Coverage and Benefit Design
Presented by:
Daniel DeSalvo, MD
Assistant Professor of Pediatrics in the Section of Diabetes and Endocrinology
Baylor College of Medicine/Texas Children’s Hospital
Houston TX
In diverse and underserved populations research shows there are racial and ethnic disparities in diabetes outcomes. Disparities in diabetes technology use has the greatest influence on glycemic disparities between Black, Hispanic and Non-Hispanic White individuals. A study recently published in Diabetes Care found that lower socio-economic status was associated with lower rates of diabetes technology use and higher levels of A1C. Importantly, this gap in technology has widened over time. Data published from the T1D exchange, shows that across all age groups, individuals that use continuous glucose monitoring (CGM) have lower A1C levels compared to those who don’t use CGM.
This webinar will highlight the improvements in glycemic and psychosocial outcomes, along with best practices from recent research findings that support the use of CGM in diverse populations.
Learn MoreSource:
Key Takeaway: In a Medicaid population of youth with Type 1 Diabetes, uninterrupted continuous glucose monitoring (CGM) use was associated with improvements in hemoglobin A1c. Interruptions in use—primarily due to gaps in insurance coverage of CGM—were associated with increased hemoglobin A1c, supporting initial and ongoing CGM coverage in high-risk, publicly insured demographics.
Learn MoreAnnouncing a new white paper based on key findings from the Therapeutic CGM Health Care Stakeholder Summit held on November 7, 2019, in Washington, DC. The stakeholder panel included payer and employer leadership along with clinical experts in the field of endocrinology. The purpose was to gather input pertinent to the coverage and application of therapeutic continuous glucose monitoring (CGM) in managed care settings. Clinical evidence supporting the clinical and economic value of rtCGM was presented and the insights of these health care stakeholders were captured en route to formulating coverage policy recommendations for the future. This input is intended to advance the uptake and appropriate coverage of evidence-based health technology interventions by managed care organizations (MCOs) and various payers.
Learn MoreSource: First Report Managed Care
Key Takeaway: Diabetes is a complex chronic disease that for some Type 1 and Type 2 patients requires the use of intensive insulin defined as 3 or more injections/day or insulin through a pump. The adverse consequences of using insulin are severe and can result in a coma, seizure or even death which leads many patients and caregivers deciding to use less insulin as prescribed preventing achievement of glycemic goals. Real-time CGM with alerts/alarms, remote monitoring and reporting can help patients use their insulin safely and effectively to achieve lower A1Cs, spend less time in hypo- and hyperglycemia and spend more time in range (TIR). The benefits of CGM are seen when it is used to make diabetes treatment decisions such as insulin dosing, diet and lifestyle in a timely manner. Accessing CGM devices via a pharmacy benefit allows patients to start CGM faster, stay safe while using insulin and engage pharmacists, providing additional support and interventions that have been shown to improve diabetes outcomes.
Learn MoreSource: Centers for Medicare & Medicaid Services
Key Takeaway: CMS expanded Medicare coverage for therapeutic CGMs. Most notably, eliminating a requirement that beneficiaries use four fingerstick tests per day prior to accessing CGM. According to the local coverage determination, “there is no evidence to support that frequent SMBG (≥4 times per day) as a prerequisite for initiating CGM use is predictive of improved health outcomes”.
New Coverage Criteria (Effective July 18, 2021)
The revised LCD indicates that Medicare coverage for CGMs will be available if the beneficiary meets the following criteria:
- The beneficiary has diabetes mellitus; and,
- The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
- The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
- Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and,
- Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.
Source: Diabetes Technology and Therapeutics
Key Takeaway: There is growing and compelling evidence that CGM coverage should be offered to all patients who can benefit from this technology regardless of diabetes type and history of SMBG use. The current restrictions, which are based on outdated evidence and questionable assessments, are not supported in the literature. Moreover, they ignore the burden frequent SMBG places on individuals. Given the growing prevalence of diabetes, the persistent preponderance of individuals with suboptimal glycemic control, and the exorbitant and largely preventable cost of diabetes complications, opinion-based constraints should not continue to supplant evidence-based clinical management.
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