Insights with Impact: managing diabetes costs with data

Prime looks beyond diabetes drugs to address the total cost of diabetes care

May 3, 2017

In a recent study, Prime put hard numbers behind a preventive statin program for members with diabetes. This is real world data. Members with diabetes not taking statins had a 23 percent higher incidence of cardiovascular events than members with diabetes taking statins.1

Diabetes was the number one driver of pharmacy spend in 2016. Members with diabetes can cost 2.5 times more than members without diabetes.2 How can plan sponsors lower those costs? One way might be to treat something besides the member’s diabetes.

Why do members with diabetes cost more?
A big part of these members’ costs aren’t from diabetes. Costs stem from treating co-morbid conditions such as:

High blood pressure
High cholesterol
Cardiovascular disease
Heart attacks
Kidney disease
Prime conducted a large study that quantified these major categories of expenses for members with diabetes.2 The study showed that expenses for a member with diabetes divide up like this:

1/3 Pharmacy benefit
2/3 Medical benefit
Which of these expenses are potentially avoidable?
Most of the pharmacy costs are diabetes related. But half of the medical costs are not diabetes related. This is where potential savings opportunities could lie. Cardiovascular disease made up the largest category of costs under the medical benefit, unrelated to diabetes costs.

Can we reduce those cardiovascular costs? Yes.
Statin therapy can help prevent cardiovascular events. Both the American College of Cardiology and the American Heart Association (ACC/AHA) recommend statin therapy as primary prevention for people with diabetes.3 Unfortunately, the data show that this is not happening.

Of the members with diabetes who were studied by Prime, 78 percent did not have a prescription for statins or were not adherent to their statin therapy. And those not taking statins had a 23 percent higher incidence of cardiovascular events than those taking statins.1

This represents a large opportunity to improve quality of care and decrease costs for these members.

Cardiovascular events among members with diabetes

Cardiovascular events, in 2015, among members with diabetes age 40 to 64 without 2014 atherosclerotic cardiovascular disease diagnosis, by sex, age, and 2014 statin use. Cardiovascular event=acute myocardial infarction, coronary revascularization surgery, or ischemic stroke; adherent to stain=meeting criteria specified in Pharmacy Quality Alliance statin adherence measure.

From insight to impact
Treatment with statins can help members lower their total health care costs. But without clinical evidence, many providers may see use of statin prescriptions only as a guideline. Studies like this provide compelling evidence.

With this research, programs like Prime’s GuidedHealth® can be used to identify and outreach to health care providers who have patients with diabetes who are not already taking statin drugs.

Only examination of integrated medical and pharmacy data can provide these kinds of findings. Why? Because:

Diabetes treatment costs are spread across both medical and pharmacy benefits
Costs for many co-morbid diabetes conditions are also covered under both medical and pharmacy benefits
Cardiovascular claims are covered under the medical benefit, however the statin drugs that might prevent them are covered under the pharmacy benefit
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1. “Any Statin Use Among Commercially Insured Members with Diabetes Age 40 to 64 without History of Atherosclerotic Cardiovascular Disease (ASCVD) and Association between Adherence to Statin Therapy in 2014 and Adverse Cardiovascular Events in 2015.” Bowen K, Gleason PP. J Manag Care Spec Pharm 2107:23(3-a):S43. Accessed at:

2. “Total 2014 and 2015 Claims Expenses Among 250,000 Commercially Insured Members with Diabetes Compared to 1,000,000 Matched Members without Diabetes.” Bowen K, Gleason P. J Manag Care Spec Pharm 2107:23(3-a):S43. Accessed at:

3. Stone, N.J. et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce Atherosclerotic cardiovascular risk in adults. Circulation (2014);129(25) (suppl2):S1–S45.

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