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Diabetes Medical Emergency Response Task ForceMinutes of the<MeetNo1> 1st Meetingof the 2018 Interim<MeetMDY1> September 20, 2018 Call to Order and Roll CallThe<MeetNo2> 1st meeting of the Diabetes Medical Emergency Response Task Force was held on<Day> Thursday,<MeetMDY2> September 20, 2018, at<MeetTime> 10:30 AM, in<Room> Room 171 of the Capitol Annex. Representative Danny Bentley, Chair, called the meeting to order, and the secretary called the roll.Present were:Members:<Members> Senator Ralph Alvarado, Co-Chair; Representative Danny Bentley, Co-Chair; Senator Reginald Thomas, Representatives Mary Lou Marzian and Addia Wuchner; Chris Bartley, Gregg Bayer, Robert Couch, Chuck O'Neal, Pat Thompson, and Troy Walker.Guests: Stewart Perry, National Diabetes Volunteer Leadership Council.LRC Staff: DeeAnn Wenk, Chris Joffrion, and Becky Lancaster.Where Kentucky Stands in the Fight Against Diabetes: Statistics, Trends, Recent Advancements, and Future OpportunitiesBob Babbage, Babbage Cofounder, stated that Kentucky is ranked seventh in the nation for incidents of diabetes. The Cabinet for Health and Family Services recognizes that 13 out of every 100 Kentuckians have diabetes. Kentucky has approximately 449,000 people with diabetes, and an additional 26,000 people are diagnosed with diabetes each year. Kentucky’s obesity rate is 34.3 percent and ranks eighth in the nation. There is a new urgency around diabetes and the high cost to individuals and health plans. The Kentucky Employee Health Plan (KEHP) has seen success implementing the Diabetes Prevention Program (DPP). DPP is a lifestyle change course taught by diabetes educators who have been trained to help people deal with the extreme difficulties of diabetes. For KEHP the financial benefits of DPP are positive and have been measured by actuaries. KEHP examines supplies and medications differently than other health plans and is more aggressive about providing them to members. The diabetes value benefit in KEHP offers diabetic members a reduced copayment and coinsurance with no deductible, for most all of their maintenance diabetic prescriptions and supplies.Kentucky is not offering DPP as a part of Medicaid. There is a formal working group with representatives from managed care, hospitals, health providers that specialize in diabetes, major insurance companies, primary care associations, and key leaders from public health that are examining the complex aspects and issues of Medicaid as it relates to offering DPP. The Kentucky Prescription Assistance Program (KPAP) serves citizens, who face hardships, in obtaining diabetes related drugs at low or no cost from major companies. In 2018, drug companies have given over $8 million in products to 1,321 Kentuckians in need of assistance. The Diabetes Action Plan (DAP) passed by the Kentucky legislature has been copied by other states. DAP pulls together medical professionals, public health employees, Medicaid employees, and public employees to review diabetes progress in the state. The next DAP report is due in January of 2019. Kentucky was the first state to add licensing of diabetes educators. Kentucky has increased the number of professionals who are qualified and available to teach DPP. Kentucky is the only state to recognize in statute that November 14th is World Diabetes Day.In response to questions from Gregg Bayer, Mr. Babbage stated that there are many initiatives to address the issues of eating healthier and lowering the financial burden for Type 2 diabetic patients. In response to questions from Senator Alvarado, Mr. Babbage stated that Dr. Jeffrey Howard and Dr. Connie White, in the Department for Public Health at the Cabinet for Health and Family Services, would be a good points of contact for legislators and task force members to discuss recommendations and other concerns regarding diabetes in Kentucky.Access to Insulin, Other Diabetes Drugs, and SuppliesGeorge Huntley, Treasurer, National Diabetes Volunteer Leadership Council; Treasurer, Children with Diabetes; Past National Chair, American Diabetes Association; and Chief Operating Officer, Chief Financial Officer, Theoris Group Incorporated, stated that the National Diabetes Volunteer Leadership Council (NDVLC) is a patient advocacy organization committed to improving the safety and quality of life for people with diabetes. Christel Marachand Aprigliano, Chief Executive Officer, Diabetes Patient Advocacy Coalition, stated that the Diabetes Patient Advocacy Coalition (DPAC) is a patient-led policy advocacy organization focused on federal and state diabetes issues in the areas of safety, quality, and access. Mr. Huntley stated that the typical type 1 insulin pump user list price per month is approximately $835. The type 1 insulin pump user with a $35 copayment and a 30 percent coinsurance, the price per month is approximately $116. The majority of that cost is the insulin. The National Center for Health Statistics reports that 43 percent of employees are covered by high-deductible health plans. A high deductible plan requires that pharmacy benefits be part of the deductible. There is an increase in the use of coinsurance in pharmacy benefit and an increase in the list price of drugs. Pharmacy Benefit Managers (PBM) have been instrumental in the rise of the cost of drugs by using higher rebate and discount programs, having exclusive formularies, and implementing non-medical switching of prescriptions. In 2016, 83 percent of employer plans have a pharmacy deductible in comparison to 55 percent in 2006. The average price of brand name drugs have more than doubled from 2008 to 2016. Between 2014 and 2018, more than one-fifth of all the formulary exclusions announced by Express Scripts and CVS were for diabetes related medications and treatments. The Centers for Disease Control and Prevention (CDC) recognizes that one in every three adults with diabetes require insulin every day. The CDC reports that 57 percent of people on insulin are affected by list price at some point in the year. Actuarial studies show that if a patient taking basal insulin pays more than $75 per month, then patients will start to ration their diabetes medications. Insulin rebates can exceed 60 percent. The discounts negotiated by PBM and others are not passed on to patients at the point of sale. Nonadherence to insulin therapy affects many parts of the body and is associated with serious complications. However, if adherence increases 10 percent, the annual healthcare cost is decreased between 9 to 29 percent. The contracts between a PBM and the drug companies are not transparent and it is not known how much of a drug rebate is held by a PBM. The PBM and plan provider will receive more money when the higher priced brand insulin is covered rather than the less expensive biosimilar. Manufacturers increase list prices mostly to pay larger rebates. From 2007 to 2016, the list price of insulin grew 252 percent while the net price grew 57 percent. There are patient assistance programs for individuals that are uninsured or have low income, but the programs can be difficult to navigate. For individuals covered by commercial insurance there are copayment assistance programs that are usually temporary, difficult to navigate, and there is no credit towards the insurance deductible when using these assistance programs. The Blink Health program offers assistance for patients with diabetes; however, there is no credit towards the insurance deductible or out-of-pocket costs. The Lilly Diabetes Solutions Center is a call center offering individual assistance to people with diabetes. Patient advocacy organizations are asking policy makers to consider through legislation: that insulin be on the preventive drug list and be exempt from the deductible; that the PBM be required to pass rebates and discounts on to patients at the pharmacy; ensure that insulin be affordable and accessible; address non-medical switching; pass gag clause bills, and pass patient-centric transparency bills. New legislation should increase adherence, decrease complications, and provide open dialogue on how to increase insulin dosage adherence by decreasing rationing and omission, thereby decreasing hospitalizations. In response to a question from Senator Alvarado, Mr. Huntley stated that the $562 monthly cost of insulin at list price is based on a rapid acting insulin product. In response to questions from Senator Thomas, Mr. Huntley stated that eliminating PBM would solve problems regarding prescription costs. He stated that if the legislature would exempt insulin from a health plan’s deductible, it would force PBM to pass the savings of a rebate on to the consumer providing immediate relief for people with diabetes. Ms. Aprigliano encouraged everyone to read An American Sickness by Elisabeth Rosenthal, for an insight to the history of health insurance in the United States. In response to questions from Representative Wuchner, Ms. Aprigliano stated that DPAC has a website, , that provides data and statistics for patients to take to their human resource department when inquiring about having insulin exempt from their deductible to increase affordability. She has created a worksheet available on the website, to help patients compare current and proposed insurance plan costs. Stewart Perry, National Diabetes Volunteer Leadership Council, stated that that the average doctor treating patients with diabetes spends 1500 hours a year doing appeals on non-medical switching without receiving reimbursement.In response to questions from Representative Marzian, Mr. Perry stated that one out of every four healthcare dollars are spent on diabetic related illnesses. In 2012, Kentucky spent $3.85 billion on medical costs and lost wages due to diabetes. The projected economic impact for 2020 is $6.5 billion in total medical costs and lost wages. KEHP gives diabetic members their diabetes medications and supplies without a deductible or copayment. In response to a question from Dr. Couch, Ms. Aprigliano stated that diabetes patients spend a great amount of time each year asking for prior authorizations for diabetes medicine and supplies that were previously approved. AdjournmentThere being no further business, the meeting was adjourned at 12:35 P.M. ................
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