New Paper Explains How Barriers, Cost Hinder Diabetes Care

Diabetes is becoming more common.  But access to appropriate care for people living with diabetes?   Not so much.   So explains a new white paper from the Institute for Patient Access.

Authored by a dozen health care providers and advocates, “Protecting Access to Diabetes Care” notes that diabetes now affects about one in every 10 women, men and children in the United States.  Last year the disease cost the nation $237 billion in direct medical costs and $90 billion in reduced productivity.

Proper treatment can help patients manage their diabetes, but access isn’t a given.  The paper identifies three problematic health plan barriers:

  • Prior authorization. Health care providers and their patients with diabetes may be required to get a health insurer’s permission before proceeding with the prescribed course of care.  Known as “prior authorization,” the process can delay necessary treatment, drive up health care costs, and burden physicians and staff who would otherwise be tending to patients.
  • Step therapy. When people with diabetes are forced to fail on an insurer-preferred medication before getting the therapy their physician prescribed, they may see the severity of their condition worsen. “Some health plans make my patients fail off-label drugs before they can get one of the FDA-approved therapies that I prescribed,” explained John Anderson, MD, one of the paper’s authors, adding, “For the health plans, it’s all about cost.”
  • Non-medical switching. Health plans may drop certain insulin products from their list of approved drugs. Or perhaps switch a patient’s medication to a higher coverage tier with an increased out-of-pocket payment.  Whatever form it takes, non-medical switching can derail people with diabetes’ efforts to effectively manage their disease.

Cost issues also present a challenge.  The price of insulin more than tripled over the last decade, the paper notes.  And people with diabetes may also face the expense of insulin pumps, injection pens, blood glucose meters and strips, and continuous glucose monitors.

The factors impacting patients’ costs are multifaceted.  As the paper explains, middlemen known as pharmacy benefit managers drive up insulin prices by demanding higher and higher rebates from manufacturers who want a preferred spot on an insurer’s formulary of approved drugs.

Meanwhile, new co-pay accumulator adjustment programs make access still more difficult.  Under the programs, a co-pay coupon can help patients pay for their medication – but it does not count toward their annual deductible.  When coupons run out, patients may discover that they are responsible for their full annual deductible.  Depending upon their deductible and the price of the drug they take, that full amount could be due in a single pharmacy visit.

The practice is designed to save health plans money but may be more likely to spur nonadherence, the paper explains.

Improving access for people with diabetes requires clearheaded policies, the paper argues.  Several state legislatures have taken up step therapy and non-medical switching, while policymakers at the federal level have also begun investigating cost and access issues related to diabetes.

To learn more, read “Protecting Access to Diabetes Care.”

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