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40% of American Patients with Diabetes Report Financial Hardship 

Apr 4, 2020
Editor: Steve Freed, R.PH., CDE

Author: Mit Suthar, PharmD. Candidate, LECOM School of Pharmacy 

Even patients with diabetes who have insurance are experiencing more financial hardship than those without diabetes.   

The results from the National Health Interview Survey in 2013-2017 were recently published online in Circulation. The survey analyzed medical bill data among adults aged 18-64. 


8,967 adults with diabetes were surveyed, and almost two in five of these adults reported financial hardship resulting from medical bills, medical debt, or just being unable to afford the needed medical care. The economic hardship that patients experienced as a result of their diabetes diagnosis was linked with high financial distress, food insecurity, cost-related nonadherence, and medical care that was either delayed or just skipped. 

Carabello and colleagues determined that their “study findings illuminate the health- and nonhealth-related consequences as a potential side effect of burdensome medical bills from diabetes mellitus management. These findings underscore the need for price transparency and clear communication with patients and their families on the costs of care. Great consideration should be taken on presenting less expensive but still effective treatment options, as well as a need to comprehend patient’s insurance coverage and financial obligations in our management decision-making processes.”  

Unfortunately, the older Medicare population is not exempt from the burdens of medical costs.  

Another study available online in early February found that “Lower insulin prices and other solutions are necessary to improve access to treatment for Medicare beneficiaries with diabetes.” This study was published in Diabetes Care by Chien-Wen Tseng, MD, of the Department of Family Medicine and Community Health, University of Hawaii, Honolulu, and colleagues. 

This study, focused on the costs affecting the Medicare population (65 and older) that requires insulin, found that the benefit provided by the Affordable Care Act which was meant to alleviate the brunt of the Medicare Part D “doughnut hole,” was offset by the increasing cost of insulin. 3.1 million beneficiaries of Medicare Part D with type 1 and type 2 diabetes require insulin.  

The “doughnut hole” is a colloquialism for the Part D coverage gap, wherein patients must pay a percentage of the drug price until they reach the point of catastrophic coverage. To minimize this burden, the Affordable Care Act slowly decreased beneficiaries’ cost-sharing during this gap. In 2010 the cost was 100% but had been reduced to 25% in 2019. Manufacturers were also required to provide more substantial discounts of up to 70% by 2019. 

The sample of 8,967 adults with diabetes included in the National Health Interview Survey study by Caraballo, can be extrapolated to represent 13.1 million patients in the United States. The mean age of these participants was 51.6 years old, and 50.9% were men.  During the survey, 41.1% of patients were part of families that reported financial hardship as a result of medical bills. This 41.1% represents 5.4 million patients nationally. Regrettably, 15.6% of patients said they were unable to pay their medical bills at all. This corresponds to around 2 million Americans who cannot afford care. 
The inability to afford medical care/pay medical bills was most common in populations who had a low income and were uninsured (39.1%). The failure to pay medical bills was least common for middle or high-income individuals (8.5%). 

Patients with diabetes had more significant financial hardship due to medical bills (odds ratio [OR], 1.27), higher financial distress (OR, 1.14), greater food insecurity (1.27), more cost-related nonadherence (OR, 1.43), and more had delayed or completely missed medical care (OR, 1.43). All these factors had a P-value of <0.01. Even after adjusting for sociodemographic, economic, and clinical confounders, these factors in patients with diabetes continued to be significant. 

Tseng and colleagues analyzed a total of nine insulins, including the top five by 2017 Part D spending. They found that from 2014 to 2019, the average insulin price rose 55%, going from $3,819 to $5,917. Monthly out-of-pocket costs for insulin in the covered phase (not in the doughnut hole) increased 18%, going from $49 to $58. The projected yearly out-of-pocket cost for insulin rose 11% from $1,199 to $1,329, even when accounting for all Part D phases. 

However, if insulin prices had remained at the level they were in 2014, annual out-of-pocket costs would have dropped 19%, to $967 specifically, due to lower co-insurance when patients are in the doughnut hole/coverage gap.  

The price of Lantus had the smallest increase at 19%, which allowed the annual out-of-pocket cost to drop by $167. However, patients could have saved $292 if the price had not increased at all. The price of Levemir increased the most, with a 165% increase. This caused the out of-of-pocket cost to increase by $992, whereas it would have dropped by $297 if the price had not changed.  

Tseng and colleagues conclude that: “Insulin list prices continue to rise, driven by multiple complex factors including manufacturers competing by offering greater proprietary rebates to pharmacy benefit managers for formulary placement. 

“Since measures to close the Part D gap were fully implemented in 2019, future price increases will not be counteracted unless new policies are enacted to reduce patients’ cost-sharing.”  

Practice Pearls: 

  • American patients with diabetes are experiencing more significant financial hardship than those without diabetes, even if they have health insurance. 
  • The Affordable Care Act reduced the cost-sharing of beneficiaries who fall into the coverage gap known as the doughnut hole to 25% in 2019. 
  • The price of insulin is still increasing, and new policies must be enacted to reduce patients’ cost-sharing. 

Tucker, Miriam E. “Two in Five Americans With Diabetes Report Financial Hardship.” Medscape, Medscape Medical News, 28 Feb. 2020, www.medscape.com/viewarticle/925845#vp_2. 

Mit Suthar, PharmD. Candidate, LECOM School of Pharmacy 


Related: Insulin cost-benefit analysis