Treating patients with type 2 diabetes is already a complex process, given the myriad available medications and insurance plans. It's become even more difficult for physicians as insulin prices rise and recent evidence highlights the benefits of some newer classes of drugs for patients who also have other medical conditions, including heart disease or impaired kidney function.
The cost of insulin has nearly tripled over the last 15 years, according to research cited by The Endocrine Society in a 2021 position statement detailing the need for more affordable options. In the early days of the COVID-19 pandemic, one-quarter of patients with diabetes reported self-rationing medical supplies to reduce treatment costs, according to a survey released by the American Diabetes Association and The Diabetes Research Company in July 2020.
Meanwhile, medical guidance in recent years has moved toward recommending newer classes of drugs, such as sodium-glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists, for patients with type 2 diabetes. In its latest guidelines, published in January in Diabetes Care, the American Diabetes Association recommended that SGLT-2 inhibitors and GLP-1 receptor agonists be considered along with or instead of metformin as initial treatment for patients with comorbid conditions, including cardiovascular disease, heart failure, or chronic kidney disease.
Even so, “the best medicine is one that someone can afford,” said ACP Member Peter Ubel, MD, a physician and behavioral scientist at Duke University in Durham, N.C. Physicians should try to gain a sense of whether a particular prescription will strain a patient's ability to pay for food and housing or force shortcuts on other medical care, he said. “It's another side effect to consider when figuring out what's best for that patient that you're with right at that moment.”
A growing body of evidence shows that a sizable chunk of patients do not consistently fill their prescriptions. One recent analysis, which looked at 5,146 adults enrolled in a mix of public and private insurance plans, found that one-third of them didn't start either an SGLT-2 inhibitor or a GLP-1 receptor agonist within 30 days after it was prescribed. Patients were more likely to not pick up the medications if they were ages 65 years or older or had a history of nephropathy or hyperlipidemia, according to the findings, published online Jan. 19 in the Journal of General Internal Medicine. Black adults also were less likely to be adherent than White adults.
The researchers did not survey the patients to determine their reasons for not starting these drugs, said the study's lead author, Jing Luo, MD, MPH, a general internist and assistant professor of medicine at the University of Pittsburgh. But the patient's insurance might not have covered the medication, leading to high out-of-pocket costs, or may have declined to do so without prior authorization or other additional steps, he said.
Other researchers have described a “treatment paradox” regarding these newer classes of diabetes medications, Dr. Luo said. “It's the idea that people who are most likely to benefit from the medications are paradoxically least likely to be dispensed these medications when you look in these large observational claims databases. And that's really unexpected.”
The newer medications may be beyond the reach of older individuals on fixed incomes, who also are more prone to heart disease and other medical conditions, Dr. Luo said. However, if someone is younger and still working, with private health insurance, he said, “even though you're not likely to have coronary artery disease or chronic kidney disease, where you might benefit from these medications as much, you're probably more likely to pay for these medications, or it's less of a hurdle for you.”
Rising costs and deductibles
The costs of the newer classes of diabetes medications, which also include dipeptidyl peptidase-4 (DPP-4) inhibitors, dwarf those of second-line drugs that used to be routinely prescribed after treatment with metformin, according to a research letter published December 2020 in JAMA Internal Medicine. The annual list prices for newer drugs range from $5,202 to $11,225 compared with $250 to $355 for sulfonylureas and thiazolidinediones, respectively.
For patients covered by Medicare Part D, annual out-of-pocket costs range from $1,231 to $1,981 for the newer drug classes compared with $250 to $355 for the more traditional medications, the analysis found. The problem is that physicians typically don't know what patients will have to pay when they prescribe, and research shows that patients are reluctant to talk about cost if they hit a daunting bill at the pharmacy, said Colette DeJong, MD, a study author and cardiology fellow at the University of California, San Francisco, School of Medicine. “And so sometimes the doctor might not be aware that either it's causing duress or that their patient hasn't been able to afford to pick it up, or to take it as prescribed,” she said.
Broadly speaking, 10.3% of Medicare recipients with type 2 diabetes report skipping medication doses or taking smaller doses of prescribed drugs, according to survey data published in June 2021 in the Journal of Managed Care and Specialty Pharmacy. The older adults were more likely to cut back if they were dissatisfied with the cost of the medication, or if they reported spending less on basic needs to save for medication. That self-reported figure might be even higher, as some patients might not want to admit that they are skimping on medication, said Boon Peng Ng, PhD, a health economist and health services researcher at the University of Central Florida in Orlando.
A few academic medical centers, including at Duke University, have begun to design their electronic health records so physicians and other prescribers can see the out-of-pocket medication cost for each patient, depending on their health insurance and where they are in their deductible, Dr. Ubel said. But otherwise, he said, there's no way that an individual physician could be asked to predict out-of-pocket costs.
While it's unfair to ask busy physicians to shoulder another task, more up-front discussion about costs might save time later, Dr. Ubel noted. “Think about how much time you spend trying to find out whether someone is taking their medicine or why they are not taking their medicine or trying to remind them to take their medicine,” he said. “And you might not even realize, they are too embarrassed to tell you that they can't afford it.”
When talking about medication options, including for diabetes treatment, physicians should develop a spiel to introduce the subject of cost, making it clear that they raise the issue with every patient, “so that they don't think, ‘You're only asking me because of the color of my skin or because I only have a high school education,’” Dr. Ubel said. “You don't want a patient to wonder that.”
Dr. Ubel suggested saying something like, “I ask all my patients: How is your coverage? Are you worried about how expensive this medicine will be and whether you can afford it?” That way, he added, it's clear not only that all patients get the question, but that it's the coverage, not the patient, that is being blamed.
Dr. DeJong said that when she recommends a new, costlier medicine, such as a SGLT-2 inhibitor, she will describe the potential clinical benefits but also note that some patients may pay a higher price. One approach she has adopted is to send a test prescription to the pharmacy and tell her patients that there are alternatives if the cost comes back higher than they can afford.
Dr. Ubel, who has conducted research related to cost and patient decision making, has observed physicians who prescribe patients two drugs if they have similar efficacy. Then the patient can compare prices at the pharmacy counter and fill the one that is cheaper, he said.
But physicians should not assume that their patients can't afford pricier drugs before running it through their insurance first, said ACP Member Rozalina McCoy, MD, MS, a general internist, endocrinologist, and associate professor of medicine at the Mayo Clinic in Rochester, Minn. Given the complexities of insurance designs, she said, “sometimes you're pleasantly surprised.”
When Dr. McCoy submits an electronic prescription, she also includes a note to the pharmacist to share the price with the patient before filling it. If the cost is too steep, she asks the pharmacist to tell the patient to call her, so they can sort out an alternative. “And I tell my patients that I'm doing this, so they also know to call me,” she said.
Dr. McCoy, who coauthored a guide published in October 2021 in Clinical Diabetes to provide clinicians with strategies to ease diabetes costs, cited Fingertip Formulary as a useful resource to check formulary tiers for specific medications (it's free, but registration and a login are required). Also, patients on commercial insurance plans may get a hefty discount on brand-name medications through manufacturer savings cards, she said.
To determine if there is a savings card available, patients can search online for the brand-name diabetes drug, including both insulin and noninsulin drugs, look for the page referencing “savings card” or “discount card” or “coupon,” and fill out the requested information, Dr. McCoy said. (These savings cards are different from patient pharmaceutical assistance programs, which are income-based programs offered for select drugs by some manufacturers, she noted.) One key drawback is that the eligibility criteria for manufacturer savings cards typically exclude patients covered by government-sponsored prescription medication plans, including Medicare Part D or Medicare Advantage, she said.
Dr. McCoy was lead author on a study published Feb. 1, 2021, in JAMA Network Open finding that adults with type 2 diabetes were more likely to initiate treatment with an SGLT-2 inhibitor, DPP-4 inhibitor, or GLP-1 receptor agonist if they were covered by commercial insurance versus Medicare Advantage, despite similar formulary designs. She and her coauthors wrote that lack of eligibility for manufacturer savings cards could have been a factor for Medicare Advantage patients, who “may face a ‘donut’ hole with limited or no prescription drug coverage, both of which may make out-of-pocket cost-sharing expenses more unaffordable for them than for commercial insurance enrollees.”
When Dr. McCoy prescribes one of the newer classes of diabetes drugs, she makes sure to document patients' heart disease and other relevant conditions in an effort to reduce insurer denials. She also cites support from medical guidelines, such as those from the American Diabetes Association.
At the policy level, at least 19 states as of September 2021 had enacted some type of monthly insulin copayment cap, according to the National Conference of State Legislatures. Meanwhile, federal legislative efforts persist to cap insulin costs at $35 per month, with the outcome uncertain as of early spring 2022.
For the foreseeable future, diabetes treatment costs and related decisions will remain complex, given the array of medication options. Physicians must strive to foster trust and candor with patients, letting them know that they're working as a team, Dr. McCoy said. “It's important to tell patients ahead of time that there may be hurdles to getting them this drug but that we're going to do everything we can to get it for them,” she said. “I just need them to be honest with me and let me know if they can't afford it.”
Dr. McCoy also emphasized the importance of reassuring patients that even in a worst-case scenario, other treatment options are available. “They may not be the ones we would prefer, but they are going to be fine,” she said. “So it's important not to demonize the other options, because if your patient will need them, you don't want them to feel like they're not going to have good diabetes control.”