Quarter of Insulin Users Skimp Because of Cost: Study Published

A study showing that one in four insulin-treated patients surveyed at an urban US diabetes center were found to be cutting back on insulin use because of cost has been published.

The results, first released at the American Diabetes Association (ADA) 2018 Scientific Sessions in June, as reported by Medscape Medical News, were published December 3 in JAMA Internal Medicine, authored by Darby Herkert, BS, of Yale College, New Haven, Connecticut, and colleagues.

The survey results also reveal that cost-related insulin underuse was associated with worse glycemic control and that more than a third of patients did not discuss the insulin underuse with their clinicians.

"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," Herkert and colleagues write.

"At minimum, individual clinicians should screen all patients for cost issues to help them address these challenges."

In an accompanying editorial, Elisabeth Rosenthal, MD, editor-in-chief of Kaiser Health News, writes, "People with type 1 diabetes are both beneficiaries and pawns in the business ventures of drug makers, device manufacturers, and insurers, and sometimes these companies seem willing to sacrifice a pawn or two for profits."

Citing a 2012 study (Diabetes. 2012;61:2987-2992) in which researchers estimated that children with diabetes born between 1965 and 1980 were living 15 years longer than those born between 1950 and 1965, Rosenthal asks, "Will that 15-year gain now be erased because of the price [of insulin]?"

Those Skimping on Insulin Three Times More Likely to Have Poor Control

The surveys were completed by 199 of a total of 354 eligible patients who had been prescribed insulin and had an outpatient visit at the Yale Diabetes Center between June and August 2017. Of the 199 patients, 51% were women, 61% were white, and 42% had type 1 diabetes.

Cost-related insulin underuse was defined as a "yes" answer to one or more of the following practices because of cost: using less insulin than prescribed, attempting to "stretch out" insulin, taking smaller doses than prescribed, stopping insulin use, not filling an insulin prescription, or not starting insulin in the first place.

Of those who completed the survey, 25.5% (51) reported cost-related insulin underuse.

Type of prescription drug coverage was not significantly associated with cost-related underuse, but patients who did report the practice were more likely to report lower incomes.

Of those who underused insulin because of cost, 61% said they discussed the cost of insulin with their clinicians and 29% changed insulin type because of cost.

In multivariable analysis adjusting for sex, body mass index, diabetes duration, and income, patients who did, compared with those who did not, report cost-related insulin underuse were almost three times more likely to have poor glycemic control, defined as HbA_1c ≥ 9% (43% vs 28%; odds ratio, 2.96; P = .03).

Who's to Blame?

Rosenthal says that the for-profit manufacturers who sell insulin and insulin delivery devices have "increased the price of their products year after year because, simply, they can."

And, she adds, they've spent millions of dollars and filed lawsuits to keep lower-cost competitors off the US market.

Basaglar (Eli Lilly), a biosimilar of Sanofi's Lantus, approved in Europe in 2014, wasn't available in the United States until the end of 2015 because of a lawsuit.

Moreover, Rosenthal says that now it is available in the United States, the price of Basaglar is "only minimally lower" than the original branded product.

She also accuses disease foundations, including the American Diabetes Association and JDRF, and many patient groups of withholding protest until recently, "in part, likely because so many receive funding from pharmaceutical companies."

(Both the ADA and JDRF have recently stepped up calls for more transparency in insulin pricing and other efforts to increase accessibility.)

Until there is a solution, Rosenthal writes that the 25% of patients "will quietly skimp on their insulin, taking less than they need but more, perhaps, than they can really afford."

"Some of them will die," she concludes.

The study was supported by the Global Health Field Experiences Award, Yale College Fellowship for Research in Global Health Studies, and Global Health Field Experiences Seed Funding Award. Herkert has reported no relevant financial relationships. Rosenthal is the author of An American Sickness: How Healthcare Became Big Business and How You Can Take it Back.

JAMA Int Med. Published December 3, 2018. Abstract

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