When health plans are detrimental to diabetes care
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Susan Weiner, MS, RDN, CDCES, FADCES, talks with Donna Ryan, RN, RDN, MPH, CDCES, FADCES, about changes to standard practices of health plans that could improve diabetes care and health of people with diabetes.
Weiner: How is the U.S. doing in terms of health care spending efficacy and equity for diabetes?
Ryan: The U.S. is a global leader in health care expenditures for diabetes, spending approximately $327 billion for direct and indirect costs. According to the American Diabetes Association, people with diabetes have 2.3 times the health care costs of persons without diabetes, with estimated average annual medical costs of approximately $17,000.
Higher spending has not led to better outcomes, especially in communities of color. Diabetes impacts diverse populations disproportionately, with increased prevalence, complications and subsequent health care costs. Black Americans are 50% more likely to have diabetes and twice as likely to die from diabetes as white Americans. People of color with diabetes are more likely to have an amputation, three times more likely to be hospitalized from diabetes-related causes and 3.5 times more likely to have end-stage renal disease. Additionally, rurality and social determinants of health adversely impact many Americans’ access to diabetes care.
Some of the highest health care costs are related to complications and comorbidities. It follows that health care costs increase based on the progression and severity of the disease. These include direct medical costs, like heart and kidney disease, and common comorbidities, like anxiety and depression. When diabetes care is not optimally provided and maintained, complications develop, quality of life declines and the cost burdens increase.
Effective diabetes care mitigates the risks for eye, kidney and nerve disease by 40%. Blood pressure management can reduce the risks for heart disease and stroke by 33% to 50%. Improved cholesterol levels can reduce cardiovascular complications by 20% to 50%. Regular eye exams and timely treatment could prevent up to 90% of diabetes-related blindness. Regular foot exams and patient education could prevent up to 85% of diabetes-related amputations. Yet, people with diabetes continue to experience barriers to diabetes care that would prevent or delay complications and comorbidities.
The question is what is driving these challenges for patients to diabetes care and what can be done?
Weiner: If diabetes-related modifiable risk factors can be mitigated, why do people with diabetes still experience medical consequences associated with the disease?
Ryan: Diabetes care is preventive health care. Every person with diabetes deserves access to affordable medications, diabetes devices and individualized, timely diabetes care that delays or prevents complications. People with diabetes deserve access to tools of diabetes preventative care, including oral, injectable or inhaled medications; medical devices, such as meters, continuous glucose monitors, and insulin pumps and delivery devices; basic medical supplies, syringes, needles, lancets and glucagon devices; medical services, grounded in the standards of care, including lifestyle coaching, diabetes self-management education and support (DSMES) training and medical nutrition therapy that help with modifying behaviors like diet, exercise, medication taking, stress management and healthy coping.
Improved access to these tools is associated with improved outcomes for weight management, glucose management, blood pressure, lipid panels, foot care, diabetes technology use and quality of life.
However, people with diabetes have even more difficulty affording health care than those without diabetes. Financial challenges include copays for prescription drugs and doctor visits, monthly insurance premiums, and medical bills before meeting deductibles. People with diabetes have twice the average out-of-pocket spending compared with those who do not have diabetes.
Weiner: What are the challenges of improved diabetes management?
Ryan: The fragmented U.S. health care system, with our numerous payers and payment models, is essentially confusing and confounding to consumers and providers and is at odds with care continuity for chronic conditions, such as diabetes.
There are almost 6,000 insurance companies registered in the U.S. offering multiple plans and varying costs and coverage. Medicare, Medicaid and the military pay 67% of U.S. diabetes costs. Health care plan designs can be detrimental to continuity of diabetes care. The amount of time spent by providers and people with diabetes trying to navigate the system is often excessive. “Hold, please” has taken on new meaning when calling insurance companies. “Hold diabetes care” is the unfortunate result, and many productive hours are whisked away when trying to navigate insurance policies.
Certain practices central to insurance plans fragment diabetes care. For example, step therapy requires a person to try one or more preferred drugs before coverage for a more expensive alternative is approved. Prior authorization requires a review of certain medications before an insurance company plan covers them. While step therapy and prior authorization may seem harmless, they are actually fail-first policies and not evidence-based.
In addition, utilization reviews delay or limit diabetes care. These practices override patient and prescriber decisions for care, injecting non-medical barriers into diabetes care, ultimately costing money, causing frustration and possibly impacting glucose control.
Formulary changes compel non-medical switching — therapeutic substitutions driven by financial interest rather than medical necessity or clinical efficacy.
Weiner: Are there solutions?
Ryan: Several changes to current practices would help:
- Reduce insulin out of pocket prices and assign “first dollar coverage.” Insulin would have no deductibles or co-pays. This solution would have little or no impact on premiums or other coverage.
- Use evidence-based practice guidelines rather than step therapy or prior authorization.
- Cover medically necessary prescriptions and devices. All U.S. health plans, including Medicare and Medicaid, should cover medically necessary prescription medications and diabetes devices as determined by the provider and person with diabetes.
- Eliminate forced non-medical switching.
- Institute no or low predictable cost-sharing. Insurers would provide coverage for preventive diabetes care, including DSME and medical nutrition therapy, with little or no cost-sharing, which would improve health and curb costs. Barriers would be eliminated that prevent access to care.
Weiner: What are next steps for the diabetes care community?
Ryan: The role of health care providers and the diabetes community at large in improving diabetes outcomes is understanding the non-medical issues that affect diabetes care and advocating for health care and health plan reform. We need to be asking people with diabetes about their experience with out-of-pocket costs, insurance coverage and any barriers to diabetes care that impair their ability to self-manage diabetes. And we need to provide resources for assistance. We must focus on improving access for people with diabetes.
References:
- Diabetes Leadership Council. Consensus Statement on U.S. Healthcare Reform for People with Diabetes: 2020. Available at: https://assets.website-files.com/60a758512e4466f587bb4ca7/60b7b4c851e266a9f4968cef_Diabetes_health_care_reform_consensus_statement.pdf. Published December 2022. Accessed March 30, 2023.
- Diabetes Leadership Council. Reduce Insulin Out-of-Pocket Costs. Available at: https://assets.website-files.com/60a758512e4466f587bb4ca7/62d1c47c360d5947dd2fa30d_DLC_Reduce-Insulin-Costs-2022.pdf. Accessed March 30, 2023.
- Kamal R, et al. Peterson-KFF Health System Tracker. How have diabetes costs and outcomes changed over time in the U.S.? Kaiser Family Foundation. Available at: https://www.healthsystemtracker.org/chart-collection/diabetes-care-u-s-changed-time/#prevalence-and-mortality. Published Nov. 15, 2019. Accessed March 30, 2023.
- Thomas A, et al. The Conundrum of Diabetes Care: It’s More Than Counting Carbs. Presented at: Academy of Nutrition and Dietetics Food & Nutrition Conference & Expo; Oct. 16-19, 2021 (virtual meeting).
- ADA https://diabetes.org/about-us/statistics/cost-diabetes
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Peterson-KFF Health System Tracker. Accessed December 2022. https://www.healthsystemtracker.org/chart-collection/diabetes-care-u-s-changed-time/#prevalence-and-mortality
For more information:
Donna Ryan, RN, RDN, MPH, CDCES, FADCES, is a Board member for the Diabetes Leadership Council, an advocacy organization uniting former leaders of national diabetes organizations. She can be reached at dryancde@gmail.com.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; Twitter: @susangweiner.
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