Treating diabetes these days is exciting, considering there are many more options for us to choose from, and it seems like new drugs are coming on the market every other day. While some of these drugs are novel, focusing on a new mechanism of action to combat a complex disease process, other medications seem to provide little advantage over medicines that have been available for some time.
When these new drugs come to market, the pharmaceutical companies tend to offer great rebate programs and/or co-pay savings cards where the patient can get the new medication for as little as zero dollars per month for a period of time, sometimes for 1 to 2 years. However, these programs can’t be used if the patient receives insurance through a government agency, like Medicare or Medicaid. Generally the patient who has Medicaid will have reduced co-pays anyway so this is not really a problem. It’s very problematic or frustrating when treating patients who have a Medicare part D plan, and are on a fixed income but do not qualify for additional help or low income subsidy. It’s often difficult to use new, novel medications with these patients because of the increased co-pay for them. Even trying to use basal bolus therapy with synthetic rapid-acting insulins plus the longer-acting basals can be quite expensive for patients. Often, it seems the practitioner is faced with trying to use cheaper medications (if they are not already using them) that may not work as well given duration of disease, or may have more side effects, simply because they are more affordable. If Medicare Part D patients may be able to obtain some of these medications throughout the year, it may be a different story once they fall into the gap. Although the amount the individual patient is responsible for during this period is improving due to reforms, it often is still too expensive. In addition, several articles suggest that increased copays lead to lower adherence. (Cole JA, et al. Pharmacotherapy 2006;26:1157–1164; Schultz JS, et al, Am J Manag Care. 2005;11:306–312; Goldman DP, et al, JAMA 2007;298:61–69)
It’s also frustrating to have to change medicines throughout the year because of the formulary change. Many practices try to be proactive when prescribing by searching formularies ahead of time. However, the formulary available may not be the most current, or the formulary may only be available to the individual patient covered by the plan. Many of my patients don’t quite understand the ins and outs of insurance, let alone understand that I need them to bring in their updated formulary booklet each time they receive one.
I fully support research and development of new entities, the approval and use of new medications when they are beneficial (i.e. empagliflozin and cardiovascular outcomes [N Engl J Med 2015; 373:2117-2128]) as well as the opportunity or availability of insurance. I understand the need for restrictions regarding insurance coverage, the need for formularies, and the need to improve medication use across the board. However, I wish the costs of these newer medications were not as high, and that more programs were available for those that need it most—the patients who fall in the gaps. I also wish the process related to obtaining medications through insurance was less cumbersome and time-consuming. But for now, I’ll keep working with patients to optimize the medications they do obtain, tolerate, and take as well as helping to improve other non-drug measures such as meal planning and physical activity. I’ll keep researching formularies online with the hope that coverage is still the same as well as completing prior authorizations when needed, while holding in my frustrations and remaining hopeful for continued progress in our health care system. Can I just use the best medicine, even if somewhat expensive, in all patients to get the best outcome??