Can Lower Out-of-Pocket Costs Help Improve Diabetes Patients’ Short-Term Health?


Cohort study explores value-based insurance designs, while also determining how one’s place of residency can potentially play a role.

Image Credit: Adobe Stock Images/

Image Credit: Adobe Stock Images/

Over the past 20 years, type 2 diabetes—a disease in which the pancreas has trouble creating insulin and converting it to energy—has increased in prevalence from 10% to 13%. As a result, issues related to both acute and chronic diabetes are also on the rise, which often signifies a rise in medication costs.

When it comes to antidiabetic meds, such as antihypertensives and lipid-lowering drugs, out-of-pocket (OOP) costs continue to increase, and consequently, patients are paying approximately $150-$500 a year for these drugs.

Being that research in this space has been fairly limited, a cohort study published by JAMA Health Forum1 sought to explore whether a value-based insurance design that decreases OOP costs for cardiometabolic medications could improve the short-term health of patients with diabetes.

Using data from a large national commercial (and Medicare Advantage) claims database for commercially insured individuals with diabetes whose employers adopted preventative drug lists (PDLs) between the timeframe of Jan. 1, 2004 and June 30, 2017 (excluding those with Medicare coverage), 10,588 patients ages 12-64 (55.2% male; mean [SD] age, 51.1 [10.1] years) served as the intervention group, while the control group consisted of 690,075 patients whose employers did not adopt PDLs (55.2% male; mean [SD] age, 51.1 [10.1] years).

Participants were analyzed and enrolled for one year before and after the index date, which is the final day of each annual period that begins on the policy date, and the same day of each year after that. Subgroup analysis was also evaluated for patients with diabetes who lived in lower- and higher-income areas. 

Specific data elements that were analyzed included information on enrollment, whether one qualified for a health savings account, deductible level, and census tract of residence, along with medical and pharmacy claims. In this specific study, the available PDL consisted of two types: core and expanded. Antihypertensives and lipid-lowering agents qualified for both lists, while diabetes medicines and supplies were solely on the expanded list.

In this particular study, a majority of the employers only had one plan type or account with the health insurer, so if the account met any of the rules below, it was considered a PDL employer year:

  1. During the first six months of a benefit year, if more than 90% of claims in a month for PDL-listed medications had no co-payment or deductible payment, while 30% or more of non-PDL medications had positive co-payments or deductible amounts, the month was labeled a possible PDL benefit month.
  2. If an employer account met the above requirements for at least five of the first six months of its benefit year, it was considered to have a PDL in that year.
  3. If more than 90% of fills for PDL-listed medications in the year were with a deductible or co-pay of $0, and 30% or more of fills for non-PDL agents with a deductible or co-payment of more than $0.
  4. If there were no fills in the year for PDL medications with a deductible or co-pay of more than $0, and five or more fills for non-PDL agents with a deductible or co-payment of more than $0.

For the PDL group, the number of days that were covered by noninsulin antidiabetic agents increased by 4.7% (95% CI, 3.2%-6.2%) and rose to 7.3% (95% CI, 5.1%-9.5%) for PDL members living in lower-income areas compared with controls. The PDL also experienced a greater use of noninsulin antidiabetic agents, which increased by 11.3% (95% CI, 8.2%-14.5%), 15.2% (95% CI, 10.6%-19.8%) for the lower-income PDL group, compared with controls.

The study investigators also dove into other promising findings, while concluding that overall, “ … a value-based medication benefit that lowers antidiabetic medication out-of-pocket costs was associated with small to moderate increases in antidiabetic medication use and an 8.4% reduction in acute, preventable diabetes complication days. Patients with diabetes residing in lower-income areas experienced a 10.2% relative reduction in complication days after enrollment in PDL plans.”

The results, they added, suggest that perhaps, “a strategy of incentivizing adoption of targeted cost-sharing reductions among commercially insured patients with diabetes and lower income to enhance health outcomes” is necessary.


1. Wharam JF, Argetsinger S, Lakoma M, Zhang F, Ross-Degnan D. Acute Diabetes Complications After Transition to a Value-Based Medication Benefit. JAMA Health Forum. 2024;5(2):e235309. doi:10.1001/jamahealthforum.2023.5309

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