While most Americans know someone with diabetes, this blog post is meant to inform readers about certain challenges diabetics face when searching and paying for care, and explain how technology can alleviate some stress for this large portion of the population.
To start, it is important to understand that diabetes is a condition that limits the body’s ability to process glucose (sugar) in the blood. Type 1 diabetes occurs when the body can no longer produce insulin—the hormone that allows your body to ‘use’ glucose. Type 1 diabetics are often fully reliant on external sources of insulin to manage their body’s glucose levels. Type 2 diabetes, which is much more common, occurs when the body produces some insulin, but cannot utilize it effectively. Type 2 diabetics can often manage their diabetes without insulin, although insulin is sometimes used in combination with a variety of other drugs.
Both types of diabetes can be extremely harmful, causing nausea, fatigue, trouble breathing, or more seriously, stroke and heart disease—if not managed carefully. According to the CDC, more than 10% of the U.S. population has one form of diabetes, totaling over 34 million people. An additional 88 million adults have prediabetes, where blood sugar levels are elevated, but not high enough to be diabetic. With such a large portion of the population affected by this one condition, it is easy to see why diabetes is a pressing topic in healthcare today.
- In 2016, 16 million emergency department visits were reported with diabetes listed as a diagnosis among adults 18 or older
- In 2017, there were nearly 84,000 deaths attributed to diabetes, making it the seventh-leading cause of death in the U.S.
- In 2018, the number of type 1 diabetics was around 1.6 million people, or around 5.2% of the total diabetic population
- In 2017, the direct and indirect costs associated with diabetes were $327 billion
The Rising Cost of Diabetes Treatment
When Frederick Banting discovered insulin in 1923, he refused to put his name on the patent. He believed it was unethical to profit from a drug that could save many people’s lives. As time went on however, large corporations saw an opportunity to develop their own insulin analogs (a more reliable version of the drug), and the ‘big three’ manufacturers began investing in their own insulin formulations. There is no question that insulin is expensive to produce. Years of research have gone into perfecting its life-saving properties, and making it effective, consistent, and predictable. Further, since insulin is a biologic comprised of complex molecules, it must be approved by the FDA before making its way to patient’s hands. The formulation of insulin is so valuable that manufacturers often bring competitors to court for even attempting to create similar versions of their proprietary products. The development, distribution, and protection of insulin costs pharmaceutical manufacturers billions of dollars that they hope to recoup by selling their patented products to health plans and PBMs.
On the other hand, insulin isn’t nearly the most common drug taken by diabetics, since it is primarily only used by those who have Type 1 diabetes. According to the Mayo Clinic, management of Type 2 diabetes may include healthy eating, regular exercise, and more recently, the use of medication. Across the last decade, new drug therapies have been developed to help Type 2 diabetics lower glucose production, secrete more insulin, or reduce blood sugar levels. However, these new drugs are also proprietary and are created by a variety of manufacturers. For example, sulfonylureas medications help a person’s body secrete more insulin. Specific drugs in this class include DiaBeta, Glynase, Glucotrol, Amaryl, and many more. While it is amazing that there are a variety of potentially life-saving medications on the market, each drug has been researched, developed, and distributed by a manufacturer whose primary goal is to make a profit.
The real challenge today is that the pricing of diabetes drugs is often a mystery, since agreements between health plans and pharmaceutical companies are made in secret. This allows price gouging to occur so that both parties can profit on the drugs that they offer. With patient drug prices rising year over year, manufacturers and plans have given themselves an unjust advantage, since the cost to produce the drugs has remained somewhat flat. Additionally, most plans only cover select therapies and manufacturers set artificial prices to gain preferred status on a plan’s formulary—giving patients no choice when it comes to the drugs they can select. When all is said and done, patients may pay thousands of dollars for their diabetes medications, causing many to wonder how they can manage this disease without breaking the bank (NYTimes).
The Scary Ways Patients Manage Rising Costs
What do patients do when artificially high prices are set for their medications or it is difficult to understand which therapies are covered under their insurance?
For Type 1 diabetics who need insulin to survive, devastating stories include limiting their insulin intake to extend its usability, borrowing it from friends and family, shipping it from countries where it is more affordable, and stealing it from clinics or from those who are recently deceased. Patients are often using their retirement savings, anxiously coordinating with different insurance companies to find coverage, or foregoing insulin altogether.
For millions of Type 2 and prediabetic individuals across the country, it may be difficult to understand which therapies are covered, how formulary changes might affect access, and how much they will pay at the pharmacy. As mentioned previously, there are often a handful of different medication classes that a doctor can choose from to treat Type 2 diabetes, and up to a dozen medications under that class. Adding to this complexity, a patient’s insurance may only cover one drug in each class, or none at all, since the plan may recommend a different type of treatment altogether. All of this makes it nearly impossible for doctors to know which drugs they should prescribe, since each patient may be on a different plan with different coverage options.
Another portion of the diabetic population is taking a different approach: working with doctors to uncover which medicines are covered at a specific moment in time. In this case, prescriptions are written for one or more diabetes drugs, and the patient goes to the pharmacy to see which prescription is filled at the best price. This is an incredibly dangerous practice that can result in multiple prescriptions being filled and taken inadvertently.
Diabetics with insurance are even being denied coverage when they pick up their medicines because their insurance plan has switched which drugs they cover, or removed coverage for chronic conditions altogether—causing additional coordination, complications, and stress.
How Real-Time Prescription Benefit Can Help
Real-Time Prescription Benefit (RTPB) allows prescribers to see a patient’s coverage information at the point of prescribing. Arrive Health (formerly RxRevu) offers a RTPB solution embedded within Epic, Cerner, and athenahealth EHRs, making it easy to see which diabetes medications are covered for each patient that walks through the door. If the prescriber selects a drug that is not covered, an alert window presents covered options which adhere to that patient’s specific plan formulary. Further, if the patient is not covered under one of the plans in our network—or has no coverage at all—our RTPB tool can show the price of various medicines that are available via coupon partners like GoodRx.
Without a RTPB solution in place, diabetic patients must understand which medications are on their plan’s formulary, ask their doctor about affordable prescription options, and investigate which options are available on platforms like GoodRx. With annual diabetic patient volumes reaching the millions, hospitals across the country need to set up RTPB tools to alleviate this unnecessary patient burden; with real-time data at their fingertips, providers can easily streamline the prescribing workflow and improve one-on-one patient conversations. Technologies like Real-Time Prescription Benefit allow for clinically appropriate, cost-effective prescribing, giving diabetics across the country reassurance that they will get the medicines they need, at prices they can afford.
Written by Adam Rosenberg, Director