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Research Letter
July 27, 2020

Potential Change in Insulin Out-of-Pocket Spending Under Cost-Sharing Caps Among Pediatric Patients With Type 1 Diabetes

Author Affiliations
  • 1Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
  • 2Division of Pediatric Endocrinology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
  • 3Institute for Health System Innovation and Policy, Questrom School of Business, Department of Markets, Public Policy, and Law, Boston University, Boston, Massachusetts
JAMA Pediatr. Published online July 27, 2020. doi:10.1001/jamapediatrics.2020.1065

To improve insulin affordability, several states and insurers have implemented cost-sharing caps. For example, Colorado implemented a $100 cap for a 30-day insulin supply, while the insurer Cigna implemented a $25 cap.1-3 We estimated the potential change in insulin out-of-pocket spending among privately insured children and young adults with type 1 diabetes if national $25 and $100 caps were implemented.

Methods

We conducted a cross-sectional analysis of the 2018 IBM MarketScan Commercial Database, which includes nonelderly patients across the US with private insurance coverage from medium to large employers.4 We included patients aged 1 to 21 years with continuous enrollment in 2018, 1 or more type 1 diabetes diagnosis codes in 2017 (to limit the population to established patients), and 1 or more insulin pharmacy claims in 2018. The Institutional Review Board of the University of Michigan Medical School exempted this study from review, and informed consent was not required. This article followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

We calculated mean and median annual insulin out-of-pocket spending (sum of copays, deductibles, and coinsurance) without caps. We assessed changes under national caps that constrained out-of-pocket spending for a 30-day insulin supply to $25 or $100, assuming caps were applied per prescription. Under a $25 cap, we constrained out-of-pocket spending for insulin prescriptions to $25 if days supplied was 30 days or less, $50 if days supplied was between 31 and 60 days, $75 if days supplied was between 61 and 90 days, and so on. Under a $100 cap, the corresponding maximums were $100, $200, and $300, respectively. Under each cap, we determined the proportion of patients who would benefit and changes in annual out-of-pocket spending among those who would benefit. We repeated analyses among high-deductible health plan (HDHP) enrollees and nonenrollees.

We compared proportions and changes in out-of-pocket spending using χ2 and Wilcoxon rank sum tests. Two-sided P values less than .05 were considered statistically significant. Analyses were conducted using SAS version 9.4 (SAS Institute).

Results

Of 13 255 patients with continuous enrollment in 2018 and at least 1 type 1 diabetes diagnosis code in 2017, 12 185 (91.9%) had 1 or more insulin claims in 2018. Of these patients, 2088 (17.1%) were aged 1 to 11 years, 5054 (41.5%) were aged 12 to 17 years, and 5043 (41.4%) were aged 18 to 21 years, and 3116 (25.6%) were HDHP enrollees. Patients had a mean (SD) of 7.7 (4.8) annual insulin claims. The mean (SD) days supplied per claim was 49.3 (28.4) days.

As shown in the Table, the mean (SD) annual out-of-pocket spending was $494 (640). The median (25th and 75th percentile) spending was $308 (120-638). Annual out-of-pocket spending exceeded $1000 for 1538 patients (12.6%) and comprised copays ($303 [61.3%]), deductibles ($77 [15.6%]), and coinsurance ($114 [23.1%]). A $25 cap would benefit 7302 patients (59.9%); their annual out-of-pocket spending would decrease from $741 to $261 (mean decrease, $481). A $100 cap would benefit 2151 patients (17.7%); their annual out-of-pocket spending would decrease from $1343 to $786 (mean decrease, $558) (Figure).

Table.  Annual Insulin Out-of-Pocket (OOP) Spending Under $25 and $100 Monthly Caps Among Pediatric Patients With Type 1 Diabetes Overall and by High-Deductible Health Plan (HDHP) Enrollmenta,b
Annual Insulin Out-of-Pocket (OOP) Spending Under $25 and $100 Monthly Caps Among Pediatric Patients With Type 1 Diabetes Overall and by High-Deductible Health Plan (HDHP) Enrollmenta,b
Figure.  Potential Change in Insulin Out-of-Pocket (OOP) Spending Under Cost-Sharing Caps Among Pediatric Patients With Type 1 Diabetes Overall and by High-Deductible Health Plan (HDHP) Enrollment
Potential Change in Insulin Out-of-Pocket (OOP) Spending Under Cost-Sharing Caps Among Pediatric Patients With Type 1 Diabetes Overall and by High-Deductible Health Plan (HDHP) Enrollment

Data derived from the 2018 IBM MarketScan Commercial Database.4

Among 3116 HDHP enrollees, the mean (SD) annual out-of-pocket spending was $643 (741). The median (25th and 75th percentile) spending was $428 (102-917). Annual out-of-pocket spending exceeded $1000 for 677 patients (21.7%) and comprised copays ($238 [37.0%]), deductibles ($171 [26.5%]), and coinsurance ($235 [36.5%]). A $25 cap would benefit a greater proportion of HDHP enrollees than nonenrollees (2277 of 3116 [73.1%] vs 5025 of 9069 [55.4%]; P < .001). Among those who would benefit, annual out-of-pocket spending would decrease more among HDHP enrollees ($628 vs $414; P = .02). A $100 cap would benefit a greater proportion of HDHP enrollees than nonenrollees (994 of 3116 [31.9%] vs 1157 of 9069 [12.8%]; P < .001). Among those would benefit, annual out-of-pocket spending would decrease to similar degrees ($549 vs $565; P = .60) (Figure).

Discussion

In 2018, mean out-of-pocket spending for insulin among privately insured children and young adults with type 1 diabetes was $494; for 1 in 8, spending was more than $1000. For perspective, 40% of those in the US lacked the savings to pay for a $400 emergency in 2018.5 For 60% and 18% of patients, out-of-pocket spending would decrease under national $25 and $100 caps, respectively. Caps would benefit HDHP enrollees more than nonenrollees.

Caps have limitations. They do not address rising insulin prices, improve insulin affordability for the uninsured, or limit cost-sharing for diabetes-related supplies, such as insulin pumps. Additional policies are needed to alleviate the financial burden among patients with type 1 diabetes.

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Article Information

Accepted for Publication: January 21, 2020.

Published Online: July 27, 2020. doi:10.1001/jamapediatrics.2020.1065

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Chua K-P et al. JAMA Pediatrics.

Corresponding Author: Kao-Ping Chua, MD, PhD, Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, 300 N Ingalls St, SPC 5456, Room 6E18, Ann Arbor, MI 48109-5456 (chuak@med.umich.edu).

Author Contributions: Dr Chua had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Chua, Conti.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Chua, Conti.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chua, Conti.

Administrative, technical, or material support: Lee, Conti.

Study supervision: Conti.

Conflict of Interest Disclosures: Dr Lee reports serving as a consultant for the Type 1 Diabetes Exchange, receiving grant funding from Lenovo, and serving on the medical advisory board of GoodRx. No other disclosures were reported.

Funding/Support: Dr Chua is supported by career development grant number 1K08DA048110-01 from the National Institute on Drug Abuse. Dr Lee is supported by grants NIH 1-R01-HD-074559-01-A1 and NIH UH3HD087979 from the National Institute of Child Health and Human Development, the Juvenile Diabetes Research Foundation, and the M-Diabetes Center of Excellence at the University of Michigan.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Biniek  JF, Johnson  W. Spending on individuals with type 1 diabetes and the role of rapidly increasing insulin prices. Accessed January 7, 2020. https://www.healthcostinstitute.org/research/publications/entry/spending-on-individuals-with-type-1-diabetes-and-the-role-of-rapidly-increasing-insulin-prices
2.
Cigna and Express Scripts introduce patient assurance program to cap out of pocket costs at $25 per 30-day insulin prescription. News release. Cigna. April 3, 2019. Accessed January 7, 2020. https://www.cigna.com/newsroom/news-releases/2019/cigna-and-express-scripts-introduce-patient-assurance-program-to-cap-out-of-pocket-costs-at-25-per-30-day-insulin-prescription
3.
Reduce Insulin Prices, HB19-1216, 72nd General Assembly (Col 2019). May 22, 2019. Accessed January 7, 2020. https://leg.colorado.gov/bills/hb19-1216
4.
IBM Watson Health. Solution brief: IBM MarketScan Research Databases. Accessed February 8, 2020. https://www.ibm.com/downloads/cas/4QD5ADRL
5.
Board of Governors of the Federal Reserve System. Report on the economic well-being of U.S. households in 2018. Accessed May 20, 2020. https://www.federalreserve.gov/publications/files/2018-report-economic-well-being-us-households-201905.pdf
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