Data Highlight Potential Insulin Cost Cap Savings for Pediatric T1D Population

July 30, 2020
Gianna Melillo
Gianna Melillo

Gianna is an assistant editor of The American Journal of Managed Care® (AJMC®). She has been working on AJMC® since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey.

Insulin cost-sharing caps may benefit children and young adults with type 1 diabetes (T1D), according to new research published in JAMA Pediatrics.

Insulin cost-sharing caps may benefit children and young adults with type 1 diabetes (T1D), according to new research published in JAMA Pediatrics.

Rising costs of insulin have long been a major roadblock for individuals with diabetes, leading some patients to resort to drastic measures such as insulin rationing. Between 2002 and 2013, insulin prices rose from $4.34/mL to $12.92/mL, while estimated spending for insulin per patient increased from $231 to $736.

One of the methods states and insurers utilize to improve insulin affordability is through cost-sharing caps. In 2019, Colorado became the first state to implement a $100 cap for a 30-day insulin supply while Cigna also instituted a $25 cap.

To combat rising prices at the federal level, President Trump recently signed 4 executive orders on drug prices, one of which directs federally funded community health centers to pass on 340B discounts they receive for insulin directly to patients. Under the order, individuals would also be able to re-import their own insulin from Canada, HHS Secretary Alex Azar said. In May, CMS announced seniors in certain Part D and Medicare Advantage plans will see insulin cost caps in 2021.

In a cross-sectional analysis, researchers utilized 2018 IBM MarketScan Commercial Database information to estimate the potential change in insulin out-of-pocket spending among privately insured children and young adults with T1D if national $25 and $100 caps were implemented.

All individuals in the study were continuously enrolled in private insurance (either from medium or large employers) in 2018 and between the ages of 1 and 21 years.

The researchers calculated mean and median annual insulin out-of-pocket spending (sum of copays, deductibles, and coinsurance) with and without caps. “Under a $25 cap, we constrained out-of-pocket spending for insulin prescriptions to $25 if days supplied was 30 days or less, $50 if days supplied was between 31 and 60 days, $75 if days supplied was between 61 and 90 days, and so on,” they write.

Of the 12,185 individuals included, 2088 (17.1%) were aged 1 to 11 years, 5054 (41.5%) were aged 12 to 17 years, and 5043 (41.4%) were aged 18 to 21 years, and 3116 (25.6%) were high-deductible health plan (HDHP) enrollees.

For those not enrolled in HDHPs, mean (SD) annual out-of-pocket spending was $494 ($640). In addition:

  • Annual out-of-pocket spending exceeded $1000 for 1538 patients (12.6%) and comprised copays ($303 [61.3%]), deductibles ($77 [15.6%]), and coinsurance ($114 [23.1%])
  • A $25 cap would benefit 7302 patients (59.9%); their annual out-of-pocket spending would decrease from $741 to $261 (mean decrease, $481)
  • A $100 cap would benefit 2151 patients (17.7%); their annual out-of-pocket spending would decrease from $1343 to $786 (mean decrease, $558)

For individuals enrolled in HDHPs:

  • Mean annual out-of-pocket spending was $643 (741)
  • Median (25th and 75th percentiles) spending was $428 ($102-$917)
  • Annual out-of-pocket spending exceeded $1000 for 677 patients (21.7%) and comprised copays ($238 [37.0%]), deductibles ($171 [26.5%]), and coinsurance ($235 [36.5%]).
  • A $25 cap would benefit a greater proportion of HDHP enrollees than nonenrollees (2277 of 3116 [73.1%] vs 5025 of 9069 [55.4%]; P&thinsp;<&thinsp;.001)
  • Among those who would benefit, annual out-of-pocket spending would decrease more among HDHP enrollees ($628 vs $414; P&thinsp;=&thinsp;.02)
  • A $100 cap would benefit a greater proportion of HDHP enrollees than nonenrollees (994 of 3116 [31.9%] vs 1157 of 9069 [12.8%]; P&thinsp;<&thinsp;.001)
  • Among those would benefit, annual out-of-pocket spending would decrease to similar degrees ($549 vs $565; P&thinsp;=&thinsp;.60)

A lead author of the study, Kao-Ping Chua, MD, PhD, put the findings in perspective, explaining how in 2018, 40% of Americans did not have enough savings to pay for a $400 emergency, according to the Federal Reserve Board.

“Cost-sharing caps don't help the uninsured and don't address the underlying problem of high insulin prices,” Chua said. “However, our study shows that caps could be a useful stop-gap measure to improve insulin affordability until more comprehensive reforms are implemented."

Exacerbating insulin unaffordability, the coronavirus disease 2019 (COVID-19) pandemic has subsequently left millions of Americans without jobs and health insurance coverage.

Job losses between February and May 2020 due to COVID-19 resulted in 5.4 million Americans losing their health insurance compared with the 3.9 million adults who lost insurance during the Great Recession in 2008-2009.

“Unfortunately, patients who lose health insurance and cannot afford insulin are becoming additional victims of the COVID-19 pandemic,” Chua noted.

Reference

Chua K, Lee JM, Conti RM. Potential change in insulin out-of-pocket spending under cost-sharing caps among pediatric patients with type 1 diabetes. JAMA Pediatr. Published online July 27, 2020. doi:10.1001/jamapediatrics.2020.1065