The doctors say that the out-of-pocket costs for insulin, ranging from $25 to upwards of $600 a month, depending on insurance coverage, are forcing many of their low-income patients to choose between treatment and paying their bills.
“Some of my patients have to make the choice between rent or insulin,” said Dr. Bismruta Misra, an endocrinologist with the Stamford Health Medical Group. “So they spread out taking insulin [injecting it less frequently than a doctor has prescribed] or don’t take it.”
Experts and recent studies point to drug companies’ long-standing patents and the lack of generic or “biosimilar” insulin as key reasons why the drug is so expensive.
A study by Philip Clarke, a professor of health economics at the University of Melbourne in Australia, reported that the price of insulin has tripled from 2002-2013. The findings were published in a research letter in the April 5 issue of the Journal of the American Medical Association.
Studies report that the cost of insulin has risen by triple-digit percentages.
In the United States. Just three pharmaceutical companies hold patents that allow them to manufacture insulin: Eli Lilly, Sanofi and Novo Nordisk. Put together, the three made more than $12 billion in profits in 2014, with insulin accounting for a large portion. All three hiked their prices in the last five years by 168 to 325 percent, says Dr. Kasia Lipska, an endocrinologist at the Yale School of Medicine.
A diabetic needing insulin but unable to buy it “ultimately will hit our emergency room,” said Dr. Cunegundo Vergara, who specializes in internal medicine at Hartford Hospital.
Vergara says “plenty” of low-income diabetics in the Hartford area are living without physician-prescribed insulin.
Similarly, in New Haven, Dr. Anne Camp, an endocrinologist at the Fair Haven Community Health Center, said she has seen “many patients referred to me because their diabetes is out of control, and the major reason is that they can’t afford their insulin. Many other patients are prescribed insulin, and they don’t return for a follow-up, because they are too embarrassed to admit they can’t afford it.”
About 257,000 Connecticut adults (8.9 percent) have been diagnosed with diabetes. Hispanics and African Americans are more than twice as likely to have the disease compared with whites and they are at greater risk of dying from diabetes-related causes, according to the latest data from state Department of Public Health. Diabetes was the seventh leading cause of death in Connecticut in 2013, killing 664 people.
The U.S. Centers for Disease Control and Prevention reports that the number of Americans diagnosed with diabetes increased from 5.5 million in 1980 to 22 million in 2014. Type 2 diabetes is the most common form.
The higher rates of Type 2 diabetes among African Americans and Hispanics “appear to be based on a number of factors, including [differences in] access to healthy foods, physical activity and genetics,” said Dana Marnane, a vice president for public relations at Greenwich Hospital. The hospital reported a 19.5 percent increase in patients discharged with diabetes as a primary or secondary diagnosis in fiscal year 2015, compared with 2014.
Diabetes is a disease in which blood sugar levels are higher than normal. Insulin keeps blood sugar from rising too high. Without insulin for an extended period of time, a diabetic increases the likelihood of heart attack, stroke or death.
Lipska, the Yale endocrinologist, criticized pharmacy benefit managers—who negotiate with drug companies on behalf of employer and government insurance programs—for being more focused on accepting rebates from drug manufacturers than on bargaining for lower drug prices.
To make insulin more affordable, Lipska said, more competition is needed among insulin manufacturers, and biosimilar products must be made available for patients in the United States. There also is a need for better pricing transparency and regulation, she said.
Eli Lilly spokeswoman Julie Williams said she could not disclose the average cost to manufacture, package and distribute insulin to each user, because manufacturing and distribution costs are proprietary. Eli Lilly introduced the world’s first commercial insulin in 1923.
A biosimilar product hasn’t emerged from other manufacturers, she said, “because developing and manufacturing insulin requires billions of dollars in investment, along with deep scientific and technical expertise.”
She said the reason people say insulin is expensive “are complex and go beyond the medicine’s list price,” Williams said. “One of the primary reasons is the advent of new insurance plan designs—particularly the increased use of high-deductible health plans, which shift more of the cost to the individual.”
Many low-income Americans get insulin through Medicaid, and in Connecticut Medicaid covers insulin and diabetes supplies at no cost. Lilly offers patient- assistance programs that provide free medicine for one year to low-income patients who meet specific financial qualifications. But Williams acknowledged, “Additional solutions are needed so all patients have access to their medicine.”
Novo Nordisk and Sanofi did not return calls seeking comment.
The American Diabetes Association, which represents 441,000 people, says that no diabetic should go without insulin because of “prohibitive costs or accessibility issues.” The association says that “many parties, including pharmacy benefit managers, insurers and retailers are involved in the path of medications” from manufacturer to patient. The ADA advocates “transparency by all parties in their pricing policies and a continued dialogue” to develop lasting, affordable solutions.”
At the Fair Haven clinic, many patients turn to discount retailers, such as Wal-Mart, where a cheaper but older type of insulin is sold, Camp said. But many doctors won’t prescribe it because it often isn’t as effective in managing and treating diabetes, Camp said.
The retail cost for a month’s supply for a typical Fair Haven clinic patient who uses 100 units of insulin daily to treat Type 2 diabetes is about $600 to $800, Camp said. And diabetic patients commonly have other health problems, including high blood pressure and high cholesterol that also require medication and treatment.
“What person making $30,000 a year can lay down $600 a month for insulin?’’ asked Camp, whose clinic treats about 16,000 patients annually, 72 percent Hispanic, 20 percent African American and 80 percent below the federal poverty level.
About 25 percent of the clinic’s patients have no health insurance, and those with private insurance often have “enormous deductibles, such as $4,000 a year,” she said.
Fair Haven participates in the federal 340B program, which requires drug manufacturers to provide outpatient drugs to eligible health care organizations at significantly reduced prices.
“In this country,” Camp said, “we have the potential for really good diabetes treatment. Yet, sadly, because diabetes has become such a high-cost condition, many people can’t get access to it.”
]]>The state Department of Public Health reports that 83,000 adults in Connecticut have prediabetes, which occurs when a person’s blood sugar level is higher than normal but not high enough to be classified as Type 2 diabetes. Nearly 9 percent of adults in the state—about 257,000 people—have been diagnosed with Type 2 diabetes.
Prediabetes has few early warning signs, but a blood test by a primary care doctor can detect at-risk patients. Once detected, changes in diet and exercise, sometimes with medication, can stave off the disease, doctors say.
iStock Photo.
African-Americans are 1.7 times more likely to be diagnosed with diabetes than are whites.
“Prediabetes is completely silent,” said Dr. Bismruta Misra, an endocrinologist at the Diabetes & Endocrine Center at Stamford Hospital. While those with prediabetes might feel a bit sluggish or unusually thirsty, she said, the disease is typically discovered through routine blood tests and not on the basis of symptoms.
The problem is that people who don’t get regular checkups likely don’t get screened, Misra said.
A 2002 study of prediabetic patients by the National Institutes of Health’s Diabetes Prevention Program found that lifestyle intervention—including a change in diet and regular exercise—reduced the incidence of diabetes by 58 percent.
“Prediabetes is a huge problem,” said Maria Daigneault, an advanced practice registered nurse at Hartford Hospital’s Diabetes LifeCare center. “People are walking around with it and have no idea what the risk factors are.”
Dr. Latha Dulipsingh, population management champion at the Center for Diabetes and Metabolic Care at St. Francis Hospital and Medical Center, said that screening for the disease should be done at the primary care level. “But if your doctor is not aware of your risk factors and doesn’t screen,” prediabetes can go undetected and become Type 2 diabetes.
Making people aware of those risk factors—such as a family history, poor diet, and a sedentary lifestyle—might encourage more high-risk people to seek screenings, doctors say.
Lack of sleep is also a major risk factor. Misra cites statistics showing that people who routinely sleep less than eight hours a day have a 22 percent higher risk of developing prediabetes or diabetes than those who get adequate sleep; those who sleep less than six hours have a 48 percent greater risk.
Daigneault said she can often look at a patient and see if he or she is at risk.
“People with central obesity, who carry their weight at the center of their body, are at elevated risk. A bigger waistband is a contributing factor to Type 2 diabetes,” Daigneault said. Other signs include acanthosis nigricans, which Daigneault describes as “a darkening of the skin around skin folds, at the neck or the wrists.”
Misra said, “I would much rather have a patient who is prediabetic than diabetic. We have an opportunity to make a big impact by intervening when people are prediabetic. Once you’re diabetic, you’re diabetic.”
The American Diabetes Association recommends that people with risk factors be screened for diabetes and prediabetes, as should people over age 45.
The Centers for Disease Control and Prevention, which uses data from the National Health Nutrition Examination Surveys to calculate prediabetes population estimates, reports that men are more likely to be prediabetic than women. Prediabetes and diabetes are more common among African Americans and Hispanics compared to whites, the CDC reports. Overall, risk increases with age. On its website, the CDC has a one-minute diabetes quiz to check for risk.
Patricia Baker, president of the Connecticut Health Foundation, said, “People of color are at higher risk, and we don’t know why.”
Baker says that Connecticut’s African-Americans at 13.6 percent and Hispanics at 10.7 percent have significantly higher rates of diabetes than whites at 8.1 percent.
And, she said, data from 1995 through 2013 show an “increased prevalence of diabetes disparity between blacks and whites.” Diabetes-related mortality rates were more than twice as high for blacks than for whites: 92.6 per million black people versus 47.5 per million white people.
But Baker said relatively small lifestyle changes, such as losing seven to 10 percent of your body weight, can significantly reduce the risk of prediabetes and diabetes.
“You can intervene and make a difference,” she said. But, for most people, Baker said, “Something is not happening early enough to stop this disease.”
C-HIT is hosting a free community forum on diabetes from 5 to 7:30 p.m. Thursday at Chrysalis Center, 255 Homestead Ave., Hartford. Live Spanish translation will be provided. The event will include an appearance by Chef Jay Lewis who will offer some healthy food choices. Please register here.
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Approximately 250,000 Connecticut adults (8 percent) have been diagnosed with Type 2 diabetes and an estimated 83,000 state residents don’t realize they have the disease, according to 2011-13 data from the U.S. Centers for Disease Control and Prevention (CDC). Nationally, 29.1 million people (9.3 percent) have diabetes and 8.1 million people don’t know they have the disease, reports the CDC.
Connecticut’s Hispanics (14.6 percent) and African-Americans (14.1 percent) have significantly higher rates of diabetes than whites (6.7 percent). In addition, adults with annual household incomes below $25,000 are 2.3 times more likely to have diagnosed diabetes compared with adults with household incomes over $75,000, according to the CDC.
Health experts cite multiple barriers to comprehensive diabetes care, including inadequate prescription coverage for costly medications and testing supplies; a shortage of Spanish-speaking medical specialists and community health workers; insensitivity among health care providers to cultural food preferences; a lack of neighborhood markets offering healthy foods; and a dearth of safe recreational opportunities.
“We need a more comprehensive set of solutions that happen at the neighborhood level to get at the root causes of diabetes,” said Dr. Mehul Dalal, chronic disease director for the state Department of Public Health. He said the data show “shocking disparities.”
The “Silent Killer”
Diabetes occurs when blood sugar (also known as glucose) levels remain abnormally high because the body doesn’t produce insulin (Type 1 diabetes) or doesn’t use insulin properly (Type 2 diabetes). About 95 percent of people with the disease have Type 2 diabetes, reports the American Diabetes Association (ADA).
Health experts often call diabetes the “silent killer” because people do not experience symptoms during the early years of the disease. But the long-term complications of diabetes can be deadly and costly. Diabetes can lead to serious health issues such as blindness, kidney failure, lower extremity amputations, stroke and heart disease. One report estimates the total cost of diabetes in Connecticut at $2.43 billion annually, reports the ADA.
Research shows some ethnic and racial groups are genetically predisposed to developing diabetes, including Hispanics, African-Americans, Asians and Native Americans.
In Connecticut, blacks and Hispanics are more likely to die from diabetes and experience higher rates of diabetes-related hospitalizations and amputations than whites, according to data from DPH.
• Black adults had 4.2 times the rate of hospitalizations for diabetes and four times the rate of diabetes-related lower extremity amputations compared with white adults.
• Hispanic adults had 2.2 times the rate of hospitalizations for diabetes and nearly twice the rate of diabetes-related lower extremity amputations compared with white adults.
• Black adults had the highest diabetes and diabetes-related mortality rates, followed by Hispanic residents.
“Diabetes is one of the most serious health problems that African-Americans and Hispanics face today,” said Lindsay Scheinblum, manager for fundraising and special events with the Connecticut chapter of the American Diabetes Association. The ADA offers outreach programs to increase awareness among Hispanics and blacks.
While genetics play a role in the onset of diabetes, lifestyle issues such as obesity and physical inactivity are the main culprits behind the increased prevalence of Type 2 diabetes among people of all ages, said Dr. Raul Arguello, chairman of the Pediatric Department at Danbury Hospital and chief of the Pediatric Endocrine and Diabetes Program.
Danbury Hospital Photo
Dr. Raul Arguello
“There has been an explosion of Type 2 diabetes in teenagers nationwide,” said Arguello, a pediatric endocrinologist who noted that diabetes in children was “practically nonexistent” two decades ago. “Now it is a fact of life for many families.”
Expensive Medications
Dr. Bismruta Misra, an endocrinologist at Stamford Hospital, sees some “positive trends” in her medical practice, where up to 60 percent of all patients have diabetes. More people are seeking medical care after gaining health insurance with passage of the Affordable Care Act. Primary care physicians are actively working to identify patients with pre-diabetes — those with high blood sugar levels at risk of becoming diabetic.
But many patients can’t afford the expensive medications and blood sugar testing supplies that are crucial for managing the disease. People with diabetes spend an estimated $7,900 a year on medication and supplies, reports the ADA.
“People living on a fixed income may have to choose between paying for their insulin or paying their rent,” Misra said. “They have health insurance to see a doctor. But their prescription coverage is terrible or they don’t have any at all.”
Other challenges include “structural barriers” that make it difficult for urban and rural residents to manage diabetes, Dalal said. These hurdles include a shortage of neighborhood markets that carry fresh produce and few recreational options in communities that lack sidewalks or aren’t safe.
“For a while, we thought we weren’t getting the right messages across,” he said. “But telling people to eat healthy food and stay active only goes so far. Many patients at higher risk for diabetes live in neighborhoods where that simply is not an option.”
Cultural Barriers
A shortage of medical providers who understand the cultural and language preferences of their patients can create barriers to care, said Arguello, a native of El Salvador who speaks English with his pediatric patients and Spanish with their parents. “People feel more comfortable when they can communicate in their own language,” he said.
Understanding cultural food preferences is also key. For example, white rice — which the body metabolizes as sugar — is the basis of many meals for Hispanics and Asians. Fried foods enjoyed by African-Americans and other ethnic groups increase the risk for obesity. Even Sunday dinners that bring Italian families together can pose a health threat because pasta is a carbohydrate that acts like sugar in the body.
“Certain cultural food staples are not always ideal,” Misra said. “But asking people to stop eating a food that has been a part of their family traditions for years doesn’t work.” Educating patients about portion control, nutrition labels and ways they can limit — not eliminate — certain foods from their diets are more effective strategies, she said.
Home-based Interventions
Home-based interventions with specially trained bilingual community health workers can help low-income residents achieve their Type 2 diabetes goals, said Sofia Segura-Perez, associate director of the Center for Community Nutrition at the Hispanic Health Council in Hartford.
In a recent study, patients who were linked to community health workers successfully attained better blood glucose control. The workers provided education about nutrition, grocery shopping, medications, exercise and diabetes medical management, in addition to assisting with translation services and transportation to doctor visits. The HHC study was conducted in conjunction with the University of Connecticut and Hartford Hospital.
“Community workers can identify things at home that make it difficult for people to adhere to a regimen,” said Segura-Perez. These include “social stressors” such as lacking money to buy food, worrying about eviction, or raising grandchildren because the parents are absent. “These are things that the doctor doesn’t see during an office visit.”
Other studies show that Hispanics who immigrated to the United States are at a greater risk of developing diabetes the longer they live in America. “Acculturation seems to be another factor among Latinos that may impact their risk for diabetes,” she said.
Looking Ahead
Experts point to prevention and self-management initiatives underway to help stem the prevalence of diabetes. State health officials are working with the state Department on Aging to increase the use of diabetes self-management programs in community settings and to offer programs in Spanish and English.
Local organizations, such as YMCAs, are offering evidence-based intervention programs to reach at-risk residents. More health care systems are using health information technology to identify and track patients who would benefit from diabetes prevention and self-management education programs.
Segura-Perez looks forward to a time when insurers cover home-based strategies that help diabetics avoid more costly complications such as hospitalizations and amputations.
“My hope is that people will recognize the value of home-based interventions to the individual and society,” she said.
Information on diabetes is available at these websites:
Connecticut Department of Public Health (diabetes prevention and control program)
American Diabetes Association, Connecticut Chapter
Centers for Disease Control and Prevention (Diabetes Home page)
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