Payer Reimbursement Differences in Diabetes Treatments: Public vs Private

A recent study published in the American Journal of Managed Care compared the payer benefits of using cost-effectiveness estimates to help inform step therapy policy decisions for diabetes patients.

The researchers conducted a cost-effectiveness analysis—which they note is useful to a health plan when estimates are specific to a utilization management policy question—to assess the 3-year cost-effectiveness of “adding a sodium-glucose cotransporter 2 (SGLT2) inhibitor vs switching to a glucagon-like peptide-1 receptor agonist (GLP-1 RA) in patients with type 2 diabetes who are on metformin and a dipeptidyl peptidase-4 (DPP-4) inhibitor from both private and public payer perspectives in the United States.”

“Assuming a $50,000 willingness-to-pay threshold,” Anna Hung, PharmD, PhD, Duke Clinical Research Institute, Durham, NC, and colleagues explained, “adding an SGLT2 inhibitor was cost-effective compared with switching from a DPP-4 inhibitor to a GLP-1 RA from a private payer perspective but not from a public payer perspective.”

The study utilized a decision-analytic model for with the main effectiveness measure was achieving goal glycated hemoglobin level. The researchers also measured for adverse effects, discontinuation rates, and performed a one-way, probabilistic sensitivity analysis.

According to the results per 100 patients, adding an SGLT2 inhibitor resulted in an added $3.9 million and 93 patients reaching goal A1C compared with switching from a DPP-4 inhibitor to a GLP-1 RA.

From these results, the incremental cost-effectiveness ratio per patient to achieve goal A1C levels was $42,125 and $103,829 in the private payer and public payer groups, respectively. The researchers noted, “These results were most sensitive to changes in drug costs and the proportion of patients achieving A1C goal or discontinuing.”

“This study highlights how differences in payer reimbursement rates for medications can lead to contrasting results,” concluded researchers of a recent study.

—Edan Stanley

Reference:
Hung A, Jois B, Lugo A, Slejko JF. Cost-effectiveness of diabetes treatment sequences to inform step therapy policies. Am J Manag Care. 2020;26(3):e76–e83. Published 2020 Mar 1. doi:10.37765/ajmc.2020.42639