Which is it?

Which is it?

We’re beginning to wonder what the end game is for this debate over the “high” cost of insulin. Are the advocates for lower out of pocket costs doing this so that insulin using patients save money or achieve better outcomes. Listen we have no problem if this is all about money nor do have a problem if it’s about better outcomes. However, it can’t be both. Either this is about helping the patient save money or helping the patient achieve better outcomes.

We mention this as we have read another study that attempts to correlate the “high” cost of insulin to poor patient outcomes. This one appears in JAMA Internal Medicine and is titled Cost-Related Insulin Underuse Among Patients With Diabetes by
Darby Herkert, BS1; Pavithra Vijayakumar, BA2; Jing Luo, MD, MPH3; et al. The study concludes;

“Insulin is a life-saving, essential medicine, and most patients cannot act as price-sensitive buyers. Regulators and the medical community need to intervene to ensure that insulin is affordable to patients who need it. At minimum, individual clinicians should screen all patients for cost issues to help them address these challenges”

Given the authors of this study are from Yale we aren’t surprised by this high minded yet useless conclusion. But there’s more-

“Patients with cost-related underuse were more likely to report lower incomes” really ya think. Now we don’t want to make light of our friends at Yale, but it does not take an advanced degree from a prestigious Ivy League school to know that patients with lower incomes are going to have greater cost concerns than those who are middle or upper income.

“One in 4 patients at an urban diabetes center reported cost-related insulin underuse and this was associated with poor glycemic control. These results highlight an urgent need to address affordability of insulin.” Just in case anyone has forgotten “urban diabetes center” is the politically correct way of referring to poor folk who live in the city most of whom are minorities. Yet that aside these smart researchers never define affordability. At what price will insulin go from being unaffordable to being affordable which of course means it will be used effectively and patients will go from poor glycemic control to good glycemic control.

But let’s not stop there as there is no mention anywhere in this study of what exactly these patients are paying for their insulin. The study does breakdown participants by type of diabetes, annual income, race/ethnicity and what type of prescription drug coverage they have. But there is no mention whatsoever as what they are paying for insulin. Are they paying $20 per month or $100 or more?

Perhaps this is why the authors noted;

“This study has limitations. This single-center study may be limited in its broader generalizability. Given its cross-sectional design, a causal relationship between cost-related underuse and poor glycemic control cannot be established.”

Our contention which no one has bothered to study is insulin could be given away for FREE and we would not see a corresponding improvement in patient outcomes. That there is a causal relationship between the cost of insulin and outcomes. We believe that just because a patient has access to all the insulin, they need that they will use it effectively.

Thankfully our friends at Yale did not blame the high cost of insulin on anyone. They did not venture into the let’s blame big bad pharma for the high cost. Nor did they get into the complex dynamic, all the factors which ultimately determine what a patients pays for their insulin. Nor did they attempt to offer any possible solutions. Nope all they did was state in this one diabetes center there are issues with insulin affordability whatever that means.

This debate over insulin affordability isn’t going away. Yet it doesn’t help matters any to tell us what we already know or offer no possible solutions. This reminds us of all those articles we’ve seen that show how the cost of insulin has skyrocketed over the years. However, what none of these articles mention is even when insulin was cheaper than it is today the majority of patients weren’t achieving better outcomes. There is no hard evidence that proves a causal relationship between the cost of insulin and patient outcomes.

So, which is it? Is it about money or is it about outcomes? As it cannot be about both. You cannot state that the “high cost” of insulin is causing poor control without having any hard evidence to back up this claim. You cannot do a study about insulin affordability and not define just what affordability means. You cannot look at the cost of insulin alone and draw a straight line between that cost and patient outcomes.

Listen we are all for patients with diabetes saving money. As we have stated on numerous occasions diabetes is not just a chronic disease it can be a very expensive disease to manage. Besides the cost of insulin patients must endure the cost of testing supplies, syringes, pens or pumps. And let’s not forget about doctor visits and regular blood work. Managing diabetes is not just a 24x7x365 job it’s also can be a huge financial burden as well.

However, when it comes to achieving better outcomes, we have yet to find one study that proves a causal relationship between costs and outcomes. Everyone believes this to be true but so far no one has proved it be true.

So again, which is it? Is this about saving patients money. Or is it about helping the patient achieve better outcomes. Both by the way are admirable goals.

Frankly we are getting more than a little tired of hearing how the high cost of insulin is the cause of poor outcomes. It’s about time someone prove this to be the case or let’s move on. It’s also time that we stop the charade and acknowledge what this is really about. That we be honest and state this is either about saving money or improving patient outcomes as it cannot be about both. So, which is it?