Smerconish: A toehold on the confusing world of pharma pricing

I'm about to violate my own HIPAA protections to illustrate the illogical nature of health-care costs.

I have toenail fungus on one toe. Right foot, middle toe. Gross, I know.

I never did anything about it until a routine visit to the dermatologist last year. When she saw that nasty dawg, she told me there were meds that could fix it.

My doctor then handed me a prescription for Jublia (efinaconazole), made by Valeant Pharmaceuticals, and a coupon to be redeemed at a particular pharmacy. Without the coupon, she told me, the cost would be huge.

The national pharmacy specified in the coupon is not near my house, so I went to my usual, local pharmacy, to no avail. They couldn't honor the coupon, and without it, said the cost would be several hundred dollars for a tiny, four-milliliter vial. Instead, after a 20-minute drive to the national pharmacy, I paid nothing. The receipt said the "retail price" was $648.09. I'd sooner give up the toe than pay six bills.

But price didn't matter to me. All that mattered is that I wasn't paying, somebody else was.

Which is often the lack-of-control issue with insurance generally, but medicine in particular. We worry about our out-of-pocket expenses, but not about the overall costs where we are not personally on the hook. And despite its name, the Affordable Care Act never did control these costs.

As Steven Brill brilliantly illustrated in his book America's Bitter Pill, the ACA was all about who pays, not how much. Hence the stories about spikes in drug prices are legendary. Last month came the report that the price for Evzio, an injectable drug that contains naloxone and is used as an antidote to opioid overdoses, has jumped from $690 in 2014 to now, $4,500.

And, of course, there was Daraprim, the drug that treats parasitic infection, which in 2015 jumped from $13.59 to $750 after being acquired by a former hedge-fund manager. That CEO, Martin Shkreli, is no longer with the company and today the price has settled at about $375. President Trump was right when he recently told pharmaceutical executives he'd summoned to the White House that "the pricing has been astronomical."

But back to my toe.

The good news is that Jublia really works, and I wanted a refill. (I'll leave for another day that a different medication, Ciclopirox, is only 4 percent less effective but 30 times less expensive.) The first time there was no issue. I returned to the national pharmacy identified in my coupon, and paid nothing. But when I tried to get another refill, I was told there'd been a change in my coverage. My insurer was no longer honoring the coupon deal.

The denial letter said that Jublia does not meet the medical-necessity criteria outlined in the pharmacy policy titled "onychomycosis agents," and I lacked documentation that "condition is causing debility or a disruption in their activities of daily living." True that.

At the pharmacy they said that if I wanted more of the topical solution, I'd have to pay $125 out of pocket. Why that amount? I had no idea, but now, for the first time, I was interested in the economics of my minor treatment.

When I called the manufacturer, I was told that the "actual" cost of Jublia is $620.65 and that in filling my initial two scripts, I had insurance coverage for all but a $40 co-pay. I pointed out that I didn't remember paying $40. That's right, I was told, Valeant paid. Hmmmm.

I could only conclude that Valeant was willing to eat the $40 co-pay because somewhere between $580 and $600 was being paid by my insurance company, or the insurance company was getting a write-down on the retail cost. Either way, with my toe now nearly clear, I was invested in finishing this treatment, so I coughed up the $125 and walked out of the pharmacy.

So, who paid the balance, which I was told was $495.65? Valeant!

In other words, they were willing to sell the medication where my insurer was paying $600 or some lesser negotiated price, and equally willing to sell it directly to me for $125. Perhaps that willingness is reflective of the need to recoup the cost of bringing the medication to market - the Tufts Center for the Study of Drug Development reports the cost to be, on average, $2.6 billion.

The cost of medicine today is often fungible, and the end user has very little skin in the game, pun intended. For many, these issues are life and death. Lucky for me, thus far it's only involved one toe.

Michael Smerconish can be heard 9 a.m. to noon on SiriusXM's POTUS Channel 124. He hosts "Smerconish" at 9 a.m. Saturdays on CNN.