First Look: Effects of the Medicare Out-of-Pocket Cost Cap on Persistence to Basal Insulin

Session Description: Diabetes is the seventh leading cause of death in the U.S. and incurs annual costs of more than $330 billion on the U.S. healthcare system. Treatment with basal insulin is recommended for individuals that fail to meet glycemic targets, though insulin continues to be underutilized. In 2020, PQA membership endorsed Persistence to Basal Insulin (PST-INS), a health plan performance measure that evaluates the percentage of individuals 18 years and older who were treatment-persistent to basal insulin during a measurement year. PST-INS was developed to meet a specific need for quality measurement; prior to its development, no quality measures addressing insulin use existed in Medicare Part D quality programs.
In 2023, the Inflation Reduction Act included an out-of-pocket $35 monthly cost cap on insulin for Medicare beneficiaries. PQA partnered with Inovalon to explore the impact of the cost cap, comparing rates of persistence to basal insulin before and after implementation of the cost cap using PQA’s PST-INS measure at the population level as well as across a variety of subgroups. This impact analysis provides early insights into the effects of this important policy change, the results of which have far-reaching implications for patients, policymakers, health plans, providers, manufacturers, and other healthcare stakeholders, especially as other medications are being considered for price negotiation and price caps.