high insulin cost leads to underuse

Following on the trail of a recent blog on skyrocketing generic prices, a recent Research Letter in JAMA Internal Medicine found that the high cost of insulin resulted in one quarter of the patients under utilizing it because of cost constraints (see drug co high cost insulin jamaintmed2018 in dropbox, or doi.org/10.1001/jamainternmed.2018.5008).

Details:

-- 199 patients with type I or type II diabetes were given a questionnaire at the Yale Diabetes Center in 2017

-- 52% women, 60% white/25% black or African-American, 47% type I diabetes, 43% on Medicaid/33% employer-sponsored plans/20% Medicare part D

-- primary outcome was cost-related underuse of insulin in the past 12 months, defined as a positive response to anyone of the following, specifically because of the cost on insulin:

    -- did you use insulin less than prescribed?

    -- did you try to stretch out your insulin?

    -- did you take smaller doses of insulin than prescribed?

    -- did you stop using insulin?

    -- did you not fill in insulin prescription?

    -- did you not start insulin?

Results:

-- overall 26% reported cost-related insulin underuse.

-- By annual ncome, with odds ratio relative to income > $100,000

    -- less than $10,000: 20% reported cost-related insulin underuse, OR 6.42 (0.65-154.07)

    -- $10,000-$25,000: 25% insulin underuse, OR 9.79 (1.15-220.25)

    -- $25,000-$50,000: 38% insulin underuse, OR 11.50 (1.62-239.06)

    -- $50,000 $100,000: 39% insulin underuse, OR 12.51 (1.83-255.85)

    -- >$100,000: 4% insulin underuse

-- 56% reported difficulty buying diabetes medical equipment, OR 5.89 (2.52-14.50)

-- 61% of patients with cost-related insulin underuse discuss this with their clinician, 30% changed insulin type because of cost

-- 43% reporting cost-related insulin underuse had an A1c >9%, vs 28% of those without this issue, OR 2.96 (1.14-8.16), p=0.03

Commentary:

-- pretty striking study:

  -- 25% of patients going to this urban diabetes center underused there insulin because of cost

  -- 40% of patients did not mention this to their clinician

  -- more than half reported difficulty buying diabetes medical equipment

  -- and, not surprisingly, those limiting their insulin use had poorer diabetes control

-- the recent blog also commented on dramatic increases in insulin costs (see http://gmodestmedblogs.blogspot.com/2018/12/generic-drug-prices-skyrocketing.html )

    -- insulin is clearly a life-saving drug for many people, especially those with type I diabetes. a recent political demonstration took place in Boston where 2 mothers delivered the ashes of their diabetic children who had died because of the high cost of insulin, directly to Sanofi pharmaceuticals (see this blog for more details)

-- and, the World Health Organization considers insulin in their Model List of Essential Medicines, meaning that it should be made available at all times of the price the individual and the community can afford

So, this is pretty dramatic in any country, but truly pathetic in the richest nation in the world. It is quite striking how the increasingly naked and accelerating quest for profits by drug companies has such profound effects on public health. And, it reinforces that in a country like ours, the real solution is to have a single-payer public system with the economic and political power to control these costs.

geoff

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