From the Journals

High prices driving insulin underuse

Publish date: December 3, 2018

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High prices can lead to death

This study by Herkert and colleagues reinforces that American drug makers, device manufacturers, and insurers are willing to sacrifice human lives in their quest for profit, according to Elisabeth Rosenthal, MD, of Kaiser Health News.

Diabetes is a disease that starts in childhood, she noted, which means young Americans who are often low-earning and uninsured must start managing it with insulin before they are financially stable. And if drug prices keep going up – and if competitors are sued out of the market – then that means people with chronic disease will suffer, including the 25.5% that Herkert et al. found underuse insulin because of cost.

“As drug costs have generally increased in the United States, we know that many patients are skimping on medicines, taking less than prescribed, and cutting pills in half to make every fill last longer. This is terrible, but for many diseases, it is not catastrophic,” she wrote.

“But skimping on insulin,” she added, “can be rapidly deadly in people whose bodies make none of their own and can result in a life-threatening metabolic disturbance.”

Dr. Rosenthal shared the story of a 29-year-old diabetes patient in Missouri who would consider only doctoral programs outside the United States. “My one goal in life has been to move to Europe so I don’t have to pay these staggering prices just to survive,” the patient revealed.

But others – that 25% – will quietly skimp on their insulin, taking less than they need but more, perhaps, than they can really afford. Some of them will die.

Dr. Rosenthal is the author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.” These comments are adapted from an accompanying editorial (JAMA Internal Med. 2018 Dec 3. doi: 10.1001/jamainternmed.2018.5007).

FROM JAMA INTERNAL MEDICINE

One in four patients at an urban diabetes center reported underusing insulin because of concerns about cost, according to a survey of patients with type 1 or type 2 diabetes mellitus who were recently prescribed the drug.

“These results highlight an urgent need to address affordability of insulin,” lead author Darby Herkert of Yale College in New Haven, Conn., and her coauthors wrote in a study published online in JAMA Internal Medicine.

In the survey of 199 diabetes patients who had an outpatient visit at the Yale Diabetes Center between June and August 2017, 25.5% reported cost-related insulin underuse. Only 60.8% of those patients discussed the prohibitive costs with their clinician, and 29.4% changed insulin types because of high prices. Patients who reported insulin underuse were also more likely to have poorer glycemic control than patients who did not, at a rate of 43.1% versus 28.1% (odds ratio, 2.96; 95% confidence interval, 1.14-8.16; P = .03).

The authors noted potential limitations in their study, including focusing on patients of just one treatment center and the inability to establish a causal relationship between cost-related underuse and poor glycemic control. Nonetheless, they strongly encouraged asking diabetes patients about potential cost issues; they also stressed the need for larger forces to step in and guarantee insulin’s availability. “Insulin is a life-saving, essential medicine, and most patients cannot act as price-sensitive buyers. Regulators and the medical community need to intervene to ensure that insulin is affordable to patients who need it,” they wrote.

This study was supported by the Global Health Field Experiences Award, the Yale College Fellowship for Research in Global Health Studies, and the Global Health Field Experiences Seed Funding Award. The corresponding author reported receiving funding from the Centers of Medicare and Medicaid Services to develop publicly reported quality measures. Another author reported receiving support from Health Action International and Alosa Health. No other disclosures were reported.

SOURCE: Herkert D et al. JAMA Internal Medicine. 2018 Dec 3. doi: 10.1001/jamainternmed.2018.5008.

High prices driving insulin underuse

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