Pricier Diabetes Care for Low-Income Patients With Marketplace Insurance?

For Coloradans with diabetes and lower incomes, those eligible for Medicaid saw better antidiabetic agent access than those covered by one of the state’s subsidized Marketplace insurance plans, a new study found.

Looking at nearly 23,000 patients with diabetes living in the state, those on Medicaid had both higher prescription drug utilization and lower drug costs compared with individuals enrolled in one of Colorado’s subsidized state-based Marketplace plans, Peggah Khorrami, MPH, of Harvard T. H. Chan School of Public Health in Boston, and colleagues reported in JAMA Network Open.

More specifically, those enrolled in a Marketplace plan had significantly lower rates of filling a dipeptidyl peptidase 4 inhibitor (DPP-4 inhibitor) prescription (adjusted difference -3.7%, 95% CI -5.3 to -2.1) or a sulfonylurea prescription (-6.6%, 95% CI -8.9 to -4.3) than those enrolled in Medicaid.

While rates of insulin use weren’t significantly different between the two groups, there was a big difference when it came to out-of-pocket costs for the treatment.

On average, out-of-pocket costs for insulin ranged from 76.7% to 94.7% lower for Medicaid beneficiaries. Average yearly co-pays for all insulin brands were also higher with the Marketplace-based insurance than with Medicaid. Total annual costs for insulin were higher with the Marketplace insurance save for just three types of insulin (Humulin N, Humulin R, and Novolog 70/30).

As for non-insulin prescriptions, similar trends followed. On average, out-of-pocket medication costs were 84.4% to 95.2% lower with Medicaid, and total costs were 9.4% to 54.2% lower as well.

Not surprisingly, the biggest differences in adjusted monthly co-pays were seen with three categories of brand-name only drugs:

• DPP-4 inhibitors: $21.93 higher with Marketplace

• GLP-1 agonists: $50.03 higher with Marketplace

• SGLT2 inhibitors: $20.72 higher with Marketplace

These differences are likely due to differences in drug pricing rules with Medicaid, Khorrami’s group pointed out. “By statute, Medicaid programs receive the larger of a mandatory rebate and the best price that brand-name manufacturers offer to the private market as well as additional rebates to account for drug price increases over time that exceed inflation.”

“Prices for brand-name oral noninsulin medications such as DPP-4 inhibitors and GLP-1 agonists have increased yearly since their introduction to the market starting in 2005, adding to the rebate that Medicaid programs receive,” the researchers explained.

By contrast, they added, “brand-name manufacturers set drug prices for private markets at the level that they choose, and any negotiation that occurs with the Marketplace insurer or its pharmacy benefits manager results in smaller overall rebates.”

Other than sulfonylureas, all drug classes had higher total monthly costs with Marketplace insurance, as well, the study showed.

Overall, an adjusted model found that patients with Marketplace plans shelled out an average of $225.14 more annually in total pharmacy out-of-pocket costs than Medicaid beneficiaries.

“The low out-of-pocket costs may reflect the better financial protection provided by Medicaid compared with subsidized private insurance (all of the Marketplace enrollees likely qualified for cost-sharing reductions under the [Affordable Care Act]),” Khorrami’s group suggested.

In addition, the researchers said, “although policy makers have voiced concerns about the scope of coverage in Medicaid compared with private insurance, in our study, this patient population with low income and at high risk of negative health outcomes appeared to have better access to newer (and more expensive) medications in Medicaid than in Marketplace plans and less financial burden in filling those prescriptions.”

The cross-sectional study included data on 22,788 low-income patients between the ages of 19 and 64 with diabetes in Colorado. A total of 20,245 of these patients were enrolled in Medicaid and 2,543 were enrolled in a Marketplace plan.

All patients had incomes between 75% and 200% of the federal poverty levels between 2014 and 2015 (median 106% for the Medicaid-eligible group and 168% for the subsidized Marketplace plan-eligible group). Those insured by one of the Marketplace plans tended to be older and male.