By Frieda Wiley

Treating chronic illnesses usually saves lives. However, when that condition lacks a billing code, seeking treatment can become a death sentence. At least that’s what doctors told Amber Freed, a 43-year-old mother of two who learned that something seemingly as trivial as a billing code could become a life-or-death situation.

It all began shortly after Freed gave birth to fraternal twins Maxwell and Riley in March 2017. The newly found joys of motherhood quickly transformed into fear after she observed marked differences between her two children’s developmental progression.

“I noticed Riley was advancing faster than Maxwell,” she said, “[Maxwell] had strange movements, his eyes were open, and he didn’t know his name,” she recalls.

He also felt different in her arms. “He felt floppy to me compared to Riley.”

Freed could easily fill Riley’s baby book with fun memories and important milestones. Meanwhile, Maxwell’s book lacked a similar narrative and remained largely empty.

Maternal instincts trump a doctor’s experience

Worried, the new mother took her son to his pediatrician, who immediately dismissed her concerns. He assured her Maxwell was progressing normally, telling her that girls develop faster than boys. Still, Freed could not shake the feeling that something was wrong. Her gnawing gut instinct prompted her to schedule an appointment at the Children’s Hospital in Denver, Colorado, where the family lived. There, Maxwell saw a variety of specialists, including an ophthalmologist who gave Freed some startling news after conducting an eye exam on Maxwell.

“His eyes are fine, but I think you should be prepared for him not to live,” he told her.

Completely floored, Freed asked the doctor what he had seen in the exam.

“I saw nothing,” the doctor reiterated. “However, I see parents like you all day long searching for answers and thinking something’s wrong with their kids’ eyes when it’s really their brain.”

Her greatest fears now confirmed, Freed struggled to maintain her composure as she prepared to take her son in for additional testing.

The ophthalmologist’s feedback eventually led to a diagnosis she could never have fathomed. Maxwell had an SLC6A1 mutation that causes epilepsy—a condition so rare it had no name, let alone a cure. Lacking a moniker also meant limited funding for research or other supportive services.

In addition to many of these conditions being incurable or lacking sufficient treatments, patients and their families often struggle to pay for treatments at times because no International Classification of Diseases (ICD) codes have been developed for the conditions they face. The World Health Organization has ownership of the ICD codes, which are designed to track morbidity and mortality data. However, the U.S. health insurance industry has commercialized the codes by using them for billing and payment.

As Freed would soon learn, securing medical treatment for the kind of rare disease Maxwell had would prove quite challenging in the U.S. Rare conditions such as Tay-Sachs disease, hereditary hemochromatosis, Wilson’s disease, and cystic fibrosis are all rare conditions with ICD codes recognized by insurance companies for coverage. Yet, these conditions may be more of the exception than the rule. In the U.S., many other diseases the lack billing codes that insurance companies would use to provide financial coverage and reimbursement. The void amplifies a climate where the privatized and commercialized insurance system fragments healthcare coverage as much as the lack of universally available medical records fractures continuity of care.

“If we were living in Europe, Maxwell’s treatment would be covered because of the nationalized medical systems they have there,” she said.

In addition to the rarity of her son’s condition decreasing the chances of insurance coverage, Freed made another startling discovery. Many billing codes covered seemingly bizarre and rare injuries. Yet not a single billing code acknowledged her son’s nameless condition in any way. Lacking a billing code meant insurance would neither pay for nor reimburse any treatment.

“It’s funny,” she said. “There’s an International Classification Code (ICD)-10 for being bitten by a goose, but there’s no code to treat my child for his condition.”

According to the ICD-10.CM, the code, known as W61.51XD, “describes the circumstance of the injury,” if a goose attacks a person. Goose-inflicted injury is one of many billing codes one might not expect to see listed. Other bizarre ICD-10 codes include Y93.J1, which covers neck injuries from playing the piano, and V97.21, which applies to a parachutist involved in an accident. Billing code V91.07XD addresses burns caused by water skiing and 16.V97.33XD describes a “subsequent encounter” of getting sucked into a jet engine. Curiously, Y92.146 describes a “swimming-pool of prison as the place of occurrence of the external cause.”

According to Jeffrey Linzer, Sr., MD, a pediatric emergency medicine physician representing the American Academy of Pediatrics, the origins of the seemingly bizarre billing codes stem from a very unlikely source: the U.S. Congress.

“Congress directed the Department of Defense to create a distinction between codes for the military versus non-military,” he told Inside Precision Medicine. “In fact, they recommended 10,000 codes.”

It’s all about the Benjamins

As incredulous as it sounds, Freed’s challenges are not unique. Many patients and families of people with rare diseases living in the U.S. face the same challenge.

The National Institutes of Health defines a rare disease as a disease affecting less than 200,000 people living in the U.S. However, rare diseases have a substantially greater collective impact, affecting 25–30 million U.S. residents. Despite the sizeable total population affected, the prognosis looks grim for most of these 10,000-plus rare diseases as only 500 of them have any type of treatment.^,

In addition, the few treatments available often prove far more expensive than the average cost of treating more common chronic conditions in the U.S. According to the U.S. Government Accountability Office, costs for treating rare diseases in the U.S. approached nearly $966 billion in 2019.

When a rare disease affects a child, parents and other caregivers must often assume the costs while juggling additional responsibilities of advocating for their patients and the disease itself while becoming both caregivers to the child and educators to medical professionals, the federal government, and other stakeholders. The arduous undertaking has a sizeable impact on the rare disease community as children account for 50% of people diagnosed with a rare disease.³ Disturbingly, three out of ten children diagnosed with a rare disease will die before their fifth birthday.

“The doctors told me, ‘You will become the expert’,” recalled Freed.

The growing list of insurmountable obstacles Freed faced became overwhelming. Doctors told Freed that she would likely have to give up her burgeoning career to devote herself full-time not only to her son’s care but to educating herself—and others—on the condition. She eventually resigned from her position as an equity and research analyst at a financial firm.

Freed’s fastidious search for solutions ultimately led to a partnership with a scientist to develop a gene therapy for her son, but the clinical trial was halted during the COVID-19 pandemic. In the interim, her son has been receiving injections of an off-label therapy called glycerol phenylbutyrate (Ravicti^®). While not a cure, it makes Maxwell’s signs and symptoms more manageable.

When the Food and Drug Administration first approved the drug for urea cycle disorder on February 1, 2013, its cost ranged between $250,000 and $290,000 annually. However, the price skyrocketed once doctors began prescribing it off-label to treat Maxwell’s condition. As of early 2024, glycerol phenylbutyrate ranks among the top ten most expensive therapies in the U.S., costing nearly $800,000 annually for its on-label indication.

Even the cheaper option doesn’t run cheap

“The effect of glycerol phenylbutyrate on children with SLC6A1 is compelling,” Zachary Grinspan, MD, a pediatric neurologist at Weill Cornell Medicine in New York City, told Inside Precision Medicine. “[However, the manufacturer], Horizon Therapeutics, did not pursue a new clinical indication, and Amgen’s strategy is unclear.”

Prescriptive authority allows Grinspan to prescribe glycerol phenylbutyrate, but it does not fill the void of the noticeably absent ICD-10 code from Maxwell’s medical charts. Insurance companies are less likely to cover a drug written for an off-label indication—especially for such a high-dollar drug.

In the meantime, Grinspan aims to get the drug listed in one of the U.S. four drug compendia (i.e., American Hospital Formulary Service-Drug Information [AHFS-DI], Micromedex DrugDEX [DrugDEX], National Comprehensive Cancer Network [NCCN] Drugs, and Biologics, Compendium, and Clinical Pharmacology) to help increase awareness of the drug.

Although a beneficial treatment, the positive effects of glycerol phenylbutyrate therapy wear off after about a year. Much like developing gene therapy for her son, Freed will continue facing the obstacle of footing the six-figure cost.

ICD-10: the rate-limiting step to treatment, access, and potential cures

Unlike many other developed countries with universal healthcare systems, the privatization of insurance contributes to soaring medical costs. This in turn often makes access to care and treatments cost-prohibitive. However, the federal government also plays a role in this narrative as they oversee the ICD-10 codes.

The Centers for Disease Control and Prevention (CDC) is responsible for tracking mortality and morbidity information at a national level and using the data to generate information on disease incidence and prevalence. The process is relatively simple for chronic diseases affecting the masses, such as hypertension or diabetes, as these conditions have ICD-10 codes.

The Centers for Medicaid and Medicare Services, commonly known as CMS, develops and maintains what is known as the International Classification of Diseases, 10^th, Revision, Procedure Coding System (ICD-10-PCS). The CMS classifies treatment for diseases, impairments, and injuries for patients who are hospitalized. However, the approval of coding changes and other changes to the ICD-10 coding systems is a collaborative process between the CMS and the CDC’s National Centers for Health Statistics through a body known as the ICD-10 Coordination and Maintenance Committee. This interdepartmental committee meets biannually and accepts modification suggestions from both the public and private sectors.

“There are only two opportunities to apply for the code, and your application may not even be reviewed given that there’s no formal process,” Freed said.

Could another rare disease change the game?

Although many rare diseases remain unassigned, the success of another rare disease may offer a blueprint for successful ICD-10 applications in the rare disease community.

According to data published in 2022, assigning Angelman syndrome an ICD-10 code on October 1, 2018, resulted in a significant uptick in adoption and uptake in the three years following its release. Billed under ICD-10 code Q93.51, a wide variety of clinicians, including pediatric neurologists, geneticists, and developmental-behavioral medicine specialists, now use this code. In addition, the top five healthcare organizations using the billing code gained prescribing privileges at major medical institutions in the U.S., including the Children’s Medical Center Dallas, the Cincinnati Children’s Hospital Medical Center- Community, and Massachusetts General Hospital.

The Angelman syndrome ICD-10 code assignment results give Grinspan hope for a potential strategy to overcome the ICD-10 code void for SLC6A1.

“For people with rare epilepsies, improving epidemiological estimates and clinical descriptions will guide clinical diagnosis and management, support research initiatives, spur pharmaceutical and medical device development, and help families understand these devastating diseases,” Grinspan said. “ICD-10 codes for specific rare epilepsies are foundational for that effort.”

Grinspan further elaborated that the statistical data captured by the CDC helps clinicians prioritize testing when working up new patients and conduct more thorough workups. This enhances their ability to comprehensively evaluate the patient. Robust data therefore enhances the physicians’ ability to diagnose a condition and forecast the patient’s prognosis.

In addition to the ICD-10 code, clinical trials, and funding, physicians need education to improve outcomes

Clinical trials could support treatment and provide more long-term data for diseases as ultra-rare as Maxwell’s. However, clinical trials in children with rare diseases often prove more complex as they require considerations transcending those typically seen in trials for adults. Parents and caregivers often face higher demands in managing the child, observing and helping the children report their signs and symptoms, and sometimes acting as key decision-makers when enrolling a child into a clinical trial.

Historically, commercial sponsors have been less likely to support clinical trials involving child participants than those involving adults. This trend further amplifies cost woes, as pediatric trials may require more study sites and accrue additional costs for coordination. In addition, clinical trials for rare diseases are typically underpowered due to difficulties in recruiting an ample number of participants.

Various other factors inflate the cost of pediatric clinical trials. For example, they may require more time to complete study procedures and specialized (and therefore pricier) laboratory equipment that can accommodate smaller-volume biological samples. Off-label prescribing of treatments occurs much more frequently in pediatric patients, shrinking potential incentives that might entice funders to finance drugs that are already approved for the adult population. These are just a few factors unique to the pediatric population contributing to the already hefty price tags associated with clinical trials.

Pediatric population aside, clinical trials are costly regardless of the number of enrollees or disease state. In addition to population-specific idiosyncrasies, the number of sites, the anticipated number of enrollees, and phases play a factor. Lastly, the cost of the type of therapy (i.e., small molecule versus large molecule, gene therapy, etc.) is a significant factor affecting the total cost.

According to Kimberly Goodspeed, MD, assistant professor in the departments of pediatrics, neurology, and psychiatry at UT Southwestern Medical Center in Dallas, small molecule clinical trials like one involving glycerol phenylbutyrate can range from $25 million to $50 million.

Trials investigating gene therapies cost significantly more.

“You can imagine if you could enroll multiple disorders into a blanket protocol for one multi-site clinical trial at $50 million versus doing ten disorders with individual protocols at $50 million per individual protocol, the costs can climb quickly—especially in the case of gene therapy,” said Goodspeed.

Even if clinical trials were not cost-prohibitive, there remains the clinician factor. From a practical standpoint, many physicians already feel overwhelmed by the need to memorize ICD-10 codes. As Linzer stated during on March 9, 2023, during the ICD-10 Coordination & Maintenance Committee Meeting led by CMS, committing countless ICD-10 codes to memory for each rare disease may not be plausible.

“We’re very sympathetic to [the cause], but that’s not the issue,” he told the audience. “Our concern is the number of potential patients and developing unique codes for a tiny group of patients.”

Linzer went on to cite situations where proposals for larger populations were denied, as examples.

“If this proposal was to move forward, we certainly have already expressed our disagreement with the expansion to the sixth character on the ‘under the epilepsy [category]’ … but we do have concerns about unique codes for very small patient populations,” he said. “We understand it’s helpful in the research and clinical areas, but it’s just an issue of how many codes can there be?”

In a separate interview with Inside Precision Medicine, Linzer stated that creating additional codes can create problems in data tracking. Problems arise when the medical community uncovers additional information about a condition that leads to code expansion. Because the original intent of the code is to track morbidity and mortality, the code cannot be deleted.

Now approaching his seventh birthday, Maxwell Freed has already beat the odds that claim nearly one-third of children with a rare disease succumbing to their condition before their fifth birthday. Yet, the battle is far from over, as his mother, and countless other parents, continue advocating for their children in search of Federal support and cures.

“Mothers can pull from a source of energy that doesn’t exist,” Freed said of her ongoing efforts. “You hold your baby and know there’s nothing you wouldn’t give.”

As of press time, Freed’s applications for an ICD-10 assigned to SLC6A1 have remained unsuccessful and she received her most recent rejection in early 2024. Meanwhile, her son’s life—and those of others—hang in the balance.

Her solution? “I’ve learned how to fight like a mother.”

A mother’s enduring love is unmatched, and mothers never give up.

Read more:

1. What We Do. The National Institutes of Health website. Accessed on February 25, 2024.
2. The Promise of Precision Medicine: Rare Diseases. The National Institutes of Health website. Accessed on February 28, 2024
3. Numbers: Rare Disease Facts. The Global Genes website. Accessed on February 28, 2024.
4. Rare Disease: Although Limited, available Evidence Suggests Medical and Other Costs Can Be Substantial. The U.S. Government Accountability Office website. Accessed on February 28, 2024.
5. Guha, M. Urea cycle disorder drug approved. Nat Biotechnol 31, 274 (2013).
6. “The 10 Most Expensive Drugs on the Market.” The Talk to Mira website. Accessed on February 28, 2024.
7. ICD-10 Coordination and Maintenance Committee. The Centers for Disease Control and Prevention website. Last reviewed October 17, 2022. Accessed on February 24, 2024.
8. Kamada’s Prism Healthcare Map. Prism 2022.
9. Kern SE. Challenges in conducting clinical trials in children: approaches for improving performance. Expert Rev Clin Pharmacol. 2009 Nov 1;2(6):609-617. doi: 10.1586/ecp.09.40. PMID: 20228942; PMCID: PMC2835973.
10. Institute of Medicine (US) Committee on Clinical Research Involving Children; Field MJ, Behrman RE, editors. Ethical Conduct of Clinical Research Involving Children. Washington (DC): National Academies Press (US); 2004. 2, The Necessity and Challenges of Clinical Research Involving Children.

Frieda Wiley, PharmD, is an award-winning medical writer, best-selling author, speaker, and pharmacist who has written for O, Oprah Magazine, the National Institutes of Health, American History, Pfizer, Merck, AstraZeneca, and many more notable organizations.

The post Fight Like a Mother: When an ICD-10 Code Determines Life or Death appeared first on Inside Precision Medicine.

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FDA Aims To Stifle Medical Innovation Again

By Ronald Bailey, Reason, April 2024.

Excerpt:

The Food and Drug Administration (FDA) that massively screwed up COVID-19 testing now wants to apply its vast bureaucratic acumen to all other laboratory developed tests (LDTs). By insisting on its recondite approval procedures, the FDA at the beginning of the pandemic stymied the rollout of COVID-19 tests developed by numerous academic and private laboratories. In contrast, public health authorities in South Korea greenlighted an effective COVID-19 test just one week (and many more in the weeks following) after asking representatives from 20 private medical companies to produce such tests.

LDTs are diagnostic in vitro tests for clinical use that are designed, manufactured, and performed by individual laboratories. They can diagnose illnesses and guide treatments by detecting relevant biomarkers in saliva, blood, or tissues; the tests can identify small molecules, proteins, RNA, DNA, cells, and pathogens. For example, some assess the risks of developing Alzheimer’s disease or guide the treatment of breast cancer.

The FDA now wants to regulate these tests as medical devices that must undergo premarket agency vetting before clinicians and patients are allowed to use them. The FDA estimates that between 600 and 2,400 laboratories currently offer as many as 40,000 to 160,000 tests. Overall, some 3.3 billion in vitro tests are administered to patients annually.

Wow! The FDA plans to be even more detructive of human health than it has been.

How Capitalism Beat Communism in Vietnam

by Rainer Zitelmann, Reason, May 2024.

Excerpts:

The reforms adopted in the next couple of years included permission for private manufacturers to employ up to 10 workers (later increased), abolition of internal customs checkpoints, elimination of the state foreign-trade monopoly, reduced restrictions on private enterprise, elimination of virtually all direct subsidies and price controls, separation of central banking from commercial banking, dismantling major elements of the central planning and price bureaucracies, the return of businesses in the South that had been nationalized in 1975 to their former owners or their relatives, and the return of land seized in the ’70s collectivization campaign if it was “illegally or arbitrarily appropriated.”

And:

Vietnam’s gross domestic product grew by 7.9 percent a year from 1990 to 1996, faster than any other Asian country but China. Poverty fell sharply. By the World Bank’s standard for extreme poverty—living on less than $1.90 a day—52.3 percent of the Vietnamese population was living in extreme poverty in 1993. By 2008, the figure had fallen to 14.1 percent. By 2020, it was only 1 percent. That indicator was developed for “low-income economies,” though, and Vietnam has now moved to the “lower-middle-income” category, where poverty is defined as living on less than $3.20 a day. By that measure, the poverty rate dropped from 79.7 percent to just 5 percent.

Israel announces largest West Bank land seizure since 1993 during Blinken visit

by Cate Brown, Washington Post, March 22, 2024.

Palestinians have little ability to stop the land transfers. After the 1967 war, Israel issued a military order that stopped the process of land registration across the West Bank. Now families lack the paperwork to prove that they have private ownership over their land. And tax records, the only other evidence of West Bank property rights, are not accepted by Israeli authorities.

In June, the Knesset waived a long-standing legal precedent that required the prime minister and the defense minister to sign off on West Bank settlement construction at every phase. Smotrich enjoys near-total control over construction planning and approvals in the West Bank, and approved a record number of settlements in 2023.

“Israel has reached the conclusion that they could get away with this huge land grab because of the lack of international action,” said Sarit Michaeli, international advocacy lead at B’Tselem. “There have been individual economic U.S. sanctions placed on violent settlers, but the greater violence of the occupation is this colossal land theft.”

Steven Pinker: What Went Wrong at Harvard

by Nick Gillespie, Reason, March 27. 2024.

Excerpts:

Pinker: The first of the five-point plan was just consistent commitment to academic freedom. Because another reason that Claudine Gay got into such trouble is that when she was given what admittedly was a kind of a trap that she walked into—that is, if students called for genocide against Jews, would that be prohibited by Harvard’s code of conduct—she made a pretty hardcore [American Civil Liberties Union]-style free speech argument, which came across as hollow or worse, because we’ve had a lecturer who was driven out of Harvard for saying there are two sexes.

There was another professor whose course was canceled because he wanted to explore how counterinsurgency techniques could be used against gang warfare. We had a professor in the School of Public Health who had cosigned an amicus brief for the Obergefell Supreme Court case against a national policy allowing gay marriage. There were calls for his tenure to be revoked, for his classes to be boycotted. He had to undergo struggle sessions and restorative justice sessions and basically grovel in front of a mob. Given Harvard’s history of those cases and others, to all of a sudden say, “Well genocide, it’s just a matter of I disagree with what you say, but I defend it to the death your right to say it,” came off as a little bit hollow and hypocritical.

Pinker: I have nothing against diversity, equity, and inclusion. But as Voltaire said about the Holy Roman Empire: it was neither holy, nor Roman, nor an empire. Diversity, equity, and inclusion imposes an intellectual monoculture. It favors certain groups over others. It has a long list of offenses that mean you can be excluded. But it is a strange bureaucracy. It’s a culture that is kind of an independent stratum from the hierarchy of the universities themselves. The officers get hired or poached to move laterally from university to university. It’s with their own culture, their own mores, their own best practices. It’s just not clear who they report to, or who supervises them, or who allows them to implement policy.

Pinker: Yes. Not at Harvard, but at many universities. No one knew that we had this requirement. No one knew who implemented it. The faculty never voted on it. The president never said this is our policy going forward. A dean of arts and sciences must have signed off on it, but no one can remember who or when. But we just live with it. Likewise, freshman orientation consists of indoctrination sessions.

This is emblematic of a trend in universities, that this nomenklatura just got empowered and no one knows exactly how. What often happens is a dean gets into trouble because of some racial incident. They hire a bunch of staff, and that’s their way of getting out of the trouble. Then they’re there forever. And there is only one way that they’ve been changing and that’s upward.

I love the line “it was neither holy, nor Roman, nor an empire.” Aside from that, Mrs. Lincoln, how was the play?

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The covid pandemic decimated the supply chain. People needed goods — perhaps more than they ever had — but factories and warehouses struggled to keep up due to workers being sick and social distancing rules.

Truck drivers still did their jobs but, in many cases, the support systems they relied on were not operational. Rest stops and restaurants were closed and even finding an operating bathroom was a challenge.

Related: Discount retailer faces Chapter 11 bankruptcy or liquidation

It was a period that created some opportunity as the demands of the entire nation shifted, but it also increased costs. Trucks were waiting to be loaded, drivers were unable to hit the toad because they, or someone close to them, got sick, and the entire industry was under stress.

A number of regional carriers have since been driven into bankruptcy and, now, a major carrier has filed for Chapter 11 bankruptcy with parts of its filing falling under Chapter 15 of the bankruptcy code. That's a lesser-used type of bankruptcy designed to protect foreign companies operating in the United States.

"This chapter of the bankruptcy code allows for the recognition in the U.S. of foreign bankruptcy proceedings and access to domestic judicial proceedings by foreign representatives," the IRS shared on its website.

Family-owned trucking company struggles

Pride Group, a family-owned trucking company, has its headquarters in Canada, but operates in the U.S. as well.

"We are a privately held, diversified group whose subsidiaries and affiliates operate in a variety of industries including transportation, logistics, heavy-duty equipment dealerships, equipment leasing & rentals, real-estate holdings, and full-service fleet management. PGE operates and manages businesses in both Canada and the United States, employing over 500 people," the company shared on its website.

The company has struggled in recent months and has taken steps to restructure its business. This has included a bankruptcy filing, which the company explained on its website.

"Pride Group Holdings Inc. and other applicant companies (the “Applicants”) sought and obtained protection under the Companies’ Creditors Arrangement Act (the “CCAA”) pursuant to an Initial Order of the Ontario Superior Court of Justice (Commercial List) (the “Initial Order”). Other companies affiliated with the Applicants (the “Additional Stay Parties”, and together with Applicants, the “Pride Group”), although not applicants themselves, were granted a stay of proceedings as part of these proceedings under the CCAA (the “CCAA Proceedings”) for the duration of 10-days, subject to extension thereafter as the Court deems appropriate."

That's the Canadian version of bankruptcy, but there has also been a U.S. filing.

"Certain companies in the Pride Group will file cases under Chapter 15 of Title 11 of the United States Code in the United States Bankruptcy Court for the District of Delaware (the “Chapter 15 Cases”) seeking recognition of the CCAA Proceedings within the territorial jurisdiction of the United States and other related relief," the company shared.

Pride Group continues to operate

Pride Group has a complicated array of holdings that includes 16 transport companies, 45 real estate holding companies, and 10 other holding companies founded and controlled by Sulakhan “Sam” Johal, Truck News reported.

The company has roughly $2 billion in debt and the company blames the current freight market for its troubles.

“Spot freight prices, diesel prices, and interest rate trends were all initially favorable for the trucking industry following the onset of the Covid-19 pandemic. They have all deteriorated significantly since that time. The bottom-line result is made significantly worse by virtue of the increased trucking and logistics supply that was brought to market during the upturn, which is currently sitting as unused excess capacity in the market," according to a court filing.

The company, which controls 20,000 trucks,  was profitable until the pandemic, according to Johal.

 Pride Group filed for bankruptcy protection after it defaulted on debt owed to Mitsubishi HC Capital which had been personally guaranteed by Johal. More than 20 other lenders have filed claims against the company which does plan to continue operating. 

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