The diabetes community deserves less talk and more action from Congress.
Diabetes is a lifelong condition that affects one in 11 people nationwide and costs the nation $327 billion yearly. While the current political environment has seemingly stalled progress, members can take four viable, bipartisan actions.
Insulin Pricing and Availability
We still haven’t solved the high cost of insulin, a life-sustaining medication. The costs associated with diabetes management, including medication, supplies and technology, have become a financial burden for individuals and families. Absolutely no one should face the dire decision between life-sustaining medications and other basic needs.
Plan members should directly benefit from rebates and discounts negotiated on their behalf by their health plan and Pharmacy Benefit Manager, just as they can benefit from negotiated rates for office visits, lab tests and other services.
While Congress has taken steps to cap cost-sharing for insulin among Medicare Part D enrollees at $35, this should become the national standard.
Two bills address this unresolved issue. One by senators Jeanne Shaheen, D-New Hampshire, and Susan Collins, R-Maine, would cap monthly insulin copays at $35 and aim for harmful PBM practices. Another bill by senators Raphael Warnock, D-Georgia, and John Kennedy, R-Louisiana, would assure the same monthly insulin copay cap for the commercially insured while establishing a program for the uninsured.
Pharmacy Benefit Manager Reform
PBMs play a role in the drug pricing system, ostensibly to lower prices. However, due to vertical integration, a lack of transparency, and other perverse incentives, these multi-billion dollar entities increase costs for patients.
Health plans contract PBMs to negotiate with drug companies. They collect substantial rebates on pharmaceutical drugs, lowering costs for the health plans but not necessarily plan participants. In some cases, Americans are paying $300 for a drug that costs their health plan only $60. This system further disrupts patient access by favoring higher priced, higher rebate products rather than lower cost alternatives, only to drive PBM profits.
Health insurers, PBMs, pharmacies and providers have largely gone unchecked by federal authorities. Still, some states have stepped in to improve transparency and integrity across the supply chain. Other states are going to the heart of the rebate issue and require health plans to share the savings on prescription drugs with patients, reducing out-of-pocket costs.
Bills under consideration, like the Lower Costs, More Transparency Act, would ensure PBMs provide detailed data on prescription drug spending and aggregate rebate information, among other important benefits. However, Congress and the administration will need to act further to confront the perverse financial incentives in the current system.
Prior Authorization Reform
Prior authorization requires physicians to obtain approval from insurance plans before administering medical treatments or tests. These requirements have imposed substantial administrative burdens on healthcare providers, restricting access to quality patient care.
People with diabetes may be subject to a “fail-first” system, ultimately increasing out-of-pocket costs and jeopardizing health outcomes. Sadly, these barriers are created by a health plan’s financial interest rather than medical necessity or clinical efficacy. The American Medical Association found that one in three physicians say that authorization delays have led to serious adverse health events, even death.
People with diabetes and other chronic conditions can benefit from modernizing, enabling doctors to make “real-time decisions” for routine medical interventions. The Improving Seniors’ Timely Access to Care Act would provide a model for commercial plans.
Accessible Treatment for Obesity
Finally, obesity has increased substantially in the United States — more than 42 percent of adults and almost 20 percent of children live with the condition. Obesity is a crisis for America and one of the most significant causes of progression to type 2 diabetes (T2D).
A recent study revealed a 58 percent reduction in the progression from prediabetes to T2DS when lifestyle modifications were employed. However, access to Intensive Behavioral Therapy and anti-obesity medications is limited, especially under Medicare.
If wealthy Americans can access these services and therapies, why can’t Medicare Part D participants? The Treat and Reduce Obesity Act would reform Medicare and ensure improved treatment access. Physicians should be able to refer patients to other healthcare providers like clinical psychologists, registered dietitians, and nutrition professionals to increase access to IBT. TROA would also enable reimbursement for FDA-approved medications that treat obesity and reduce health risks.
A partisan environment doesn’t have to further victimize people living with chronic conditions. It’s not too late for Congress to take action by making healthcare fair, accessible and equitable for all.
