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Two Prime Therapeutics Studies Examine Diabetes Costs, How Appropriate Preventive Care Can Improve Outcomes

ST. PAUL, Minn.–(BUSINESS WIRE)–Two new studies find commercially insured members with diabetes had 2.5 times higher medical and pharmacy spending than members without diabetes matched by age, sex, state of residence and insurer. But those taking a cholesterol-lowering statin for primary prevention of heart disease – a common complication of diabetes – reduced their risk of a cardiovascular event by 23 percent. The studies will be presented next week at the Academy of Managed Care Pharmacy’s (AMCP) 2017 Annual Meeting by pharmacy benefit manager Prime Therapeutics LLC (Prime).

The first study received a silver award from AMCP. Prime researchers studied integrated commercially insured members’ medical and pharmacy claims from 2014 to 2015. Of 5.5 million members who met the study’s criteria, 281,221 (5.1 percent) had diabetes. The mean per member per year (PMPY) total cost of care for members with diabetes was $15,771. This cost was 2.5 times higher than the $6,385 PMPY total cost of care for the matched members without diabetes during the study period. Members with diabetes had an excess $9,386 PMPY total cost of care.

Of the $9,386 in excess costs, 64.8 percent was medical care, while prescription drug claims accounted for 35.2 percent. Among pharmacy claims excess costs, diabetes drugs and supplies accounted for the 72.2 percent. Excess medical care costs were lead by atherosclerotic cardiovascular disease (ASCVD) and conditions commonly due to ASCVD (15.5 percent), followed by diabetes (14.1 percent) and chronic kidney disease (13.7 percent).

“Diabetes accounts for $1 of every $10 in pharmacy benefit expense and there is additional expense for individuals with diabetes administered on the medical benefit,” said Kevin Bowen, MD, MBA, principal health outcomes researcher at Prime. “Prime best serves the needs of our health plan clients by fully understanding total diabetes costs – on both medical and pharmacy benefits. This allows us to focus interventions where they are most useful.”

A second study conducted by Prime, and receiving a bronze award at the meeting, demonstrated an opportunity to improve diabetes care and manage costs through appropriate preventive treatment. Since 2013, the American College of Cardiology (ACC) and American Heart Association (AHA) have recommended primary prevention with statins for these patients, but real-world data had not quantified the value of the guidelines.

Prime researchers identified all continuously enrolled commercially insured members from 2014 to 2015 that were younger than 65 years old and had either a diabetes treatment drug claim other than a single agent metformin, or had one inpatient or two outpatient medical claims for services that had a diabetes diagnosis code. From this group, a random sample of 250,000 members was selected for the claims analysis.

Prime’s researchers found those who were adherent to statin therapy had a 23 percent lower rate of a cardiovascular event, compared with those who were not taking a statin or were not adherent. Of the 250,000 members with diabetes, 204,560 (81.8 percent) of these members were 40 to 64 years old and had no claims for ASCVD. In 2014, just 111,865 of the 204,560 members (54.7 percent) had a claim for a statin, and 55,099 (26.9 percent) were adherent while 56,757 (27.7 percent) were not adherent or were not taking a statin. In 2015, 682 (1.24 percent) of those adherent to statin therapy in the year prior had a cardiovascular event compared to 2,407 (1.61 percent) of those not adherent. Overall, the odds of a cardiovascular event occurring in 2015 was 23.4 percent lower among 2014 statin adherent members.

To improve statin adherence, Prime’s GuidedHealth® program contacts prescribers who have written an anti-diabetic drug for identified members. The prescriber is asked to reevaluate the member’s history and assess if statin therapy could be added to better treat diabetes at a lower cost to health plans and members.

“The ACC/AHA guidelines recommend primary prevention for nearly all persons with diabetes who are age 40 to 75. It’s alarming that only half of these members were taking a statin a year after the ACC/AHA guidelines were released recommending them, and far fewer were taking their medication as prescribed,” said Bowen. “Statins cost just pennies a day, compared to the significant cost of treating a heart attack or stroke. Helping people with diabetes access appropriate statin therapy and stay on them can improve their health and better manage the increasing cost of treating diabetes.”

About Prime Therapeutics
Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Headquartered in St. Paul, Minn., Prime serves just over 22 million people. It is collectively owned by 14 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans.

For more information, visit or follow @Prime_PBM on Twitter.

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