Diabetes is an expensive chronic disease that requires constant monitoring. A slight lapse in maintaining optimal blood glucose levels can lead to catastrophic consequences — either hypoglycemia or hyperglycemia. Newer treatment options and monitoring devices have made this tightrope walk more manageable, but challenges persist. This article will delve into the complex medical needs of a diabetic patient, the cost of diabetes, and some of the barriers to accessing appropriate care.
DISEASE STATISTICS: THE COST OF DIABETES
The numbers are quite stunning. According to the American Diabetes Association, over 30 million Americans are living with diabetes.
- The total spending on diabetes grew 26% over 5 years: from $245 billion in 2012 to $327 billion in 2017
- The US healthcare system spends $1 in $7 on treating diabetes and its complications
- Diabetics spend about 2.3 more on medical expenses than their non-diabetic counterparts
- On average, patients with diabetes spend $16,752 out-of-pocket per year, of which $9,601 is attributed to diabetes
What about the cost of medicine? The daily regimen with insulin (or some newer treatments) hits a patient’s pocket hard. But medical supplies and health care services are also a significant cost burden. Below is a breakdown of how the cost is distributed in diabetes care:
- In-patient care: 30% of the medical spend
- Prescription medications to treat diabetes-related complications: 30% of the total spend
- Anti-diabetes agents and diabetes supplies, including insulin pumps: 15% of the spend
- Doctor’s office visits: 13% of the spend
There are indirect ways of looking at the cost of diabetes too:
- Absenteeism, that could lead to lost wages for the patient
- Inability to work due to disease-related disability
- Pain and suffering
- Unpaid caregiver time
WHAT DOES INSURANCE COVER?
Government-sponsored insurance (Medicare, Medicaid, military) pays for a majority of diabetes costs in the US (67.3%) while private insurance covers 30.7% of the cost. Uninsured patients cover the remaining 2% of costs.
When looking for a health insurance plan, diabetes patients must ensure that the plan covers prescription drugs, supplies and essential medical services.
Are all your supplies and services covered by your healthcare policy? These include:
- Medical devices: insulin pumps, continuous glucose monitors
- Testing supplies: test strips, monitors or meters and glucose control solutions. It is important to find out if your health plan restricts the monthly coverage of test strips. This can be determined by reviewing the plan “formulary” (the list of prescription and generic drugs that are covered by your health plan and specific policies for testing supplies).
- Prescription medications and accessories: insulin or other medication, syringes and needles. Insurance plans do not always cover all the available insulins; it is important for you to know if your specific brand of insulin or other prescription treatment is in your health plan’s formulary. Another important term is your medication’s “tier” in the formulary. Generic or “preferred” medications are usually placed on lower tiers and have lower out-of-pocket costs than higher-tiered medications.
- Laboratory testing: does insurance cover regular blood tests like blood glucose and A1C? Is the lab your doctor uses “in-network”?
- Preventive care: most health plans are required to cover preventive care, free of charge, including diabetes screening for adults with high blood pressure, cholesterol screening, obesity screening and counseling, diabetes screening for pregnant women, etc. Medicare provides free consultation for medical nutrition therapy for patients with diabetes and an annual visit for creating or updating a personal prevention plan.
- Consulting visits with other specialists such as ophthalmologists, podiatrists, etc. to assess diabetes-related complications
- Will insurance pay for consulting with a dietitian or a certified diabetes educator?
- Are health tracking wearable devices covered by your insurance plan?
Check your insurance company’s website for specific coverage information for the above benefits. Detailed information on coverage of diabetes-related services by Medicare can be found here.
THE COSTS FOR THE UNINSURED
While insured patients are not spared the mounting cost of diabetes, the uninsured or underinsured definitely have the shorter end of the stick:
- Uninsured diabetic patients have 60% fewer office visits
- They are prescribed 52% fewer medications
- They head to the emergency room 168% more than those with insurance
- Among the underinsured, those whose blood glucose monitors are not covered have a 5% higher A1C than those with coverage.
SWITCHING TREATMENTS, UNDERSTANDING YOUR SHARE
If your doctor and you have decided that switching your treatment is vital — either a new type of insulin or a new treatment — the next step is to ascertain coverage policies by your health plan. Your doctor may have to request a coverage exception if the treatment is not covered by your plan. Visit Juvenile Diabetes Research Foundation’s website to find additional information on how to navigate switching your treatment.
If the new treatment is covered, make sure you understand your share in the price of the medication based on where it is placed in your health plan’s formulary. You could potentially see an impact on your out-of-pocket cost.
For more on insurance terms, click here.
HOW CAN PATIENTS AND THEIR FAMILIES REDUCE THE COST OF CARE THEY INCUR?
- Avoid skipping doses or treatment to prevent unwanted fluctuations in your blood sugar levels and associated complications such as heart disease, kidney disease, infections, vision damage, all of which can aggravate your health and further add to your cost of care.
- Speak to your care provider, either doctor, nurse, pharmacist or a care coordinator at the clinic, about financial concerns with your care. The American Association of Diabetes Educators offers several resources to find affordable insulin, tools for healthcare savings, and more.
- Online retailers can sometimes offer good deals. Prescription medications are usually cheaper with mail-order pharmacies than retail pharmacy stores. FDA’s BeSafeRx provides tips on identifying a safe and reputable online resource for your medications.
- Pharmacy Assistance Programs. Most pharmaceutical manufacturers offer patient assistance programs that can reduce your co-pays but do not contribute toward your annual deductible.
- JDRF (For Type 1 diabetes). https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/choose-insurance-plan-diabetes/.
- Joslin Diabetes: https://www.joslin.org/.
- American Diabetes Association’s health insurance page: https://www.diabetes.org/resources/health-insurance/health-insurance-update and https://www.diabetes.org/resources/health-insurance/health-insurance-marketplace-people-diabetes.
- American Association of Diabetes Educators: https://www.diabeteseducator.org/living-with-diabetes.
- “Cut Healthcare Costs by Negotiating and Shopping” – by Patients Rising.
From the Editor:
Patients Rising University acknowledges the important contributions of Surabhi Dangi-Garimella Ph.D. in this article. Improving patient access is our mission and we’re happy to utilize a variety of experts to carry that out.