THE BUSINESS OF DIABETES
On the Cost of Being a Diabetic Patient: Variables for Physician Prescribing Behavior
Steven B. Leichter, MD, FACP, FACE, Sara Faulkner, and Joan Camp, RN
As diabetes care becomes more intensive and complex, the use of medications does as well. Patients with diabetes may often be on a mixture of diabetes medications, as well as other drugs for common associated conditions. These trends are encouraged by studies such as the United Kingdom Prospective Diabetes Study (UKPDS), which endorsed not only complex treatments for hyperglycemia, but also the aggressive addition of anti-hypertensive medications, when necessary, for diabetic patients.1,2 Published guidelines for care also endorse such trends.3
Cost is an issue that has not been emphasized but is an inherent concern as medication use becomes more complex. How expensive are complex treatment regimens for patients? What percentage of patients in a region or area have a pharmacy benefits plan or insurance coverage for medications? To what degree does the cost of medications affect the prescribing physicians when patients do have insurance coverage for their drugs?
The Burden of Drug Costs
No doubt the same pattern is true for diabetes drugs; however, this issue has not been documented completely. The last available national estimate of drug and supply costs for diabetes care was by Huse and colleagues. They calculated that the average annual national patient expenditures in the late 1980s for insulin, syringes, and self-testing equipment and supplies for glucose measurements was $0.9 billion.6 However, this and other contemporaneous estimates did not account for medications for related conditions, such as hypertension and hyperlipidemia. In addition, the oral hypoglycemic medications available at that time cost much less than the drugs that have become available since. Therefore, similar estimates today may prove to be much higher, and the inclusion of medication for related disorders would substantially increase the costs.
Current Medication Use by Diabetic Patients
Stated Cost of Drugs
In the absence of standard pricing guidelines, we survey five area pharmacies to gain an understanding of retail drug cost. As a policy, two of these are chain pharmacies, one is a pharmacy contained within a chain supermarket, and two are local independents. Prices for specific agents vary in all of our surveys by up to 30%. Usually, one of the chain pharmacies offers prices that are the least expensive or close to it, while another is always the most expensive. These prices rarely conform to the prices suggested to us by pharmaceutical representatives unless they have carried out similar surveys of local chains.
The Retail Cost of Diabetes Drugs
A second issue occurs with patients who do have health insurance coverage for their prescription drugs. Many physicians and other providers do not realize that these plans cost profile provider drug use. Providers who have costly patterns of prescribing may eventually get sanctioned or at least cited by the plan. Thus, for many providers, the use of expensive medications may not be totally without its consequences, even when insurance covers a given drug for a patient.
We suggest that physicians and other providers be knowledgeable about drug costs. Drug costs may, in many instances, be a valid consideration in the design of therapy for people with diabetes. Discussing drug costs with patients may help physicians understand both the obstacles to drug use from the patient perspective and the potential negative effects on quality of life that drug costs may exert.
2UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). Brit Med J 317:703-13, 1998.
3American Diabetes Association: Clinical Practice Recommendations 1999. Diabetes Care 22 (Suppl. 1):S1-114, 1999.
4Lagnado L: Drug costs can leave elderly a grim choice: pills or other needs. Wall Street Journal, Nov. 17, 1998.
5Tanoiwye E: Drug dependencyU.S. has developed an expensive habit: now, how to pay for it? Wall Street Journal, Nov. 16, 1998.
6Huse DN, Oster G, Killen AR et al: The economic costs of non-insulin-dependent diabetes mellitus. JAMA 262:2708-13, 1989.
Steven B. Leichter, MD, FACP, FACE, is a clinical professor of medicine at Mercer University School of Medicine in Macon, Ga., and managing director of the Columbus Health Foundation in Columbus, Ga. Sara Faulkner is a student in the Magnet Program, Columbus High School, and Joan Camp, RN, is a nurse with the Columbus Health Education and Research Foundation, in Columbus, Ga.
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