Medicare Beneficiaries with Diabetes Less Likely to Receive Newer Glucose-Lowering Therapies

Nilay Shah, PhD

While many have expressed concern over an apparent lack in prescribing of newer glucose-lowering agents, new research from the Mayo Clinic suggests Medicare beneficiaries were even less likely to be prescribed these medications.

A comparison of patients with type 2 diabetes insured with Medicare Advantage and those insured by commercial health plans from 2016-2019, results indicated Medicare beneficiaries were less likely to receive a prescription for glucagonlike peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 (SGLT2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors, with this disparity most severe among patients with lower levels of income.

To further describe and compare trends in the initiation of treatment with the aforementioned agents in older adults with type 2 diabetes, a team led by Nilay Shah, PhD, of the Mayo Clinic, designed the current analysis as a retrospective cohort study using administrative claims data. Using information obtained from the OptumLabs Data Warehouse, investigators identified 382,574 adults between 58-66 years old who were prescribed a medication to lower glucose levels from 2016-2019 for inclusion in the study.

The primary outcome of the analyses were odds of initiating GLP-1RA, SGLT2 inhibitor, or DPP-4 inhibitor treatment, which was assessed in separate logistic regression models adjusted for start and demographic and clinical factors. Investigators noted these models were also used to determine adjusted annual rates of medication initiation according to health plan.

Of the 382,754 included in the study, 172,180 (45%) were enrolled in Medicare Advantage and 210,394 (55%) had commercial insurance. The mean age of the Medicare Advantage beneficiaries was 63.4 (SD, 2.7) years, 53.7% were women, 49.8% were White, and 40.2% had an annual household income of less than $40,000. The mean age of those with commercial insurance was 61.5 (SD, 2.4) years, 41.7% were women, 66% were White, and 18.6% had an annual household income of less than $40,000. Investigators noted a greater burden of diabetes-related complications among Medicare Advantage beneficiaries, with 39.6% reporting 2 or more compared to 16.4% of commercially insured patients.

Upon analysis, results indicated adjusted rates of initiation for all 3 therapies increased in Medicare Advantage beneficiaries and those with commercial insurance. For GLP-1RAs, initiation rates increased from 2.14% to 20.02% between 2016 and 2019 among commercial insurance beneficiaries and from 1.50% to 11.44% among Medicare Advantage beneficiaries. For SGLT2 inhibitors, rates increased 2.74% to 18.15% between 2016 and 2019 among commercial insurance beneficiaries and from 1.57% to 8.51% among Medicare Advantage beneficiaries. For DPP-4 inhibitors, rates increased from 3.30% to 11.71% between 2016 and 2019 among commercial insurance beneficiaries and from 2.44% to 7.68% among Medicare Advantage beneficiaries.

Further analysis indicated rates of initiating either of the aforementioned therapies were lower among Medicare Advantage beneficiaries than those with commercial insurance. For GLP-1RAs, odds of intimating treatment ranged from 0.28 (95% CI, 0.26-0.29) among Medicare Advantage beneficiaries and 0.70 (95% CI, 0.65-0.75) among commercial insurance beneficiaries. For SGLT2 inhibitors, odds ranged from 0.21 (95% CI, 0.20-0.22) to 0.57 (95% CI, 0.53-0.61) for Medicare Advantage and commercial insurance beneficiaries, respectively. For DPP-4 inhibitors, odds ranged from 0.37 (95% CI, 0.34-0.39) to 0.73 (95% CI, 0.69-0.78) for Medicare Advantage and commercial insurance beneficiaries, respectively (P <.001 for all).

Investigators also pointed out results of their analyses suggested odds of initiating therapy with GLP-1RAs and SGLT2 inhibitors appeared to increase with increasing income. In comparison with enrollees reporting a household income of less than $40,000, those with a. Household income of 200,000 or higher were 23% more likely to initiate therapy with GLP-1RAs (1.23; 95% CI, 1.15-1.32) and 16% more likely to imitate therapy with SGLT2 inhibitors (1.16; 95% CI, 1.09-1.24).

“Our study identified gaps in the use of effective, safe, and guideline-recommended medications to lower glucose levels among patients with Medicare Advantage health insurance, particularly among patients who may benefit from preferential use of these medications, such as those with underlying cardiovascular or kidney disease,” wrote study investigators.

This study, “Comparison of Diabetes Medications Used by Adults With Commercial Insurance vs Medicare Advantage, 2016 to 2019,” was published in JAMA Network Open.