Two articles published in December 2018 should attract the attention of physicians, policy makers and healthcare purchasers. These article in the Journal of the American Medical Association Internal Medicine when taken together, are emblematic of our healthcare dysfunction.
Cost-Related Insulin Underuse Among Patients With Diabetes. JAMA Internal Medicine. Published online December 3, 2018 (abstract)
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Stan Schwartz Stanley N. Schwartz, MD, FACP is a graduate of New York University School of Medicine. He did residency training in internal medicine and infectious diseases fellowship at the University of Pittsburgh Medical Center. He practiced infectious diseases, hospital epidemiology and internal medicine in Tulsa and later was Medical Director for Warren Clinic, a […]
Researchers at Yale University’s Diabetes Center determined that 1 in 4 persons with insulin-dependent diabetes was rationing their insulin and underdosing because of the cost of insulin.
Assessment of Self-monitoring of Blood Glucose in Individuals with Type 2 Diabetes Not Using Insulin. JAMA Internal Medicine. Published online December 10, 2018 (abstract)
Researchers at University of Michigan reviewed data on almost 400,000 patients with Type 2 diabetes to determine who was using home blood sugar monitoring appropriately. Equipment and testing materials are often covered by insurance. They determined that half of almost 87,000 individuals in this study doing home monitoring had no good reason to do so and would derive little to no value for the expense, time or effort.
In the first article, the authors point out that while a quarter of all their study patients underused insulin, almost one-third of those underusers reported having employer-sponsored health insurance. Having health insurance did not guarantee affordability.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Many persons with insulin-dependent diabetes have Type 1 diabetes, an autoimmune disorder in which natural insulin isn’t made. It’s not a lifestyle problem nor is it related to obesity or poor diet. Without insulin, they will die. With inadequate insulin, they are prey to complications, poor quality of life and early death.
Thirty years ago, insulin was an economic fallback for people who couldn’t afford the more expensive oral drugs. Today, the cost of monthly insulin has generally started around $400 and for so many individuals, goes well north of that. Insulin is no longer affordable by those whose lives depend on it.
To its credit, Eli Lilly and Company just released a generic version of one of their branded insulins (Humalog) which may help reduce costs. However, it’s only one of many forms of insulin, is still not inexpensive and will not mitigate costs for many with diabetes.
The second article illustrated a huge amount of waste — defined as cost of resources and effort that produces no significant value. Many health plans cover the cost of testing supplies without regard to value.
So on one hand, there is not enough money for a critically needed benefit and on the other hand, money is freely spent on something which provides very little benefit.
Capitalists will tell you such inequalities exist throughout our nation. One poor family may struggle to heat a small home while another wealthy family luxuriates in a spacious, warm mansion many times larger than they need. We accept that as the price of capitalism. My neighbor’s profligate use of natural gas doesn’t cost me more.
But this discussion isn’t about simple capitalism. Through the collective premiums we pay and the healthcare purchases our employers make, we are all paying one way or another for the wasted materials used for home blood sugar measurements. And one way or another we will all pay for the amputations, blindness, heart attacks, strokes and dialysis the untreated and undertreated insulin-dependent persons will suffer.
- Edwards Deming’s rule that “Every system is perfectly designed to get the results it gets” is on full display here.
Are employers who purchase healthcare powerless to do something? Not at all. A first step is to assure their healthcare plan design does not subsidize situations in which blood sugar self-monitoring is of little value.
The second step is to assure plan design facilitates insulin-dependent members’ ability to purchase insulin. Consider the purpose of a copay or coinsurance on insulin: Who benefits from a financial barrier to a drug which predictably reduces both near-term and long-term healthcare costs? Is someone who doesn’t need insulin going to abuse it because now it’s free? I am still searching for evidence to justify a copay on insulin.
Some back-of-the-envelope calculations: About 5 percent of our nation’s 31 million persons with diabetes have Type 1; about 27 percent of the remaining 29.5 million persons with diabetes need insulin to replace or supplement oral medications. That adds up to around 10 million people.
In healthcare, value is benefit divided by cost. Insulin is very high value because it prevents death and disability despite its expense. In this context, self-testing is low value for persons who don’t use insulin because it provides little benefit while consuming dollars.
So almost 10 million people who depend on insulin would benefit from rethinking how we spend money on diabetes care. The money spent on low-value testing would be better used to make insulin more affordable. That can be done through benefit design.
If you are a purchaser of healthcare, do not wait for government to solve this. Find out if you are paying for low-value care or what financial obstacles in the way of persons with insulin-dependent diabetes. Work with your carrier, your benefits advisor or your local healthcare coalition now.
Photo: eromaze, Getty Images
Stanley N. Schwartz, MD, FACP is a graduate of New York University School of Medicine. He did residency training in internal medicine and infectious diseases fellowship at the University of Pittsburgh Medical Center. He practiced infectious diseases, hospital epidemiology and internal medicine in Tulsa and later was Medical Director for Warren Clinic, a 375-provider clinic in the Saint Francis Health System.
Dr Schwartz is Chief Medical Officer and co-founder of The Zero Card, Inc., a digital health enterprise that connects providers offering bundles services with self-funded employers across the US. He also organized and now leads WellOK, Inc., the Northeastern Oklahoma Business Coalition on Health, a not-for-profit organization dedicated to improving the value of healthcare for Oklahoma businesses.
He serves on the board of Oklahoma Center for Healthcare Improvement. He also serves on the Clinical Quality Committee of MyHealth Access Network HIE.
He is a diplomate of the American Board of Internal Medicine in Internal Medicine and Infectious Diseases, and Fellow of the American College of Physicians and the Infectious Diseases Society of America.
