“A group of commercially insured members with diabetes cost two-and-a-half times what a similar group without the condition cost, according to a recent analysis of pharmacy and medical claims data,” Angela Maas writes at AIS Health. “But when members with diabetes took a statin to prevent heart disease per 2013 updated guidelines, their risk for having a cardiovascular event dropped by more than 23%, according to a second study of the same patient population. Both studies were presented by Prime Therapeutics LLC last month at the Academy of Managed Care Pharmacy’s 2017 Annual Meeting. ‘There is some information out there, but not a lot [that looks at] the total cost of care’ across the pharmacy and medical benefits for diabetes, says Pat Gleason, Pharm.D., director of health outcomes at Prime and a co-author of the studies. The first study looked at ‘actual paid amounts to providers,’ he tells AIS Health. The study analyzed 250,000 commercial members with diabetes who were less than 65 years old and matched them based on their age, gender and where they lived with 1 million members without diabetes, from 2014 to 2015. Calculating the mean pharmacy benefit and medical benefit claims per member per year (PMPY), researchers found that the plans paid $15,771 for the first group. ‘This is what we really paid for a person with diabetes,’ says Gleason. The bulk of the total — $11,082 — was from inpatient and outpatient claims adjudicated under the medical benefit. That almost $16,000 compares with $6,385 spent on the members without diabetes. That means ‘we’re expending 2.5 times the rate’ of expenses for this group on the set of people with diabetes, he points out, with a total of $9,386 in excess expenses for people with the condition. Of those excess costs, 64.8% — $6,080 — was for claims under the medical benefit. Within the $3,306 spent under the pharmacy benefit, 72.2%, or $2,386, was for diabetes drugs and supplies.” Angela Maas, “Studies Show Diabetes Members’ Overall Costs, Benefits of Statins,” AIS Health.
Jeanne Pinder is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded ClearHealthCosts.
She was previously a fellow at the Tow Center for Digital Journalism at the Columbia University School of Journalism. ClearHealthCosts has won grants from the Tow-Knight Center for Entrepreneurial Journalism at the Craig Newmark Graduate School of Journalism at the City University of New York; the International Women’s Media Foundation; the John S. and James L. Knight Foundation with KQED public radio in San Francisco and KPCC in Los Angeles; the Lenfest Foundation in Philadelphia for a partnership with The Philadelphia Inquirer; and the New York State Health Foundation for a partnership with WNYC public radio/Gothamist in New York; and other honors.
Her TED talk about fixing health costs has surpassed 2 million views.