juicebox podcast is sponsored by cozy Earth. Cozy earth.com use the offer code juicebox at checkout to save 40% off of the clothing, towels, sheets, off of everything they have at cozy earth.com the episode you're about to listen to is sponsored by OmniPod and the OmniPod five. Learn more at omnipod.com/juice box. Use my links to support the show. This episode of The juicebox podcast is sponsored by the Eversense CGM, an implantable six month sensor. Is what you get with Eversense, but you get so much more exceptional and consistent accuracy over six months and distinct on body vibe alerts when you're high or low on body vibe alerts, you don't even know what that means. Do you ever sense? Cgm.com/juicebox,

Unknown Speaker 2:26
go find out.

Scott Benner 2:28
Jenny and I are doing something new together today. And while she was talking about what we were going to talk about, she got so passionate. I was like, Oh my God, wait. Let me turn the recording on. So Jenny, this is an episode of I don't understand, and I asked you to make a list of things diabetes related that you don't understand, and that could mean anything, right? We're going to do a number of these, so don't feel a lot of pressure. Your list will grow. But your first one was, what tell people what you don't

Jennifer Smith, CDE 2:55
understand? My first one is insulin shortage, right? And we've all, to some degree experience, some type of message coming from our pharmacy or our supply company that's like, you can't get your insulin right now. We are on a shortage, or it'll be around in a month. Check back with us and we'll send it to you, right I experienced it, but it seems to be over. My pharmacy has no issue sending my insulin. I still have people that I work with who are still worried about getting their insulin, because they've been told over and over, there's still a shortage going on. Humorously, saying to you, I'm like, I don't understand. How do we have a shortage, right? This is, this is made in a, let's call it a factory, right? That's kind of how I think about it. We're not, you know, worried about not having enough pig pancreas to grind up and, you know, get the insulin out of anymore. We're not doing that. So where is the shortage? And in my mind, it's clearly coming from some issue that's monetary. It's got to be driven by some monetary. Somebody's not getting enough because we've outsourced insulin production outside of the country and or to countries that aren't getting something back from something that was promised. Like this is where my brain goes with this. Like

Scott Benner 4:12
this is where your conspiracy theories

Unknown Speaker 4:15
jump to.

Jennifer Smith, CDE 4:16
How do we get an insulin shortage? Okay, when we've got plenty of chemicals to make the insulin. Yes, right. Okay,

Scott Benner 4:25
all right, so I'm going to, I'm going to go to chat, right? I actually am. So here's my first questions, where do pharmacies get insulin? Says pharmacies obtain insulin through a supply chain that involves several key players. One manufacturers. Insulin is produced by pharmaceutical companies such as Eli Lilly, novo, Nordisk Sanofi. These manufacturers create different forms of insulin, including rapid acting, long acting and intermediate acting varieties. Okay. Second, they get pharmacies, get insulin through wholesale distributors. Once the insulin is manufactured. Richard, it's sold to wholesale distributors. More pharmaceutical wholesalers in the US include companies like major excuse me, McKesson, AMERI, source Bergen and Cardinal Health. These wholesalers purchase large quantities of insulin from the manufacturers and distributed to the pharmacies. Okay, so the chain goes manufacturer, distributor, pharmacy. Then there's retail pharmacies, including chain pharmacies like CVS, Walgreens and Walmart, as well as independent pharmacies. Purchase insulin from the wholesaler. The pharmacies then dispense the insulin to patients based on prescription for Okay. Supply chain logistics. Throughout this process, the supply chain logistics involve ensuring the insulin is stored transported. So there's it's making the point that there's a lot that has to happen here for it to be stored properly and transported properly. Sure. And then Pharmacy Benefits managers and insurance companies often play a role in determining which insulin brands a formula formulations are covered. Okay, that doesn't have anything. Well, it does say it impacts what brands and formulations are covered under various health plans, influencing what pharmacies stock. So

Jennifer Smith, CDE 6:11
okay, and my understanding of the shortage was primarily shortage of vials. I understand that people were very, very able to get pens.

Scott Benner 6:23
Today's episode of The juicebox podcast is sponsored by OmniPod. And before I tell you about OmniPod, the device, I'd like to tell you about OmniPod, the company. I approached OmniPod in 2015 and asked them to buy an ad on a podcast that I hadn't even begun to make yet, because the podcast didn't have any listeners, all I could promise them was that I was going to try to help people living with type one diabetes, and that was enough for OmniPod. They bought their first ad, and I used that money to support myself while I was growing the juicebox podcast. You might even say that OmniPod is the firm foundation of the juicebox podcast, and it's actually the firm foundation of how my daughter manages her type one diabetes every day. Omnipod.com/juicebox whether you want the OmniPod five or the OmniPod dash, using my link, let's OmniPod know what a good decision they made in 2015 and continue to make to this day, OmniPod is easy to use, easy to fill, easy to wear. And I know that because my daughter has been wearing one every day since she was four years old, and she will be 20 this year, there is not enough time in an ad for me to tell you everything that I know about OmniPod. But please take a look omnipod.com/juicebox I think OmniPod could be a good friend to you, just like it has been to my daughter and my family. This is from a listener. Thank you for introducing me to cozy Earth for my birthday, I bought stuff to update my bed, sheets, comforter and a blanket. It honestly made our lives better. My husband and I used to have a conversation in quotes every single morning about who pulled the covers so far to their side, or how we were too hot or too cold. That never happens. Now, both of us sleep better and more comfortably, and don't get me started on the clothes you all should just try one piece. Use the offer code juicebox at checkout at cozy earth.com and you will, in fact, save 40% off of everything you put in that cart cozy earth.com use the offer code juice box at checkout.

Jennifer Smith, CDE 8:37
But the shortage was from a vial standpoint, which, for the majority of people who then use pumps, they're filling a pump from a vial. You're not filling it from an insulin pen. So therein, you know, lies the question of,

Speaker 1 8:53
I understand how it

Jennifer Smith, CDE 8:57
navigates through in production, but like a shortage in my brain is, oh, there just were not enough strawberries in the field to supply 20 people who wanted them. We only have enough for 10 people today because the strawberry genie came and couldn't do his job, right?

Scott Benner 9:16
So maybe it's files we're going to find out. And it says here, and by the way, I want to be clear for people, because this is a newer series. We did not look into this beforehand. This is us figuring it out right now. That's why Scott's reading online talking and I'm reading, okay, so let's back, like back engineer this if you live in a town where a lot of people work for a certain company, and that insurance company covers Humalog, and you work for a different company, and your insurance company covers, I don't know, Nova log, right, but you're the only one in town who gets Nova log, then maybe this pharmacy would stock less Nova log than Humalog, because the people in the so there's, there's a component to that. That I understand. But let's see, the recent insulin shortage has been primarily caused by a combination of manufacturing delays and an imbalance in supply and demand. Eli Lilly, one of the major producers of insulin, announced a temporary shortage of two of its products, 10 milliliter vials of Humalog and insulin list pro the shortage is expected to persist until at least the beginning of April 2024 so this is a thing that's happened in the past, and most people are cleared out now. This is why you hear somebody jump online. They're like, Hey, I went to the pharmacy and they told me there was an insulin shortage, right? Okay, now that's the first problem, you're listening to a 19 year old person who's working at Walgreens, and you're getting and you're like, oh my god, there's an insulin shortage. Becky told me, Becky was smoking weed behind the Walgreens 20 minutes before that. Just keep that in mind. Okay, as you're getting your your medical information from her, she's literally sitting there like, I want to go out and see a movie tonight, and she told you there's an insulin shortage, and now she knows

Jennifer Smith, CDE 11:04
nothing about it, other than what was written on the thing for her to tell customers. Now in the morning, she

Scott Benner 11:09
doesn't even understand the feelings in her own heart. Yet she's so young, okay? Or he doesn't matter to me, several factors contributed to this sort of shortage. Firstly, there was a brief delay in manufacturing at Eli Lilly. Additionally, the dynamic nature of insulin supply and demand has further complicated the situation leading to these products being out of stock at wholesalers and some pharmacies. So the pharmacy is telling you, I can't get the insulin, there's a shortage, but they mean they can't get it from their wholesaler. They don't know that. It means that the company hasn't gotten into the wholesaler. Not that that's probably not what happens. But do you know what I'm saying? Like, where? Where's the sticking point? Where's the break? Right? Yeah, this shortage has forced many patients to seek alternatives, such as switching to a different brand or type of insulin, which can be challenging due to insurance coverage and prior authorization requirements. Yeah? Because you'll hear people say all the time, like, well, just use this one. They all work the same. Yeah. Well, I'm, you know, I'm not buying crayons. Like, I can't just pick up the the cheap ones and go, I'll use these for a while. Like, right? Yeah, so you've got to, but that there is a pathway to that. Call your doctor. I can't get Humalog, etc. Can you write my script for this? I mean, but who knows? Like it is scary now,

Jennifer Smith, CDE 12:22
well, and the main reason, as you read, is manufacturing, right? So it starts with manufacturing. So then, yes, down the line, the consumer being the end of the line, the user is the one who sees the problem, whereas where is the manufacturing? But what did people not come to work. These are my big right? Did they lose a lot of employees? Did they not get paid? So they had to lay people off, and so now there's not enough people to make it, right? Manufacturing, I'm trying to

Scott Benner 12:54
find out right now. I asked our overlords, and I said, What was the manufacturing issue? Be more specific. Actually, I wrote Pacific, but it figured out what I meant, brief delay in manufacturing. Yeah. I mean supply constraints, wholesalers and pharmacies, Eli Lilly is actively working. Yeah, see now it's just getting to like press. Tell you

Jennifer Smith, CDE 13:16
only what Yeah, can tell you.

Scott Benner 13:18
Tell you what Eli Lilly said out loud is what it can tell you the situation has led to, yeah, okay, obviously, was it a vial shortage? Oh, it says yes. The recent insulin shortage involved a specific issue with the availability of the 10 milliliter vials. Eli Lilly reported that these particular vials would be temporarily out of stock due to a brief delay in manufacturing. This affected their supply chain. Yeah, well, I mean,

Jennifer Smith, CDE 13:44
like, isn't that right? So if you can not get vials as easily, but you can get pens, it's not the insulin in and of itself. Did they not were they not able to make enough glass to put the vial Right? Like, what is the what is the problem? I

Scott Benner 14:00
just asked Mike, how could we run out of glass vials, right? But it says raw material shortage. I mean, it's going over ways that could happen, capacity limitations, quality control issues, yeah, so there is that, right? There are times that these companies make stuff and they gotta trash it, you know, sure there's that you can get, you know, something's contaminated, or whatever they they'll blow out the whole run and throw it away. And

Jennifer Smith, CDE 14:25
understandably and thankfully, that they're looking at that for, obviously, something you're putting in your body.

Scott Benner 14:31
Yeah, no kidding. So, but what did you hear from people? Like, just, was it just, I can't get my and how long did it go on for? For

Jennifer Smith, CDE 14:39
quite a while? Like my personal was I had called for, I mean, I've got a pharmacy that ships to me, and so I do it all through my electronic medical record. I just say, hey, I need to refill my prescription. Yeah, they send it off to me. And so I actually got a physical phone call back from the pharmacist. She was like, you know, do you. Enough, are you okay? Or are you just refilling to keep up with your refills? And I said, I'm okay. I just want to keep up with my refills. And she was like, okay, because she said, right now we don't have your stuff. She said, we're looking at being able to have it within about a week, is what I was initially told. Well, it took about three weeks for me to finally get and some people it was longer than that. And that's where, you know, there are more questions than about that. Why were why were some people further delayed compared to other people? Why did some people not even know about it or not really have any issues? Was it because they had enough, and they just don't refill as often because they have enough supply at home. But it was from, I want to say, somewhere early April, definitely, through June. Yeah, I was still hearing issues in June, of people being very careful about their insulin because they were traveling with it and everything with insulation so that they didn't have to start up their reserve bottles and that kind of stuff.

Scott Benner 16:05
So I saw somebody recently online. There's a picture that says, What did it say? It was a little plastic like Tupperware container. Tupperware is not a real thing anymore, but you know what I mean? Like a little plastic container? God, how old am I? I'm like, I'm

Jennifer Smith, CDE 16:18
Tupperware parties. My

Scott Benner 16:19
mom had them. I'm referencing food storage devices that don't exist anymore. Oh, I must sound like my grandmother, okay, it said Armageddon insulin on it. Yes, I saw that, right? So whoever put that up? I thought that was brilliant. So basically, if they have insulin that dates out, they don't get rid of it. They stick it there in case the zombies come, because they can still give it a try. And I was like, Oh, right on. Never thought to do that. But I also don't throw away. I mean, I just use it up till it's gone.

Jennifer Smith, CDE 16:50
I think I last threw away, like my basal insulin, right? That I keep on hand, yeah, always refill it, you know, whenever it's expired or whatever. And I was cleaning out, maybe it was, I don't know, January or something, this year, and I came across a vial of my basal insulin that was like five years old. I could probably get rid of this one, because I have two more vials in here that are not used either.

Scott Benner 17:16
We just threw away, I'm not lying to we just threw away syringes that were, it was, my God, it was, I thought it was filled in 2014 the prescription. I was like, I don't think we're gonna use these. We can get rid of these. Hey, here's something interesting. I asked chat, G, P, t4, oh, have pharma companies been building more manufacturing for insulin and glps? Because I heard something about that. Oh, pharmaceutical companies are indeed ramping up their manufacturing capacities for insulin and GLP drugs to meet the growing demand. Eli Lilly has made a significant investment to expand its manufacturing capabilities. Recently, the company announced an additional $5.3 billion investment to build a massive manufacturing complex in Indiana, oh, aimed at producing active pharmaceutical ingredients for its diabetes and obesity drugs, including Manjaro and zepbom, the investment of Vi Oh, it sounds like they're just gonna sounds like they might just be doing it for this. But hold on a second. Novo Nordisk is significantly expanding its manufacturing capabilities of companies investing 2.3 billion to upgrade its production sites in Chartres, France, I've definitely mispronounced that, to increase capacity for current and future drugs, including jlps. Additionally, Novo Nordisk has allocated 6 billion to expand its manufacturing facilities in Denmark, focusing on increasing capacity for active pharmaceutical ingredients, including semaglutide. They're throwing a lot of money into glps, is what they're doing. Yeah, yeah. Eli Lilly has announced a $72 million investment to build out insulin manufacturing capacities at one of their facilities in Indianapolis. This is part of a broader $1.1 billion investment to expand and upgrade their US operations. Additionally, Lulu has earmarked 5.3 billion for a new manufacturing complex Indiana. We heard about that. So, yeah. So it looks like they're doing all that. Also, it says here a South Korean pharmaceutical company is investing $100 million to build an insulin manufacturing plant in West Virginia.

Unknown Speaker 19:26
Okay, interesting, that

Scott Benner 19:27
makes sense. The facility is aimed to produce insulin at a reasonable price for the diabetes population. Oh, I is this part of what's that nonprofit company making insulin. Hold on is the unit bio. That's what it was called. Story

Unknown Speaker 19:47
related to a low cost

Scott Benner 19:55
manual factoring company and. That's US based this is all me trying to say I can't remember the name of a they were on here. They came on here and did an interview with me.

God, why can't I think of what it's called? This is kind of, it's kind of wicked. So all right, yeah,

Jennifer Smith, CDE 20:20
I was looking up to it looks like

Unknown Speaker 20:23
civica. Yes, that's it. Thank

Scott Benner 20:24
you. Good job.

Jennifer Smith, CDE 20:26
Yeah, civica to manufacture and distribute affordable insulin because I remember I had gotten an article about

Scott Benner 20:32
it as well a while ago. Yeah, they were on here, long time ago. Also, I've been trying to reach out to the Mark Cuban company, but they're not getting back to me. Episode 675, how affordable insulin happened. Martin Van trice is the president and chief executive officer of civica. RX certificate is making affordable insulin. He's the one who mentioned West Virginia that stuck in my head, by the way, that I recorded that in 2022 in May, episode 675, he actually has stepped down since then. Oh, I think this was, you know how sometimes those guys who have had like, a ton of like, business success, they retire and they come back one more time and take like, another swing at something like the guy that set up the manufacturing for OmniPods in America. He was one of those guys. He worked for Pepsi manufacturing. He had retired, was playing golf, and they came and got him, and he set up all the manufacturing for OmniPod. Good dude. Chuck, very deep voice. Um, okay, do we have any other things outstanding about insulin supply that you didn't understand? No, all right, well, that was something Jenny didn't understand, yeah, and now we all understand much better. Yes,

Jennifer Smith, CDE 21:45
absolutely. So if it ever happens again, I'm assuming it will be something, I mean, did we really identify truly the manufacturing issue? No, no, we didn't, no, but because it's not disclosed, it's entirely they're not going to tell what the problem was, and that

Speaker 1 22:01
I find that the case with so many things

Scott Benner 22:06
like that. Well, you know what I always say when, when people are like, Oh my God, there's like, I did it last time. Did this happen? People like, there's an insulin shortage. Insulin shortage. Eli Lilly said that they're blah blah, and I came online, I said, Listen, if Eli Lilly is telling you what the problem is. It's already fixed. It's all right, right, yeah, you know, that's how think about how you hide from your parents or your spouse or stuff like you don't tell them about it when it's on fire afterwards go, My God, funniest story about when I was making my eggs this morning. The

Jennifer Smith, CDE 22:35
fire is out. Everything's fine. Yeah. I don't want to mention it

Scott Benner 22:39
while it was happening because I was embarrassed, but I mean, that's in the end, that's what companies do. They don't tell you anything till they know the answer. Today's podcast is sponsored by the Eversense CGM, boasting a six month sensor. The Eversense CGM offers you these key advantages, distinct on body vibe alerts when high or low a consistent and exceptional accuracy over a six month period, and you only need two sensors per year. No longer will you have to carry your CGM supplies with you. You won't have to be concerned about your adhesive not lasting, accidentally knocking off a sensor or wasting a sensor when you have to replace your transmitter. That's right. There's no more weekly or bi weekly hassles of sensor changes. Not the ever since CGM, it's implantable and it's accurate. Ever since cgm.com/juicebox, the ever since CGM is the first and only long term CGM, Eversense sits comfortably right under the skin in your upper arm, and it lasts way longer than any other CGM sensor. Never again will you have to worry about your sensor falling off before the end of its life. So if you want an incredibly accurate CGM that can't get knocked off and won't fall off, you're looking for the ever since CGM, ever since cgm.com/juicebox, and if you don't know that, you're not paying attention. So anyway, once they're telling you what the problem was, it's already taken care of.

Jennifer Smith, CDE 24:12
It's already but I do,

Scott Benner 24:14
I take your point though, like, I mean, if it's just like, we couldn't get the vials, or, you know, like the plant wasn't working. I don't know how that, like, how does it? I mean, the answer is humans, right? Like, it's always, that's always the answer.

Jennifer Smith, CDE 24:28
And the interesting thing is, it was across the board, in in both of the major Novolog and Humalog both had shortages.

Unknown Speaker 24:39
So being separate companies.

Scott Benner 24:44
Why were they getting something from the same price? Right?

Jennifer Smith, CDE 24:48
That's where there's something, something there that

Scott Benner 24:53
we're 20 minutes from Jenny, talking about the Illuminati. Hold on a second. There was, there's a recent shortage of Nova. Log products. The shortage included both flex pen and vials. The situation was due to intermittent back orders and manufacturing delays experienced by novo, the company reported that these supplies issues were expected to be resolved by December 2023 it says, despite shortage, actively producing and shipping insulin, I don't know like. What is it? It doesn't say like, and this thing only knows what it knows. You know what I mean, but Right, yeah, listen, if somebody from the pharma company wants to come on and explain how you suddenly don't have access to glass bottles, like, when I can buy them on Amazon, yo, I saw a lady. Can I tell you something that's got nothing to do with anything, but I'll end on this. Yeah, I saw a video of a lady, and she has type one, and she wants to use GLP medications, but she wants to micro dose it a little bit every day, right? And so, instead of taking, so, first of all, instead of, like, you know, getting a prescription for, I don't know, like, 2.4 milligrams a week. Ovi is, like a weight loss thing. She's got the, like, the mother of all, like pens, like, with, you know, a ton of milk milligrams, she puts, injects it into a bottle, mixes it with some hydrostatic something or other. Like, she's like, having a little project in her house, then drawing it up. She has a conversion chart for how to get the milliliters, the milligrams changed over to like insulin units, so she knows how much to use, and she's hitting herself from an insulin pen. She's every day she's given herself a little pop of it. And in

Jennifer Smith, CDE 26:32
no way is this medical advice we are not using to try to

Scott Benner 26:36
I watched it me, the guy who makes this podcast, was like, I don't know if you should be saying this out loud, but at the beginning, she said, This is not medical advice. And I thought, yeah, that's how I do it. But, um, but no kidding, Jenny, she's, she's like, I don't. She wasn't looking to lose weight, and she doesn't want to not be hungry. She just wanted a little bit of that, of that help with the the insulin resistance she was having. I was like, God damn, this is gonna happen one day. You know what I mean, although there isn't novo, hold on a second. Is Novo Nordisk working on a once daily GLP pill.

Unknown Speaker 27:16
I think I heard something about that. I think I heard something about that.

Scott Benner 27:23
And by the way, when you hear me say that, people are probably like always trying not to say where you heard something from. That's not true. I legitimately don't remember if I heard that or not. Risk is working on developing a once daily GLP one pill companies advancing with its phase three clinical trials for an oral version of semaglutide, a GL, 1p agonist. Okay, there the the oral formulation known as Robles and lower doses for diabetes treatment is being tested in higher doses for weight management, obesity treatment, the 50 milligram dose of oral semaglutide has shown promising results with significant weight loss outcomes in clinical trials, they've completed the phase three Oasis trial where the 50 milligram version of the oral semaglutide demonstrated an average weight loss of 17.4% over 68 weeks. I'll take that not bad with obesity without type two diabetes, that's obesity without type two the results are comparable to those achieved with their injectable like we covid. All right, cool. All right, Jenny, let's go find out what else you don't understand. Interesting.

Unknown Speaker 28:25
What else

Scott Benner 28:27
I don't understand? If you don't have something, there's plenty I don't understand.

Jennifer Smith, CDE 28:30
I understand the surface level. But again, this is more of a Go ahead in Jenny. In Jenny's world, everybody just get what they need to get, because they need it, right? And with type one diabetes, this is like most of what we use is in a way, life or death, especially insulin, right? Sure, products technology I get, but even with that life expectancy and all the things that we're working hard on blood sugar management for, we do better with more technology,

Unknown Speaker 29:04
right? Just has been the case. So my big

Jennifer Smith, CDE 29:07
issue is really with, why is insurance coverage such a crap shoot? Really, like, Why does one cover this? And, you know, I understand it has to do with contracts. And the companies come to the insurance and they're like, hey, we'll give you this and if you promote this product, and blah, blah, blah, blah, blah, but that is like, diabetes is not a one size fits all, and in a job like environment, you don't necessarily have a choice in insurance, right? You have to go with what they're offering you, or you can decline it and go to the marketplace and pay, like, exorbitantly more money, right? That's

Scott Benner 29:47
not a thing people can just do, right? Most people aren't going to say, oh, I'll just go pay cash for it. Don't worry about correct Exactly.

Jennifer Smith, CDE 29:53
And then the further you go with insurance coverage, it's like, once you get older and you are now in the. Medicare with type one diabetes. Do you know the hoops that people have to jump through in order to not only continue to get what their coverage is, but there's a defining time period of lab work has to be done within this like 30 day it has to be supplied in order to prove that you're still eligible to get these products. Like, why are we making this so hard? Why are we making it so that people have to do so much work just to get what they need when they're already doing so much work to just be healthy? You know what I mean I

Scott Benner 30:40
do this is, this is what I call your question on this one is, how do I explain this

Jennifer Smith, CDE 30:47
not really answerable? I

Scott Benner 30:48
know. No, no, no. It's, it comes from like a pure place. The question, yeah, I know what you said, Trust me, this is a question a 12 year old would ask. I don't know. Why is there war? Yeah? Right, yeah, I got you, don't worry. And there's nothing wrong with that. I don't mean 12 year old pejoratively. I mean a person who doesn't have the experience of being alive. And then we get into this idea that, like, you know, you know, they say people become more cynical as they get older. They'll say, like, liberal people get more conservatives, they get older. Like, that kind of stuff happens, right? And you start seeing the world work the way it works, and you think, well, that's just how things are. Like, we can't fight this, right? Like we were, you know, I told you that Arden, one of the questions Arden is gonna answer, or wants to have answered in her episode about I don't understand, is, I don't understand why there's only two political parties in America. Like, she's like, I wanna understand right there with her, right so like, and if you ask an adult in their 50s, they'll go, Oh, listen. And they'll give you some like, this is how it goes. This is what happens. But what they really mean is, is that people are trying to keep control of things. And when you have something you want to keep it makes sense. When you have something valuable you want to make money off. It makes sense, etc. I think that all applies right to this. Right? Like, this is just, this is, like, I have some stuff. I want more stuff. I want to keep my stuff. And so why can't, you know? So the the technical reasons, chat, GPD said, formulary, inclusion, cost and negotiations, clinical guidelines and efficacy contracts with manufacturers, patient demand or doctor recommendations, regulatory approvals, cost effectiveness, plan, specific policies, prior authorization requirements. These are the impacts on why some insurance companies cover a certain insulin pump and others don't cover that. And

Jennifer Smith, CDE 32:39
what is, what does it boil down to? What's the one word? Yeah, it boils down to, I mean,

Scott Benner 32:44
you're gonna say greed, I'm

Unknown Speaker 32:45
gonna say money. Okay, yeah,

Jennifer Smith, CDE 32:47
right. A lot it goes right along with greed. Really,

Scott Benner 32:50
I'm American. I don't see money as greed, but I hear what you're saying. So, like, I so here's what in my mind. The way I think of it is, there's a bunch of companies. They all make an insulin pump, for example, or they all make a glucagon, or they all make, right, you know, a CGM, or whatever. Like, there's a group of companies making a certain thing, and it kind of does fall back to Jenny's other I don't understand. Question is, like, why doesn't, why isn't there just one pump that does the best stuff that all the pumps do, which is, like, right on, you know what I mean? But the reasoning is, is that somebody dreamt up a tubeless pump. Actually, I had the guy on here one day, if you want to look for the episode called the pod father, I think this guy just dreams up a tubeless insulin pump. Well, the next thing they do when they dream it up is they patent the living hell out of it, right? So, like, you ever watch Shark Tank, and someone in a shark tank.

Jennifer Smith, CDE 33:41
I have seen it. I don't watch it very regularly, but I've seen it. One of

Scott Benner 33:45
the guys will ask every time, what's special about your product? Meaning, what can we patent about it? Because if there's nothing special about it, then you're gonna have this great idea. You're gonna start selling it. Everyone's gonna knock it off, and we're not gonna be able to make any money. Make money, right? Right? So they patent their tubeless nature, or they patent their algorithm for something, and then another company would come along and say, hey, well, we do this really well, you know, company B does something well, that company A doesn't do. If we could just combine what a does with B, my God, this thing would be way better, except we can't, because they patented it already, and we can't copy it. Do you know that the company TiVo? Do you know what that is? Tivo was like one of the first third party DVR services? Oh, yes. TiVo, yes. Uh huh. Tivo patented their something in their software, something like a season pass. So you could, I know I'm right about this, and if I'm wrong about it, I'm just the guy talking on the internet. Leave me alone. But they patented the Season Pass, which was this thing where you could go into your menu, go, Oh, here's Shark Tank, click, give me a season pass. And I would like the Season Pass to record every new episode, or I'd like it to even record the reruns you. Know, now playing, I think they called it. There was this massive list of Shark Tank episodes. They patented the Season Pass. And so the like companies like Comcast, who were making their own DVRs, couldn't give that functionality in their software, and that functionality is what makes the DVR fantastic. Like, isn't that crazy? That, right? That's insane, but that's how it works. And so if I have that story a little wrong, forgive me, but I have, I have trust of any, I have a lot of it right. Like, so why can't the insurance company here ready? We're gonna bring this whole thought around. So why can't, I don't know, Blue Cross and another company both offer me the mini med like, why can I get, like, OmniPod from them, but I can't get, I can't get Medtronic from them. That's where you get. One is

Jennifer Smith, CDE 35:49
covered better. One is covered at, like, almost 100% but yes, you can do this one, but it's not in the network, or whatever they call it, and so you're only going to get 50% coverage versus if you go with the approved product, then you get full coverage. Who I Am. Have you lived with me? Do you understand my that's where my real problem with this is, they're they're screwing with people's individual life of need and not understanding.

Unknown Speaker 36:21
They just don't understand, that's it. Yeah, yeah.

Scott Benner 36:25
They say to you, look, we're gonna pay full 100% for tandem. And you go, but I really wanted a tubeless pump. And they go, that's fine. We'll pay 70% of that. And you go, I can't afford the other 30% and they go, getting a tandem pump that is set up by the companies. Oh, absolutely right. Because when you absolutely listen, every time you hear, like, something news coming out, and you're like, oh my god, when's it coming? Why is it taking so long? You know, it takes the longest is them making their contracts with the insurance companies around the country? Yes, they are negotiating with insurance companies around the country and listen, do respect to them, if they can't sell the damn thing, then they just spent five years designing something that's going to put them out of business because they can't sell it. You know what I mean? So they've got to do what they've got to do within the system. So what's our question here? What's the real world, nitty gritty understanding of how formularies are set up. Tell me about the financial reasons behind why I can't get a certain pump product. Let's see if this let's see how devious this thing is. Also never type, shall we play a game into this? Oh, just in case you never saw war games. Jenny, Have you never seen the movie War Games, the 1980s film, war games with Matthew Broderick?

Unknown Speaker 37:51
No, although I'm sure my husband is a big guy down right? He has, yeah, no, I

Jennifer Smith, CDE 37:55
have never seen that. We'll do that

Scott Benner 37:57
at the end to see what happens. See if we can start thermonuclear war with chat GP, they probably can't, oh, that's what. That's how it started in the game. He sat down, he's like, shall we play a game? And then the game was like nuclear war, except it started anyway, war games. Check it out. Check it out. Yes. Formulary setup is complex process driven by both clinical and financial considerations. Here's a breakdown of how it works key players in the formulary decisions pharmacy and therapeutics committee. The committee is usually composed of healthcare professionals such as doctors, pharmacists and nurses, and they review and evaluate clinical data on new and existing drugs and medical devices. Their primary goal is to ensure the formulary includes effective and safe treatments that's going to be the other thing is that all these companies put out their data, it all matches up pretty well. So to them, it's a wash this pump or that pump. You're going to end up with an A, 1c about like this says the data right, right, but you're saying I might want a tube, or I might want not a tube,

Jennifer Smith, CDE 38:56
and or I might have skin issues that don't allow me to use a particular tubed pump or non tubed pump, or a particular cannula, or a particular CGM, and you've done everything you can to use it, because that's what you can use. And you do better with the other product that isn't approved, like it's such a and then the hoops you have to jump around, your doctor has to write letters, your doctor has to prove the case that you need this one versus this one. You have to prove that you're having, you know, hypo one awareness in order to get this product versus that. Like it's it's mind boggling. Yeah,

Scott Benner 39:32
and you need to do all that, because if you just took everybody at their word, everybody would just lie to get the thing they wanted. We'd be right back. And by the way, I wouldn't blame them if they did. Also, most of those letters that your doctors are writing are horses and like. So again, it's just, it's true. It's just, of course, it's true. It's adding a layer of complexity to knock out the people who won't fight the fight the whole way. It's it's just like when, whenever you turn anything into insurance, the first thing they do is deny it. You. It's because some people will pay and some people will call back, but most people will just pay. So, you know, they tell you, you can't have that pump. Most people go, okay, and that's the end of it. And some will fight, what do I do? And the doctor's like, Oh, we got to write a note of medical necessity. What does that mean? And what that what that means is the doctor's like, well, that means I sit down and I write up some that I know that they're gonna accept, and I'll say it about you, and then that becomes healthcare, right? Yeah? Like it's all just that pharmaceutical benefits managers PBMs are third party administrators of prescription drug programs for insurance companies. They negotiate with drug manufacturers and pharmacies to manage drug benefits and controls. There is an entire 10 year podcast about PBMs to be had. If somebody, you know how often I was willing to talk to you, I go online all the time. Hi, I'm looking for somebody who used to work at a PBM. Not going to get anybody, because they probably signed an NDA when they left with their fat, you know, stock options and Okay, negotiations and rebates, rebates, another part of, by the way, all this that nobody really understands, even the people are involved in it. Manufacturers often provide rebates to PBMs and insurance companies in exchange for favorable formulary placement. A rebate is a discount. Oh, I know what a rebate is off the list price of a drug or device that is paid to the insurer after the purchase. These rebates can significantly influence which products are included in the formula. So your insurance company is like, look, Jenny needs insulin. She can take any of these. If Company B is going to send me a rebate and I'm going to save when I pay for a vial of insulin, and I can still charge Jenny the same amount for it. Well, then this is the insulin Jenny's getting because it's cheaper for me the insurance company, which is something set up by the pharmacy benefits managers,

Jennifer Smith, CDE 41:46
who gets a lot of money, yeah, the job that they're doing, yeah, a lot of money. Yeah.

Scott Benner 41:53
Hold on a second. Tell me about the people who own PBMs. Are they wealthy? What island do they own that they're flying in on a rocket to? Kind of jets do they fly in? Pharmacy Benefits managers? This is going to get me killed, by the way, if I disappear. You guys know what happened? I don't know. He got hit by four cars, they'll come to me next that he fell down them stairs and then his body, yes, the question. His body landed on top of a lady with diabetes in Wisconsin, killed her instantly. Health CVS Caremark is a fortune 500 company with significant revenues in its pharmacy and health care services. As of 2023 CVS Health reported revenues exceeding $300 billion now there's what you can't get your insulin Express Scripts. Cigna Corporation acquired Express Scripts in 2018 they are a major player in the healthcare industry with revenues of approximately 174 billion. The acquisition of Express Express Scripts for 67 billion significantly boosted its PBM operations. They paid 67 billion for Express Scripts, and now it's worth 174 optimum RX. United Health Group is the largest health insurer in the United States, with revenues suppressing 350 billion. Humana is a major health insurer with revenues of over 90 billion. Its PBM operations contribute significantly to overall business and primed therapeutics owned by a coalition of Blue Cross and Blue Shield plans. Wait a minute. The insurance company can own the PBM. Okay, hold on a second. While smaller than some other competitors, Prime Therapeutics manages billions in drugs spend for its BCBS affiliates. Hey, by the way, if any of these companies don't like this, talk to chat. GPT, not me. I'm just reading the internet. You're just reading it. Absolutely wealth of PBM executives. Meanwhile, we

Jennifer Smith, CDE 43:51
have teachers who can barely afford to, you know, drive a car to get to work and teach the children what they need to learn. This is what's happening.

Scott Benner 44:01
Top executives at PBMs and their parent companies often receive substantial compensation packages, including salaries, bonuses, stock options and other incentives. I want to jump in here and say I'm okay with people making money. Okay? Like, like, yeah. But

Speaker 1 44:14
Jenny makes a point. It's a simple point. If you have type one

Scott Benner 44:19
diabetes, you ought to be able to get the pump you want. You ought to be able to get the insulin that works best for you, and the CGM in the end, it's a bunch of plastic with some wires inside of it, or not, and it comes from just what's the point.

Jennifer Smith, CDE 44:31
You make billions anyway. So just sign the paper that says, anybody who has type one or type two, or, you know, diabetes, you can have the system that you need to have if you have insurance coverage plan. This is what your these are your options you choose. I'm going

Scott Benner 44:46
to tell you, I'm going to leave this lady's name out, but in 2022 the CEO of CVS Health earned a 20 million in total compensation, right? Yeah, come on now listen. I want to say this. This is going to sound like I'm if. If this person or made $5 million in total compensation, and we had 15 million left over and we divvied it up between everybody with diabetes, you'd all get 18 cents. So like, that's not where the problem her making $20 million I mean, is Jesus Christ. That's a lot of company to make it a year. But that's not, that's not the problem. The problems up here with the $350 billion made, or 174 billion. Because if you add these up, by the way, it's 300 billion, 174 and 350 that's three companies. Then there's 90, and then Blue Cross isn't listed. But what we're talking about here is just the ones that it listed. Please add up 300 billion, 174 billion, 350

Speaker 1 45:48
billion and 90 billion. The total is $914 billion okay, $914 billion

Scott Benner 45:54
with A, B, by the way, that's what chat, G, P, t4, point it sounds like, if you let it my boil down

Jennifer Smith, CDE 45:59
to this is if you and your company and all of minions that are within this, right? I don't understand what the problem is. Just signing the paper that says, Look, give them what they want. I don't. That's where I have a really hard time with you're going to make money regardless. Can't

Scott Benner 46:20
they make this money? And let you decide between libre and Dexcom, and ever since, yeah, right, right, right, there's the human part. That's what I was talking about the beginning, right? The like, I got it, I want it. I need to keep

Jennifer Smith, CDE 46:32
it like they don't manage one of these companies. Yeah, chicken company would

Scott Benner 46:36
be broken. None of you would have a Dexcom. Then she'd be like, what happened? She's like, I just gave them to everybody. We don't have any money, and we closed so I think that is the other side of it, is that, listen, these companies, they employ probably countless people. Those people have children, those some of those people, and some of those children probably have type one diabetes. Like, you know what I mean? Like, it's, it's not as clear cut as all that. But I do wonder why a company couldn't sit down and say, Is there not a way we could all, like, we can collude to take money from people? Like, could we not collude to, like, make sure everybody gets what they want but they need? But they might tell you, it doesn't matter. Like, what if that happened? What if they sat in room and said, Listen, here's the list of you know, what we see with people who, you know, have type one diabetes. This percentage of people don't have good health, health outcomes. No matter what we do for them, we can't seem to figure it out. And this like, what if the answer is, the chips fall where they fall. They're gonna fall there no matter what. At least I have a boat like that would be horrifying. But I'd love to have that conversation with somebody who would be interested in just being honest and and say, like, look, we we've tried this, we've tried that, we tried this. It don't work. Because, I mean, I know people who work inside of big companies, and it's difficult to make anything happen. It is, you know, it's incredibly difficult to make anything happen. You can say, well, it's on the people, or it's on the leadership, but it's not. None of it's that easy. Sometimes you build this thing and it gets so big, it's controlling itself almost, you know what I mean, and then there are bad actors inside of it sometimes, and good actors, and they spend a career fighting against each other and getting absolutely nowhere. So I don't know, but I think if I had $20 million I'd be happier. I just want to say that I'm pretty sure, I'm sure I would think I'd be I

Jennifer Smith, CDE 48:25
can imagine all of the things to do with $20 million none of them involving my own yacht or my own plane, like, right? I just that's, I don't know. I have no desire for that kind of stuff. Even if I had the money, I can think of many other things that I would do with that amount of money that are serving

Scott Benner 48:47
every wealthy person says that at some point the numbers meaningless. And that number, by the way, is lower than you think. It is an amount of money that you would live your life happily with. It's less than you think it would be, and that's even more upsetting, because that means that somebody's got, you know, somebody's living a great life off of a million dollars a year, let's say, and the other 19 is sitting in a pile somewhere that's going to eventually get taxed to death, and then go to one of their kids and turn their kid into a heroin addict, because they don't have to work, and then they'll have three Other heroin addicts, and then before you know it happens, I don't know what to tell you, like, this is what happens. My

Jennifer Smith, CDE 49:26
thoughts always go the other direction they go. They could do this, and they could teach their children to be good people. That's if it works out. Financial influences

Scott Benner 49:33
and market power. PBMs wield substantial market power, negotiating prices with pharmaceutical manufacturers and pharmacies. These influences can lead to significant can lead to significant financial gains for their owners and executives. The consolidation of PBMs has also led to increased profitability as larger entities can negotiate better terms and achieve greater economies of scale. Here's from chatgpt, criticism and regulation, the wealth and influence of PBMs has attracted. Did scrutiny and criticism. Critics argue that PBMs contribute to higher drug prices and lack of transparency in their pricing and rebate practices. This has led to calls for increased regulation oversight to ensure fair practices. Blah, blah, blah, I'll tell you this, I have had some of the best conversations of my life with chat GPT four. Oh, you could sit down and ask it anything, and you get back more information than you would get if you sit down with people sometimes. Sure, it's interesting, because

Jennifer Smith, CDE 50:28
it has such a wide reach to pull from access it, right? It's just got access to. It's like having the entire encyclopedia Britannica in your head and just being able to snap out, yeah.

Scott Benner 50:42
Now also I asked it a slanted question. It did source, by the way, it sourced CVS, health annual report, sickness, financials, United Health Group, financials, Humana, Prime Therapeutics and CV, they actually did all this. So let's say this like would what you told me change, if the tone of my question changed, meaning, what if I asked if this system is necessary To make sure Americans have the supplies they need.

Unknown Speaker 51:23
Or is that a false equivalence?

Jennifer Smith, CDE 51:29
I'm amazed at the length of the question that you can give it, that it filters it well you can,

Scott Benner 51:38
it's amazing. Jenny, I can drop in, I could drop in a transcript right now of any conversation you and I had, and say, Give me the key takeaways of this. You'll read them, and it'll sound like you and I are talking to each other, and it's, it's in, kind of like a bullet point boiled down and beautiful or explained out. Depends on if you want arguments for the necessity of PBMs negotiating discounts. PBMs negotiate discounts with rebates with drug manufacturers. That's from a diatribe article formulary management. PBMs develop and manage formularies to ensure that effectiveness medications, blah, blah, blah are lowest possible cost. Claims processing, PBMs handle the complex process of claims, education, adjunction during the prescriptions are processed accurately and effective. Well, that seems like we made a big mess, and now somebody has to learn how to like weed through the mess. Yeah. Cost control measures, pharmacy networks. PBMs create pharmacy networks to provide patients with access to medications nationwide by negotiating contracts with pharmacies. PBMs ensure the patients can get their prescriptions filled conveniently. Criticisms opaque pricing practices. Critics argue that PBMs often operate with a lack of transparency. I mean, I would, if I was making three, $50 billion I'd be like, I don't think anybody needs to know what's happening over here, right? Making it difficult to understand how much of the rebates and discounts actually versus go to the patients versus the PBMs, and that that the opacity can lead to higher out of pocket costs for patients, rebate structures, systems can incentivize PBMs to favor higher cost drugs that often that offer larger rebates rather than cheaper or equally effective alternatives, potentially driving up overall health costs. The consolidation of PBMs has led to a few large companies dominating the market. I think we can all agree that that mostly doesn't end well for us. Impact on pharmacies. Independent pharmacies often struggle with reimbursement rates set by PBMs because they don't sell as much, I guess so. If you cut undercut them, they're gonna and by the way, I go to a I go to a private pharmacy, just like some nice man who started a pharmacy, started a

Jennifer Smith, CDE 53:43
pharmacy. Yeah, I actually get my products a lot less expensive going through the pharmacy that I am, comparative to where I used to get them. Yeah,

Scott Benner 53:54
now I, by the way, they calls me, Hey, your thing's ready. Come on over. Blah, blah, very nice. Like you're not rushing around notification,

Jennifer Smith, CDE 54:00
I get like a text notification, ready? You're ready for refills? You could say, yes. What do you need to refill? This, this and this, great. It'll be sent to you. Are you sure you still live at this address? Yep, sales job. Jenny,

Scott Benner 54:12
by the way, that's a sales job. They got your drugs that you need them. This conclusion is very clear. The PBM systems play a crucial role in managing drug benefits and controlling costs within the US healthcare system. However, it is not without significant criticism regarding transparency, market power and the true cost savings benefits to patients. Whether PBMs are the best or only way to ensure Americans have access to necessary medications, is a subject of ongoing debate with alternative models and regulatory reforms being actively discussed as pens, potential improvements again,

Unknown Speaker 54:44
unless we all pull up

Scott Benner 54:46
$950 billion and hire some people to go down to DC and lobby for us, I don't think it's going to change that much. Right? That's the answer to your question of, how come I can't just have that now, if you want to ask another day, why? Like, can I have a tubeless pump that uses that algorithm instead of this algorithm, and it does this instead of that? Blah, blah, blah, that answer is patents. So, oh, 100% you know, getting around that, yeah, and those companies deserve, you know, they deserve to make money off their idea. But correct

Jennifer Smith, CDE 55:16
and their ideas are valuable for the people that they meet the need for absolutely, I don't disagree with you know, your own ideas being something that could benefit this person versus that person at all. It's great to have choice. It's great to have all the choices that we really do. I just wish that we had the choice to truly make. I want to pick this just covered. It's

Scott Benner 55:43
just another thing Jenny doesn't understand. I understand question. So Jennifer, you do me a favor and you keep making that list of things you don't understand. And we're going to do this for a little bit this summer. Is that okay? That sounds fun? Yeah, you had a good time. Scott reads. The Internet. Was good for you. Perfect. It was beautiful. All right, I know you have a thing to do. Go ahead and do it. I'll

Jennifer Smith, CDE 56:01
say I do. Thank you. Okay, bye. I

Scott Benner 56:07
want to thank the ever since CGM for sponsoring this episode of The juicebox podcast, and invite you to go to ever since cgm.com/juicebox to learn more about this terrific device, you can head over now and just absorb everything that the website has to offer. And that way you'll know if ever since feels right for you, ever since cgm.com/juice box. If you'd like to wear the same insulin pump that Arden does, all you have to do is go to omnipod.com/juice box. That's it. Head over now and get started today, and you'll be wearing the same tubeless insulin pump that Arden has been wearing since she was four years old. Huge thanks to cozy Earth for sponsoring this episode of The juicebox podcast. Cozy earth.com use the offer code juicebox at checkout to save 40% off of your entire order. Are you starting to see patterns? But you can't quite make sense of them. You're like, Oh, if I bolus here, this happens, but I don't know what to do. Should I put in a little less? A little more? If you're starting to have those thoughts, you're starting to think this isn't going the way the doctor said it would. I think I see something here, but I can't be sure. Once you're having those thoughts, you're ready for the diabetes Pro Tip series from the juicebox podcast. It begins at Episode 1000 you can also find it at juicebox podcast.com up in the menu, and you can find a list in the private Facebook group. Just check right under the featured tab at the top, it'll show you lists of a ton of stuff, including the Pro Tip series, which runs from episode 1000 to 1025 okay, well, here we are at the end of the episode. You're still with me. Thank you. I really do appreciate that. What else could you do for me? Why don't you tell a friend about the show or leave a five star review? Maybe you could make sure you're following or subscribed in your podcast app, go to YouTube and follow me or Instagram. Tik Tok. Oh gosh, here's one. Make sure you're following the podcast in the private Facebook group, as well as the public Facebook page you don't want to miss. Please do not know about the private group. You have to join the private group as of this recording, it has 51,000 members in it. They're active, talking about diabetes, whatever you need to know, there's a conversation happening in there right now, and I'm there all the time. Tag me. I'll say, hi, hey. What's up, everybody? If you've noticed that the podcast sounds better, and you're thinking like, how does that happen? What you're hearing is Rob at wrong way recording doing his magic to these files. So if you want him to do his magic to you wrong way recording.com you got a podcast. You want somebody to edit it. You

Unknown Speaker 58:47
want rob you.