A composite 26-year-old's admission for diabetic ketoacidosis after rationing insulin is carried back, in this NU506 Unit 10 system analysis, through dependent coverage rules, high-deductible plan design, list prices and rebates, and state caps that stop at self-funded plans, to the bodies able to change each one. Searches like "nu 506 unit 10 assignment example", "nu506 unit 10 sample" and "nu506 unit 10 example" land here.
Three Days in the ICU After His Twenty-Sixth Birthday: A System Analysis of Insulin Rationing, From a Ketoacidosis Admission Back to the Rules and Prices Behind It
[Student Name]
Purdue University Global
NU506: Health Policy, Ethical, and Legal Perspectives of the Health Care System
Unit 10 Assignment
[Instructor Name]
[Date]
The patient and his plan are composites; the statutes, prices and research cited are published. Prices and caps are recorded as of the date of writing.
The Consequence
Mr. K., 26, has had type 1 diabetes since age 11. In March he was admitted through the emergency department with diabetic ketoacidosis: a pH of 7.08, a bicarbonate of 7 and a glucose above 500. He spent three days in intensive care on an insulin infusion, electrolyte replacement and hourly glucose checks, and two more days on a medical unit. He told the admitting nurse he had been taking about half his usual long-acting insulin for three weeks because his new plan required him to pay the full price of his insulin until he met a deductible, and he could not afford it. His nurses spent a large share of three shifts titrating an infusion for a condition that a monthly prescription would have prevented.
Mr. K. is not unusual. In a survey of patients at an urban diabetes center, about one in four reported using less insulin than prescribed because of cost (Herkert et al., 2019).
Chain 1: The Coverage Cliff at 26
Until his birthday in December, Mr. K. was covered as a dependent on his mother's employer plan, under the Affordable Care Act's requirement that plans offering dependent coverage allow children to stay on until age 26 (42 U.S.C. § 300gg-14, 2024). He then needed his own coverage. His employer, a small logistics company, offered only a high-deductible plan. The chain's links are the statute that sets the age, his mother's plan, which ended his coverage at the end of the month, and his employer's choice of plan design. The authority over the age limit is Congress; the authority over plan design is the employer.
Chain 2: Plan Design That Charges List Price
Mr. K.'s plan had a deductible of $[3,200] and applied it to insulin. Until he met the deductible, he paid the pharmacy's price for each fill, and that price was based on the list price, not the net price the plan paid after rebates. In January, a month's supply of his long-acting and rapid-acting insulins cost him $[610] at the counter. His plan is self-funded by his employer, which matters in Chain 4. The links are the employer, which chose the plan design, the third-party administrator, and the pharmacy benefit manager that set the formulary and cost-sharing rules. The authority is the employer, and, for rules on how cost sharing is calculated, Congress.
Chain 3: List Prices and Rebates
List prices for insulin rose sharply over the past two decades, even for products whose formulas changed little, and a national working group concluded that the insulin supply chain's rebate system was one driver of high list prices and of high out-of-pocket costs for patients whose cost sharing is tied to list price (Cefalu et al., 2018). Manufacturers pay rebates to pharmacy benefit managers in exchange for favorable formulary placement, and higher list prices allow larger rebates. The Federal Trade Commission's interim staff report in 2024 described how pharmacy benefit managers' practices can raise costs for patients and independent pharmacies (Federal Trade Commission, 2024). In 2023, the three largest insulin manufacturers announced list price cuts for several older insulins, and some took effect by January 2024, in part after federal law removed the cap on Medicaid rebates, which had previously limited how much manufacturers owed Medicaid for drugs whose prices rose faster than inflation. Mr. K.'s newer long-acting insulin was not among the products whose list prices fell, so the price cuts that made headlines did not reach his counter. The authorities here are the manufacturers, the pharmacy benefit managers, the FTC, and Congress for rebate and pricing rules.
Chain 4: State Caps That Stop at Self-Funded Plans
Mr. K.'s state capped insulin cost sharing at $[35] a month. The cap did not apply to him. Because his employer's plan is self-funded, it is governed by federal law, and the Employee Retirement Income Security Act preempts state laws that regulate such plans (29 U.S.C. § 1144, 2024). State insulin caps therefore reach fully insured plans sold in the state but not the self-funded plans that cover a large share of workers. The federal $35 monthly cap on insulin cost sharing, enacted in 2022, applies to Medicare enrollees, not to people with employer coverage (Inflation Reduction Act of 2022, 2022). The authority over this chain is Congress, which could extend a cap to self-funded plans, and the state, whose cap reached as far as state law can.
How the Chains Interact
The four chains did not act separately. The coverage cliff moved Mr. K. into a new plan in December, so the deductible reset in January, the most expensive month of his year, just weeks after he enrolled. Plan design tied his cost to a list price that rebates had inflated. The price cuts reached some insulins but not his. And the one protection his state offered could not reach his plan. Any one of these, changed, might have kept him out of the hospital; together they left him paying full list price for a drug he could not live without.
What Would Have Shortened the Stay First
Ranking the possible changes by how directly they would have prevented this admission: first, a cap on insulin cost sharing that applies to all private plans, including self-funded ones, which would have set his January cost at a fixed monthly amount; this requires Congress. Second, exempting insulin from the deductible, which his employer could have chosen and which federal rules allow for preventive care in high-deductible plans. Third, basing cost sharing on the net price after rebates. Fourth, extending dependent coverage or easing the transition at 26. Chain 3's price cuts matter over time, but they would not have helped him unless they covered his insulin.
For nurses, the analysis has an immediate use. Screening every patient with insulin-treated diabetes for cost-related underuse at admission and discharge, and connecting those who ration to manufacturer programs, the state cap if it applies, or a social worker, can catch the next Mr. K. before the system does. The question takes less than a minute: in the past month, have you used less insulin than prescribed, or delayed a refill, because of cost? A yes should lead to action before discharge, not to a note in the chart.
References
Cefalu, W. T., Dawes, D. E., Gavlak, G., Goldman, D., Herman, W. H., Van Nuys, K., Powers, A. C., Taylor, S. I., & Yatvin, A. L. (2018). Insulin Access and Affordability Working Group: Conclusions and recommendations. Diabetes Care, 41(6), 1299-1311. https://doi.org/10.2337/dci18-0019
Federal Trade Commission. (2024). Pharmacy benefit managers: The powerful middlemen inflating drug costs and squeezing Main Street pharmacies [Interim staff report].
Herkert, D., Vijayakumar, P., Luo, J., Schwartz, J. I., Rabin, T. L., DeFilippo, E., & Lipska, K. J. (2019). Cost-related insulin underuse among patients with diabetes. JAMA Internal Medicine, 179(1), 112-114. https://doi.org/10.1001/jamainternmed.2018.5008
Inflation Reduction Act of 2022, Pub. L. No. 117-169, 136 Stat. 1818 (2022).
29 U.S.C. § 1144 (2024).
42 U.S.C. § 300gg-14 (2024).
How this NU506 Unit 10 example is structured
The paper runs backward from the ICU bed, which is how this course reads a system. The consequence is described with enough clinical detail to show its cost, then held steady while the causes are examined, so each chain can be tested against the same admission. Chains are ordered by how directly they produced it: the coverage cliff at 26, plan design that ties cost sharing to list price, list prices and rebates, and state caps that federal law keeps from reaching self-funded plans. Each chain names the institution at every link and the authority over the last one: Congress, the employer, the pharmacy benefit manager and manufacturers, the FTC and the state. A synthesis section shows how the chains compounded one another in a single January, and the paper closes by ranking which change would have kept him out of the unit.
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NU506 Unit 10 questions, answered
How many causal chains should the paper trace?
Usually three or four, each followed to an institution with authority. Fewer can work if each is traced deeply; more tends to thin the analysis. Choose the chains that most directly produced the consequence and show how they interact, since interaction distinguishes a system analysis from a list of contributing factors.
Is a causal diagram required?
Not always, but it helps both writer and reader see how chains connect. A simple diagram with boxes for institutions and arrows for effects, keyed to sections of the paper, is enough. Check whether your section requires a particular model, such as a fishbone or systems map, and follow its conventions if so.
Should recommendations be ranked?
Ranking shows judgment. Order them by how directly and quickly each would change the consequence, and note cost and feasibility. A paper that recommends everything at once, with no priority, leaves the reader unable to act. Each recommendation should name the body that would carry it out, tying back to the chain it addresses.