Spotlight on cost-related nonadherence
Recent studies looked at how often patients underuse insulin due to cost, whether Supplemental Nutrition Assistance Program participation reduces cost-related nonadherence, and how high deductibles affect the timing of care for macrovascular complications.
Several recent studies looked at how patients respond to the costs of caring for their diabetes.
One survey, published by JAMA Internal Medicine on Dec. 3, focused on the cost of insulin. It was given to 354 adults with an insulin prescription for type 1 or 2 diabetes who were seen at the Yale Diabetes Center. A total of 199 patients (41.7% with type 1 diabetes) completed the survey, and 25.2% of them reported having used less insulin than prescribed within the past year due to cost. More than a third of the patients who underused insulin (39.2%) had not discussed the cost with their clinicians, and 29.4% changed insulin type due to cost. Patients who had cost-related underuse had lower incomes and were more likely to have an HbA1c level of 9% or higher in the past three months than patients who didn't. The study authors noted that the study was limited by its single-center design and that a causal relationship between cost-related insulin underuse and poor glycemic control couldn't be definitively established. “Regulators and the medical community need to intervene to ensure that insulin is affordable to patients who need it. At minimum, individual clinicians should screen all patients for cost issues to help them address these challenges,” the authors wrote. An accompanying invited commentary noted that the average wholesale price of four of the most popular insulins more than tripled between 2007 and 2017.
Another study, published by JAMA Internal Medicine on Nov. 19, looked at whether participation in the Supplemental Nutrition Assistance Program (SNAP) by older adults with diabetes was associated with cost-related medication nonadherence. The study included 1,385 seniors with diabetes or borderline diabetes, prescription medication use, and SNAP eligibility. Overall, 36.3% of them had participated in SNAP in the past year, and 12.9% reported cost-related medication nonadherence. Researchers matched 1,302 of the patients based on whether they participated in SNAP and found that SNAP participants had a 5.3 percentage-point decrease (95% CI, 0.5 to 10.0 percentage-point decrease; P=0.03) in cost-related medication nonadherence compared with those who didn't participate. The results were similar in the subgroups that had prescription drug coverage and under $500 in out-of-pocket medical costs in the previous year, but not for patients who lacked prescription coverage or had higher medical costs. The authors concluded that participation in SNAP may help improve adherence to treatment regimens among older adults with diabetes and that it might be beneficial to ease access to these benefits, for example, by automatically enrolling Medicaid beneficiaries. “Health professionals may also encourage participation in SNAP by highlighting its health benefits, which could lessen the stigma associated with participation in public assistance programs,” the authors said.
Another study, published by Annals of Internal Medicine on Nov. 20, analyzed how switching to a high-deductible insurance plan affected care for macrovascular conditions among patients with diabetes. Researchers compared 33,957 patients with diabetes who were on a low-deductible (≤$500) insurance plan before their employer switched to a high-deductible (≥$1,000) plan with 294,942 similar patients who stayed on low-deductible plans. The study found that the high-deductible group sought care later than the low-deductible group: 1.5 months later (95% CI, 0.8 to 2.3 months) for their first major macrovascular symptom, 1.9 months later (95% CI, 1.4 to 2.3 months) for their first major diagnostic test for macrovascular disease, and 3.1 months later (95% CI, 0.5 to 5.8 months) for their first major procedure-based treatment. The results “suggest that patients with diabetes who are switched to high-deductible health plans are affected by the increased out-of-pocket costs they face for medical services,” said the study authors, who urged policymakers and employers to be cautious in encouraging uptake of such plans for vulnerable patients with diabetes. The authors noted several limitations of the study, including potential confounding and inability to distinguish appropriate care from unnecessary care. An accompanying editorial said the data were interesting but “cannot provide a definitive answer about the value of high-deductible plans for persons with diabetes.”