Medical claim cost impact of improved diabetes control for medicare and commercially insured patients with type 2 diabetes.

Background: Diabetes prevalence is increasing in the United States, yet the control of critical clinical metrics (e.g., hemoglobin A1c [A1c], blood pressure, and lipids) remains suboptimal. Lower A1c levels have been shown to be associated with lower diabetes complication rates, and reduced medical costs have been reported in individuals with diabetes who have improved glycemic control. While many studies have quantified the impact of A1c control on medical claim costs, this article provides new information on the cost and event impact of better control for all 3 metrics for the commercial population and Medicare population separately.

Objectives: To (a) quantify current type 2 diabetes control rates for A1c, blood pressure, and lipids and (b) model the impact of scenarios for better control of these metrics on diabetes complication rates and complication costs in people with diabetes in commercially insured and Medicare populations.

Methods: 858 adults with commercial (n = 392) or Medicare (n = 466) coverage and type 2 diabetes were identified from approximately 10,000 individuals in the National Health and Nutrition Examination Survey (NHANES; combined series 2005-2006 and 2007-2008). Based on each individual's risk factors, the United Kingdom Prospective Diabetes Study modeling tool was used to project rates of 7 diabetes complications under status quo A1c, blood pressure, and lipid levels and complication rates under better management. Three improved management scenarios were created to model the impact of better control in all commercially insured and Medicare individuals with type 2 diabetes who had A1c, blood pressure, or lipids not at goal and in a subset of individuals whose A1c levels were ≥ 7%, with or without blood pressure or lipids not at goal. Thomson Reuters MarketScan Commercial Claims and Encounters Database (2006-2009) and Medicare 5% sample data (2006-2009), including the eligibility data for each, were used to develop both the average annual costs and per-patient-per-month (PPPM) costs, adjusted to 2012 dollars, in commercially insured and Medicare fee-for-service patients with diabetes and the cost of diabetes-related complications to monetize the impact of reducing complications.

Results: Analysis of NHANES data showed that type 2 diabetes prevalence is 6.1% in commercially insured individuals aged 20 to 64 years and 19.4% in Medicare beneficiaries aged 65 years and older. Of patients with type 2 diabetes, 47% of commercially insured patients and 38% of Medicare patients were found to have A1c ≥ 7%. With improved control of A1c, blood pressure, and lipid levels that were not at goal, as modeled in 3 management scenarios, reductions in the probability of complications across all patients with diabetes ranged from 43% to 67% in the commercial population and 28% to 49% in the Medicare population. The cost savings effect from reduced complications across all patients with diabetes ranged from $67 to $105 PPPM in the commercial population and $99 to $158 in the Medicare population. The high end of this savings range yielded a reduction of about 10% in total costs when compared with an average of $1,090 PPPM in commercially insured patients with diabetes and an average of $1,565 PPPM in Medicare patients with diabetes derived from large claims databases, both in projected 2012 dollars.

Conclusion: Results of this analysis suggest that better control of A1c, blood pressure, and lipids is associated with savings opportunities in commercially insured and Medicare patients with type 2 diabetes. A focus on only patients with uncontrolled A1c offers a somewhat higher per-patient cost reduction than for all uncontrolled diabetes patients but greatly diminishes the number of targeted patients.