Are Diabetes Advancements Worth The Cost?

A provocative article on the front page of the Sunday’s New York Times (April 6, 2014) took on the high cost of diabetes care and investigated several areas of medical advancements as well as outrageous pricing. The article asks startling questions such as: Are your favorite diabetes drugs and devices relevant to your treatment? Does the latest type of insulin, the best insulin pump and a CGM make enough difference to your health to pay the price for them?

While we applaud raising the question of expensive health care, especially if it is unnecessary, we wish the article had emphasized that many new drugs, therapies and devices extend life and increase quality of life. Quality of life issues are not trivial for those with a chronic disease where self-care decisions are made each and every day at home, at work, at school and during sleep. There are no vacations for those who have to rely on insulin. The burdens of diabetes, although often accounted as economic, are far more personal.

The New England Journal of Medicine recently released research showing that the rates of diabetes complications, such as heart attacks, strokes, kidney failure and amputations, fell sharply over the past two decades. The research was conducted on more people with Type 2 diabetes than Type 1, but decreases are seen in both types. DCCT and EDIC data directly link hyperglycemia in Type 1 diabetes to increased mortality, blindness, renal failure and painful neuropathy. Glucose levels have been coming down, partly through access to better and more accessible technology.

The Times’ examples of unnecessary and overly expensive medical items could have been better chosen and the tone could have been more respectful. For example, the article states “people don’t need a meter that talks to them.” We have yet to meet someone who uses a talking meter for frivolous reasons. Both young and elderly people with diabetes have higher rates of vision problems and blindness that make seeing their glucose results on a meter screen difficult or impossible. People who are born blind or become blind by accident can also develop diabetes. In these individuals, good self-care decisions can only be made from a talking meter. The Times might also note that the cost of voice-enabled meters has absolutely no impact on the nation’s health care costs.

Questions were raised in the article as to the necessity and high pricing of analogue insulins. Are analogues better than the older insulins; is Humalog really any better than Humalin Regular? And even if these insulins are improved, is the improvement worth the increase in price from $20 for a bottle of Regular to more than $200 for Humalog? Has the 10-fold price increase been accompanied by a similar improvement in effectiveness? The Times rightly points out the disparity between prices for the same vial of insulin in the U.S. compared to other areas of the world. Today’s analog insulins can be purchased for about $30 a bottle outside the U.S. versus over $200 inside the U.S. The article correctly points out that the U.S. is funding much of the cost of drug development while other countries benefit from the competitive bidding of single-payer systems.

Other pertinent questions regarding insulin pumps arose. Are pumps better than injections, are older pumps better than newer smart pumps, is the bolus calculator on one pump better than that on another? Meanwhile, the article disregards what is by far the major reason for upgrades—wear and tear on insulin pumps from daily use. The pumps worn by people with diabetes are generally much older than the cell phone in their pocket or purse. Although a cell phone may allow them to call for help if they are in danger, their pump provides the reliable insulin delivery they need each day. This Times critique seems a bit absurd when you realize that the daily expense for a pump, reservoirs, and infusion sets averages out to only 3 times more than a new iPhone with a yearly contract.

At the end of the article, Continuous Glucose Monitors (CGMs) are briefly described with details on the expensive pricing of replacement “probes” (sensors), and the article dismisses the need for these by anyone but “some patients with unstable diabetes.” The author seems not to understand that the line between hypoglycemia and the normal glucoses that protect against the accelerated aging associated with high glucose levels is very thin. A CGM provides a better floor for those who desire well-regulated glucoses to stand on and acts as a great behavior mod tool that clearly associates behavior with high or low glucose outcomes. Research on CGMs has revealed significant reductions in A1c levels with no increase in hyperglycemia. The daily cost for a CGM currently runs about twice the daily cost of an iPhone using current technology and new technologies are expected to reduce those costs significantly. The Times should be strongly encouraging greater use of “probes” in Type 1 diabetes, a condition that is inherently unstable.

We would like to see questions regarding insulin, pumps, meters, and CGMs drilled down into and discussed in more detail as to their effectiveness and expense. Should reimbursement for therapies and devices be tied to outcomes? Should someone using a pump or CGM receive coverage if they don’t use these to lower high glucose levels, stabilize their glucose, or avoid hyperglycemia? The development possibilities for new drugs has largely evaporated as successful therapies (statins, BP, insulin and diabetes oral agents) have now evolved to cover most major diseases. Drug companies today have chosen to make excessive profits from chronic diseases like diabetes to fund drug development for rare diseases, where a year’s supply of these new medications can cost $40,000 or more a year for those whose lives depend on them.

A patients’ insurance company currently has more control over what meter, insulin or pump they can get than their physician who writes their prescription. A doctor may prescribe 2 bottles of insulin per month for a patient with Type 1 because he needs 1.2 bottles a month, but the insurance company may cover only 1 bottle at the pharmacy. If the doctor prescribes 4 bottles for 90 days, the insurance may cover only a month’s worth at a time at a local pharmacy so the pharmacist may again provide only one bottle. If the person does not have $240 in their pocket to cover the extra bottle that month, their insurance company in essence has rewritten their prescription and chosen hyperglycemia or ketoacidosis as a preferred outcome.

If a physician prescribes a particular test strip for a  meter that reads blood glucose values directly into their pump, an insurance company may deny coverage for this meter and strip. Subsequently, manual entry of glucose values from another meter can lead to dosing errors if the pump wearer mixes up the pump’s fields for their glucose value with that for the for the number of carbs eaten. If a glucose value of 143 mg/dl is entered as grams of carbs, the pump’s recommended dose becomes dangerous. Valuable glucose data can be lost if the pump wearer stops taking the extra step of entering glucose values into their pump.

There is clear logic to the physician and patient’s goals, while the insurer’s goal is short-term economics. When a physician wants to get an exemption for an insurance company’s denial of care for a patient, their staff will spend a half hour or more on hold when calling the insurance company or be forced to write a letter detailing necessity. The author of the Times article seems to have little comprehension of the complexity of care in diabetes and the many ways it can go wrong.

The issues raised by the NY Times article are a beginning to a consideration of health care areas that need to be discussed . Most of the important areas are unrelated to medications and devices. Health care in diabetes today is evolving in ways that do not always have optimal outcomes. We encourage more discussion.

Many people in the diabetes community voiced their opinions after the initial article was written. We suggest you read them all for some great insight into how the community feels about the subject.