We’ve all seen the tragic news stories regarding insulin affordability. A November 2022 report published in the Annals of Internal Medicine estimated that 1.3 million US adults with diabetes (about 16.5% of those diagnosed with the disease) have rationed their insulin use in the past year. This includes those that do not refill their medications on time, skip doses, or take smaller doses – all of which can lead to detrimental health outcomes, and in some cases, even death. But with so much federal attention on the topic and numerous manufacturer assistance programs available to patients, it begs the question: why is insulin affordability still a concern in 2023?

People with Type 1 diabetes do not produce enough insulin to regulate blood sugar levels, but those with Type 2 diabetes develop resistance, becoming less sensitive to the effects of insulin. While people with Type 2 diabetes may be able to function with less-than-ideal levels of insulin, those with Type 1 require a daily dose to survive. 

In August 2022, President Joe Biden signed the Inflation Reduction Act into law, which addressed (among many things) the price of insulin. It caps the monthly cost of insulin at $35 for seniors on Medicare. But the law does not address the cost of insulin for the millions of Americans with private insurance. While insulin rationing is more common among low- and middle-income populations and the uninsured, it still occurs among 11% of higher income people and 19% of those with private insurance. Interestingly, rationing was found to be lowest among those with Medicare and Medicaid coverage.

State governments have also taken action, with 20 states now capping copayments on insulin, devices, and diabetes supplies (spoiler alert: Missouri is not one of them). Furthermore, some states, like California, have indicated the intent to start manufacturing their own insulin supply to control costs. As discussed at the 2022 BHC Annual Meeting, a new non-profit funded by a public-private collaboration, called Civica Rx, will also begin selling generic insulin to consumers in the coming year at $30 per vial and $55 for a box of five pens. 

Despite federal and state attention to the matter, a 2020 Commonwealth Fund report found dramatic variation in the total cost of insulin, among both the uninsured and those with commercial coverage, with prices ranging from $0 (e.g., a free sample) to more than $1,500 for the same unit prescription. While insulin ingredient costs have remained relatively stable among employers in the BHC’s Pharmacy Management Initiative over the last three years, aggregate plan costs (before rebates) for two insulin products ranked fifth highest among all brand drugs for PMI employers during the 2021 year. What’s more, a 2020 RAND study revealed that insulin prices in the US were five to ten times higher than other countries in the Organization for Economic Co-operation and Development, and still up to four times higher when accounting for potential rebates.

Rebates, distribution costs, and other fees in the pharmacy supply chain have made the issue complicated to address, especially in the commercial marketplace. But for uninsured patients, who may be left paying list prices without a cost-sharing cushion, the impact of insulin pricing is felt significantly. Uninsured patients may also be more likely to use older formulations of insulin, which can make managing blood glucose levels more challenging.

In response to affordability concerns, insulin manufacturers have invested in financial assistance programs for patients. Novo Nordisk, which supplies over 40% of the world’s insulin, offers several affordable options, including: 

• Up to three vials or two packs of insulin pens for $99
• Unbranded, therapeutically equivalent biologics at a discounted price
• Free, one-time immediate supply of up to three vials or two pen packs
• Income-based patient assistance programs for free insulin
• Human insulin available at national pharmacies for $25 per vial
• Coupons and copay cards to address high out-of-pocket costs

But not all patients are taking advantage of these offerings. So, what can employers do in 2023 to address insulin affordability concerns?

1. Educate employees and their family members on lower-priced insulin options that are available.  
   
2. Consider the impact of cost-sharing for preventive and maintenance medications on your population, especially lower income workers.
3. Monitor insulin adherence with your health plan or PBM and explore clinical programs available to enhance diabetes management. 
4. Amplify the purchaser voice surrounding medication affordability and monitor regulatory actions on a state and federal level.
   

In a country where drug prices continue to make headlines, insulin rationing reminds us that this problem is not just about numbers…it’s about lives. And as with many challenges facing our health care system, it will take the collaboration of many stakeholders to find the right solution. In the meantime, the BHC looks forward to supporting our employer members in their benefit, well-being, and advocacy efforts. For other resources to prevent, better manage, and reverse diabetes in your workforce populations, visit the BHC’s Defeat Diabetes Campaign webpage. 

Warm Regards,

Lauren Remspecher, MPH, CHES

BHC Senior Director, Member Engagement & Communications

ST. LOUIS, MISSOURI, December 6, 2022 – The Leapfrog Group announced today that Mercy Hospital Jefferson and Mercy Hospital South have been named to its 2022 national list of Top Hospitals, the only two hospitals in Missouri to be recognized. The elite award is one of the most competitive honors American hospitals can receive in safety and quality. The winning facilities will be officially recognized today as part of Leapfrog’s 2022 Annual Meeting & Awards Dinner.

The St. Louis Area Business Health Coalition is a Leapfrog Regional Leader, working with providers, purchasers, payers, and patients in Missouri to drive safe, high-quality health care.

“We are thrilled to see two Missouri hospitals on Leapfrog’s Top Hospitals list this year,” said Louise Probst, Executive Director, St. Louis Area Business Health Coalition. “Mercy has demonstrated itself to be a leader in safety and quality in our region year-over-year, and we appreciate their partnership in advancing the value of health care for employers, workers, and their family members.”

The Leapfrog Group is a national nonprofit watchdog organization that rates hospitals on how well they protect patients from errors and infections, as well as the effectiveness of procedures and other care they provide. A total of 115 hospitals were selected as Top Hospitals, including: 12 Top Children’s Hospitals, 32 Top General Hospitals, 13 Top Rural Hospitals, and 58 Top Teaching Hospitals.

“It takes a focused effort by every one of our co-workers to earn a Leapfrog A grade,” said Alisyn Beffa, Mercy Jefferson Chief Nursing Officer and Chief Operating Officer. “Going above and beyond that to earn Top Hospital recognition is an extraordinary achievement only a limited number of hospitals can claim. Maintaining the level of care for a second straight year is something our entire community should be proud of.”

The Top Hospital award is given to teaching, general, rural, and children's hospitals that publicly report their performance through the Leapfrog Hospital Survey and meet the high standards defined in the Top Hospitals Methodology. This includes infection rates, maternity care, and a hospital’s ability to prevent medication errors, among other standards.

"Being recognized as a Top Hospital for a second straight year is an honor,” said Dr, Aamina Akhtar, Mercy South Chief Medical Officer. “But the real honor is what this means for our patients and the entire community. They can be assured that when they need us, we will provide the quality, safe care every patient deserves.”

To see the full national list of institutions honored as 2022 Top Hospitals, please visit www.leapfroggroup.org/tophospitals.

About The Leapfrog Group
Founded in 2000 by large employers and other purchasers, The Leapfrog Group is a national non-profit organization driving a movement for giant leaps forward in the quality and safety of American health care. The flagship Leapfrog Hospital Survey and new Leapfrog Ambulatory Surgery Center (ASC) Survey collect and transparently report hospital and ASC performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog's other main initiative, assigns letter grades to hospitals based on their record of patient safety, helping consumers protect themselves and their families from errors, injuries, accidents, and infections.

About the St. Louis Area Business Health Coalition

The St. Louis Area Business Health Coalition (BHC) is a non-profit organization representing nearly 70 leading employers, which provide health benefits to thousands of lives in Missouri and millions nationally. For 40 years, the BHC has worked to achieve its mission of supporting employer efforts to improve the well-being of their employees and enhance the quality and overall value of their investments in health benefits. To accomplish these aims, the BHC centers its work on providing pertinent research, resources, and educational opportunities to help employers understand best practices for the strategic design (and informed use) of benefits to facilitate high-quality, affordable health care. To learn more, please visit www.stlbhc.org.

Often not recognized, unbranded generic medications are priced lower in the US, at only 84% of the average paid in comparison countries, according to a Rand study. The average out-of-pocket payment for a generic prescription in a US commercial health plan was just $5.30 in 2021. Today, generics account for 9 of 10 prescriptions filled; yet, only 18% of overall US retail prescription drug expenditures. Brand-name drugs, priced 344% higher in the US, based on 2018 data, are responsible for the significant disparity between drug spending in the US and other nations.  

Interestingly, advancing the use of generic medications has been a decades-long cost reduction strategy in the US, ushered in by the Drug Price Competition and Patent Term Restoration Act of 1984. Better known as the Hatch-Waxman Act, unfortunately, this legislation also paved the way for the high-priced brand drug problem the US experiences today. The legislation lengthened the monopolies on brand prescription drugs by up to seven years, despite opposing research that longer patents would substantially increase prescription drug costs to consumers. In an effort to increase the supply of generics and appease the opposition, Hatch-Waxman also enabled manufacturers to make drugs that had gone off patent without having to replicate the same expensive clinical trials. An interesting look back shares the story of how lengthening drug monopolies became the political price for permitting the abbreviated generic drug approval process and the expansion of generic drug use in the US. 

Although generic drugs are among the best deals in the US health care system, the generic drug supply has been plagued with problems: dangerous drug shortages, medications tainted with hazardous materials, manufacturers falsifying safety records, and steep price increases for some drugs, including price gouging schemes. It seems that generic prices have become so low that companies have stop making them or cut corners to be able to sustain their business. Few generic drugs are manufactured in the US any longer – making adherence to US quality standards hard to ensure and inspect. According to this New York Times overview of the problem, “competition for market share at rock-bottom price points has led to chronic shortages, unpredictable price-spikes, allegations of illegal price-fixing, and substandard and even dangerous practices.”  

According to the article cited above, of the top 100 generic medicines that Americans consume, 83 had no US source of active pharmaceutical ingredients, and no American source existed for 97% of the most commonly prescribed antivirals and 92% of the most commonly prescribed antibiotics. Sudden severe generic drug price spikes, consolidation among drug manufacturers, and access to life-saving drugs for US patients during periods of international unrest have garnered the concern of the federal government, which has been working to shape solutions. An interagency report led by the Food and Drug Administration, entitled Drug Shortages: Root Causes and Potential Solutions, three root causes were identified for drug shortages:

(1) Lack of incentives for manufacturers to produce less profitable drugs;
(2) Market failure to recognize and reward manufacturers for “mature quality systems” that focus on continuous improvement and early detection of supply chain issues; and
(3) Logistical and regulatory challenges that make it difficult for the market to recover from a disruption.

The generic drug supply chain problems demand attention and collaboration from all stakeholders, not just government. Many hospital systems in the private sector have come together to take action, employing a uniquely American solution: competition. The product of their efforts, Civica Rx, now delivers high-quality and fairly priced generic medications produced on US soil. SSM Health is one of the founders of this critical collaboration. Join us at the BHC’s 2022 Annual Meeting where you can learn more about Civica Rx's progress from West Health CEO, Shelley Lyford. Focused on philanthropic efforts to lower health care costs and enable successful aging, West Health will also share the results of their recent research with Gallup focused on American perceptions of health care in the post-COVID era.

Warm Regards,

Louise Y. Probst,

BHC Executive Director

Last week, Missouri Foundation for Health hosted a forum entitled At What Cost to shine light on the experiences of Missouri patients when using our health system and the resulting cost impact. Dr. Elisabeth Rosenthal, editor of Kaiser Health Network, started the conversation by sharing insights from her book An American Sickness: How Healthcare Became Big Business. She shared 10 points on why American health care is not a market–based system and some of the unfortunate, yet all too common, situations and billing practices that occur and bring financial harm to patients nationally.

She gave the example of Duexis, a FDA-approved medication that combines Pepcid and Ibuprofen into one pill, and is known to most employers as a prime example of a low-value pharmaceutical. When purchased over the counter, this therapy would cost about $11 per month, but when written by a physician as a single prescription, the cost is over $2,300 a month. Dr. Rosenthal asks the important question, "Why do we allow this?" She noted that no other nation would.

She also cautions patients, that when being told that you may need to spend a night in the hospital, to confirm that your services will be classified as an inpatient stay and not an observation visit. Although the room and level of care is the same, an observation visit is considered outpatient care and will likely be subject to much higher patient cost sharing than an inpatient stay. 

Altarum, a nonprofit research organization, fielded its Consumer Healthcare Experience State Survey to more than 1,100 Missouri adults during April 2022. The survey results unmask Missourians’ perceptions on a wide range of health system issues, including prescription drug costs and health care affordability. A few of the key findings include: 

• 62% of respondents experienced at least one health care affordability burden in the past year, including 51% of respondents with family incomes more than $100,000.
• 82% worry about affording health care in the future;
• 60% of uninsured adults under the age of 65 say they have postponed getting the health care they needed due to cost, as did about half (48%) of insured adults.
• Lower-income respondents and respondents with disabilities reported higher rates of going without care and incurring debt due to health care costs. 
• Adults ages 25-34 years rationed medication due to cost more often than any other age group. 
  

More than two-thirds of respondents believe Missouri’s health care system needs to change. Respondents, across party lines, express strong support for government-led solutions. They cited drug companies, hospitals, and insurance companies as the main drivers of out-of-control costs and identified a number of ways the government could tackle these issues. Sheldon Weisgrau, Missouri Foundation for Health’s Vice President of Health Policy stated, “This is not a partisan issue. Missourians want policymakers working together on solutions that will make a real difference in their lives and ensure people get the care they need at a price they can afford.” Curious about survey results in other states where you may have employees? Check out Altarum’s Healthcare Value Hub. 

The good news is that many provider, health plan, labor union, and employer leaders agree. In fact, over the summer they have been meeting to discuss shared opportunities to improve health care affordability and quality. To learn more about the American public’s perceptions of health care and efforts to reduce the growth in health care spending, we invite you to attend our 2022 Annual Meeting on Friday, November 18, in St. Louis, Missouri. Tickets are complimentary for BHC members, and travel stipends are available to assist out-of-town members in attending. We look forward to sharing our progress with you and celebrating our 40th anniversary as employer partners in health care.

Warm regards,

Louise Y. Probst,

BHC Executive Director

Warm regards, 

Louise Y. Probst

BHC Executive Director