The primary focus of the pharmacy benefits industry tends to gravitate to the most expensive or new-to-market medication. Why? The unpredictable nature of these medications can impact the financial well-being of many self-funded employer groups. That volatility can be a motivating factor for deploying specific risk management measures. Yet, there has also been a steady trend increase occurring in the chronic condition space that has largely gone overlooked and, as a result, off the radar of many self-funded employers who could be impacted by it. When it comes to chronic conditions, employers can’t afford to ignore the financial impact of diabetes.
Over 37 million people have diabetes, and there are more than 90 million people with prediabetes.1 As a matter of simple economics, there is a current demand for treatment and services, an expectation of exponential growth in that demand, and staying power for that demand that can create a financial risk for benefit plans. Today, not only is diabetes a consistent top three cost driver for medical spend, but it can also represent 15 to 20% of total gross pharmacy spend.2 Yet, where will we be tomorrow should those with prediabetes progress to diabetes? Furthermore, with an average health care spending that is 2.3 times higher than someone without diabetes, these members may also have increased absenteeism, reduced productivity, and an inability to work resulting from a disease-related disability, which creates issues beyond the individual to impact the plan population.3
This stark reality feels even grimmer when you realize that members with diabetes often don’t adhere to their medication treatment and prevention regimens, don’t understand their condition, and resign to live with their condition without considering the long-term effects. To take care of this growing population and protect themselves from rising costs, self-funded employers must understand the impact of diabetes on their employees, the cost of care of diabetes due to healthcare misalignments, and how to help facilitate better outcomes for everyone involved.
A Gap in Specialized Physicians Can Lead to a Lack of Specialized Care
When you go to see your general physician, how much time do they spend with you? What questions are asked of you? Do you know how to respond? What do you consider relevant to mention? Limited face time coupled with a lack of health literacy often stalls care in the general population. It can be a particularly big deal for those with diabetes due to a gap in specialized care.
As mentioned earlier, there is a current demand for treatment and services with an expectation of exponential growth in demand. In 2019, there were roughly 8,000 endocrinologists to care for the millions of diabetes patients in the U.S.4 When you do the math, that’s one specialist for every 4,625 diabetic patients and one for every 12,000 prediabetic patients. There simply aren’t enough endocrinologists to dedicate their time and expertise to service diabetes patients as well as the other conditions they specialize in.
This means most diabetes treatment falls to primary care physicians and even urgent care offices. While these services are of value, individuals with diabetes are complex in nature, have specific beliefs, behaviors, and biases, and often don’t know what they don’t know to effectively communicate to their provider. The primary care provider or urgent care office can be left attempting to treat a diabetic patient to achieve a specific lab value or metric without addressing the patient holistically. They also rely on self-reporting by the patient, which is impacted by their lack of health literacy. Unfortunately, without extensive expertise, these providers may be swayed by patient requests for specific care. This is where misalignment can occur as patients, desiring to live a more fulfilling life, rely on direct-to-consumer advertising to make an informed prescription choice.
If a patient sees several ads and asks their general physician for Ozempic to help manage their weight and prediabetes, the doctor might well say, “sure, let’s try it.” It’s not that this provider is not knowledgeable about the disease – they want their patient to feel heard, involved in their own care, and generate patient satisfaction. Couponing may also be a compounding factor as many providers see an opportunity to provide access at a low patient cost. However, in the same scenario, an endocrinologist with more training in the available medications would likely start with encouraging diet and exercise and place a prediabetic patient on metformin instead of Ozempic, which could save a plan thousands of dollars over the course of a year.
A Growing Impact on the Body and Medical Spend
In the above scenario, it becomes easy to see how diabetes (or even prediabetes) can represent up to 50% of non-specialty pre-rebate drug cost or more.2 Employers are encouraged to be diligent about communicating with their benefits advisor, who should keep an eye on the marketplace as more and more medications to treat diabetes are biologic in nature. These medications come with a higher price tag than traditional tablets, and they are highly advertised to members. Unfortunately, this can lead to a costly and poorly fit prescription regimen.
If the patient is taking an inappropriate medication correctly or the correct prescription incorrectly, the wrong fit for a given patient can lead to complications. So it is important to review the complex nature of these specific patients. The average patient with diabetes takes nine prescriptions and has seven associated medical conditions – four of which are considered chronic.5 High blood pressure, heart disease, respiratory symptoms, obesity, joint disorders, kidney disease, impaired vision, and amputation are all associated with diabetes.6,7,8
Therefore, having conversations with an invested expert can help a patient find the right medication and lifestyle regimen for their body and lifestyle. After lifestyle modifications, medications are often the first line of defense for these patients. If members with diabetes can be empowered and held accountable for the right lifestyle and medication regimen, they can see a reduction in negative outcomes and flourish, a reduction in overall health costs can also occur.
How Human-to-Human Interaction Can Turn the Tide on the Diabetes Dilemma
Because of the growing population and impact of diabetes, employers could use help with engagement, empowerment, oversight, and accountability to improve overall health outcomes.
A lot of people simply “live” with diabetes, and they don’t consider what additional complications can develop in five, 10, or 20 years – conditions such as chronic kidney disease, degenerative eye disease, nerve damage leading to numbness and tingling in the fingers and toes, and even complications that result in amputations. They also don’t understand that their condition can improve to the point of remission when they are intentional about their health care. That is why a human touch with someone who understands the disease is so important.
Patients and employers could benefit from expanding their baseline health literacy surrounding diabetes, including the best treatment options and sticking to a regimen. For instance, studies show that a lifestyle change program can reduce the risk of type 2 diabetes by more than 50% for people at high risk, and people who have the knowledge and support to manage their diabetes are healthier than those who don’t.9,10 So, why not address the person with diabetes holistically instead of looking at the disease in a silo?
This is one reason why RxBenefits has partnered with Tria Health for our newly launched Optimize MyCare Diabetes Support Program. Connecting patients with a pharmacist to fully maximize their care through education and empowerment is the foundation by which RxBenefits and Tria Health improve patient lives while reducing overall healthcare costs.