Best practices and rationale for expanding Medicaid access to continuous glucose monitoring

Abstract

Numerous studies have demonstrated that use of continuous glucose monitoring (CGM) significantly improves overall glycemic control and reduces the frequency and severity of hypoglycemic events in individuals treated with intensive insulin, nonintensive insulin, and noninsulin therapies, with reductions in both all-cause and diabetes-related health care resource utilization and lower costs. However, implementation of CGM including prescribing and assessment of the ambulatory glucose profile to make clinical decisions in primary care settings is low. A recent pilot program was initiated at MetroHealth System (Cleveland, Ohio) to implement a CGM integration program for primary care offices throughout the system. Based on the experience and successes from this health system as well as current literature, rationale will be discussed to support the expansion of CGM to individuals enrolled in all Medicaid programs.

Plain language summary

Use of continuous glucose monitoring (CGM) confers significant glycemic benefits on individuals with diabetes who are treated with intensive insulin, nonintensive insulin, and noninsulin regimens in real-world settings. However, implementation of CGM use in primary care clinic workflow is low. The Ohio Managed Care Medicaid payers spent nearly 3 years collaborating on an initiative to improve patient and provider access to CGM, particularly at the primary care level. This article presents a rationale for expanding access to CGM and best practice considerations with a call to expand CGM access to all Medicaid beneficiaries.

Implications for managed care pharmacy

Expanding access to CGM to more patients with diabetes mellitus improves patient outcomes, as supported in the real-world studies showing a decrease in hemoglobin A1c and health care resource utilization. The use of CGMs in patients with diabetes mellitus has demonstrated glycemic benefits for patients on intensive insulin, nonintensive insulin, and noninsulin therapies. This article presents a rationale for expanding access to CGM and best practice considerations with a call to expand CGM access to all.

The availability of continuous glucose monitoring (CGM) has transformed the way individuals with diabetes mellitus manage their disease. Unlike traditional self-monitoring of blood glucose, which provides a “point-in-time” blood glucose value, CGM presents a continuous stream of interstitial fluid or sensor glucose data in real-time numerical and graphical formats. Trend arrows indicate the directionality and velocity of changing sensor glucose levels, which is important as sensor glucose lags behind blood glucose levels. Most CGM devices provide audible alerts warning users when their sensor glucose levels have or are predicted to cross preset upper and lower thresholds. These features enable users to quickly address current and/or impending hypoglycemia and hyperglycemia and make more informed decisions about their medications, diet, and exercise.

Over the past 10 years, numerous studies have demonstrated that use of CGM significantly improves overall glycemic control and reduces the frequency and severity of hypoglycemic events in individuals treated with intensive insulin (multiple daily insulin injections or insulin pump),^1-6 nonintensive insulin (basal insulin),^7-18 and noninsulin therapies in real-world settings.^10,12,16,17 Use of CGM has also demonstrated significant reductions in both all-cause and diabetes-related health care resource utilization (HCRU) and lower costs.^19-23

Although Medicare and most commercial insurance plans have expanded coverage for CGM to include individuals on a single insulin injection per day or based on specific hypoglycemia criteria (regardless of pharmacotherapy), many state Medicaid programs have not expanded access or do not provide coverage for CGM.²⁴ Among Medicaid programs that provide coverage, eligibility criteria varies greatly from state to state. One of the most progressive programs is the Ohio Department of Medicaid managed care payers, which provide CGM coverage for all individuals living with diabetes.²⁵ The expansion of coverage came after a statewide initiative quality improvement pilot lead by the Ohio Managed Care Medicaid payers. One of the sites involved in this quality improvement project was MetroHealth System in Cleveland, Ohio. This article will present rationale for expanding access to CGM to individuals enrolled in all Medicaid programs and describe how the one Ohio health system has been working to break down barriers to CGM use.

Clinical and Economic Benefits of CGM

Based on results from randomized controlled trials and large database analyses,^1-18 national diabetes guidelines recommend the use of CGM as a standard of care for individuals with insulin-treated diabetes and those with problematic hypoglycemia.^26,27 Although the majority of evidence supporting this recommendation was derived from randomized clinical trials or prospective/retrospective database analyses, the clinical value and utility of CGM use has also been demonstrated in real-world clinical practice settings. For example, in their recent prospective, interventional, single-arm study, Grace et al assessed the impact of CGM use in 38 adults with type 2 diabetes (T2D) with a mean hemoglobin A1c of 10.1%.¹⁷ Among these patients, 22 were treated with noninsulin medications prior to CGM initiation. At 6 months, CGM use was associated with a 3.0% decrease in the mean baseline A1c (P < 0.001) and a significant increase in the percentage of time in range (%TIR, standard %TIR range = 70-180 mg/dL), from 57.0% to 72.2%. For individuals with a goal A1c of less than or equal to 7%, the recommended target for %TIR is greater than or equal to 70% along with an average blood glucose of less than 150 mg/dL.²⁸

In addition to the positive clinical outcomes associated with CGM use, large claims database analyses have demonstrated significant reductions in both all-cause and diabetes-related HCRU and lower costs.^19-23 In a retrospective, observational study, Miller et al analyzed data from the MarketScan administrative claims database to assess the effects of CGM on rates of all-cause hospitalizations and acute diabetes-related events in a large cohort of adults with diabetes (n = 10 282) treated with nonintensive insulin therapy or noninsulin medications.²¹ Six months following acquisition of a CGM device, participants experienced significant reductions in all-cause hospitalizations, from 0.177 to 0.151 events/patient/year, P = 0.002), and acute diabetes-related events decreased from 0.076 to 0.052 events/patient/year (P < 0.001).²¹ These decreases were significant in both the insulin-treated and noninsulin-treated patients (−0.040 [P < 0.001] and −0.014 [P = 0.015] events/patient/year, respectively).²¹

Reductions in HCRU have been associated with lower health care costs. As demonstrated in a recent retrospective analysis of administrative claims data from commercial and Medicare Advantage with Part D beneficiaries with T2D, Norman et al assessed diabetes-related costs for physician office visits, inpatient hospitalizations, outpatient visits, emergency department visits, and other medical care.¹⁹ Investigators observed a significant association between CGM use and overall cost reductions, reporting that the average per-patient-per-month (PPPM) costs for diabetes-related medical care decreased by $424 (P = 0.035) after initiating CGM.¹⁹ The reductions were driven primarily by lower diabetes-related inpatient medical costs, −$358 (P = 0.044).¹⁹ Notable reductions in inpatient hospital admissions rates (−0.006 PPPM, P = 0.057) and total hospital days (−0.042 PPPM, P = 0.139) were also observed.¹⁹

In an earlier study, Frank et al used a budget impact model to assess the effects of increasing the proportion of adult and children/adolescent Medicaid beneficiaries treated with intensive insulin therapy who use CGM.²³ Investigators applied a 3-year time horizon to report differences in costs in the first year of CGM use (including setup costs).²³ The analysis included glucose monitoring device costs (CGM and self-monitoring of blood glucose), cost savings resulting from reductions in A1c, severe hypoglycemia events, and hyperglycemic emergencies such as hyperosmolar hyperglycemic state diabetic ketoacidosis.²³ The net change in costs per person to adopt CGM were calculated to estimate the impact of increasing CGM use by 10% on the US Medicaid budget over 1-3 years.²³ The analysis showed that increasing use of CGM by 10% was associated with a $19.4 million decrease in overall costs over the first year and continued to reduce costs by $25.3 million in years 2 and 3.²³

Evolution of CGM Eligibility Criteria

In July 2017, the Centers for Medicare & Medicaid Services (CMS) initiated coverage for use of CGM among Medicare beneficiaries with diabetes who were treated with intensive insulin therapy, multiple daily insulin injections (at least 3 insulin injections per day), or insulin pump.²⁹ However, despite the demonstrated clinical benefits of CGM, many Medicare beneficiaries with diagnosed diabetes were denied access to CGM technology because of the eligibility criteria established by CMS.³⁰ For example, eligibility requires treatment with intensive insulin therapy and documentation of 4 or more self-monitoring of blood glucose tests per day for 90 days.³¹ Responding to pressure from the medical community and patient advocacy organizations,^31,32 CMS eventually removed the self-monitoring of blood glucose requirement in 2021, and in 2023 the agency expanded coverage to all insulin-treated beneficiaries and those with a history of documented severe hypoglycemia, regardless of therapy.³³

Additional Changes to CGM Eligibility Criteria Are Needed

Although CMS has taken significant steps in expanding access to CGM among Medicare beneficiaries, the agency’s policy regarding continued coverage raises concerns. Specifically, coverage will be discontinued in beneficiaries who no longer require insulin or experience problematic hypoglycemia.³³ This stipulation is in direct conflict with the American Diabetes Association Standards of Care in Diabetes, which state that “People with diabetes who have been using CGM, continuous subcutaneous insulin infusion, and/or automated insulin delivery for diabetes management should have continued access across third-party payers, regardless of age or HbA1c levels.”²⁶

Importantly, denying CGM coverage for individuals who have been using CGM may result in a return to poor glycemic control. A recent study by Aleppo et al found that discontinuation of CGM leads to significant deterioration of glycemic control.¹⁰ In their recent, randomized, 2-phase, multicenter study, investigators evaluated the effect of discontinuing CGM after 8 months of use.¹⁰ In the first phase, patients were randomized to either CGM or self-monitoring of blood glucose. At 8 months, CGM use resulted in a significant reduction in A1c compared with the self-monitoring of blood glucose group. CGM use was also associated with significant improvements in %TIR, compared with self-monitoring of blood glucose use. In the second phase, the self-monitoring of blood glucose group continued to use self-monitoring of blood glucose (n = 57) and the remaining CGM users (n = 108) were randomized to continue CGM (n = 53) or discontinue CGM use (n = 53). At 6 months, patients who discontinued CGM experienced significant deterioration in glycemic control. In the group that discontinued CGM use, the mean %TIR decreased from 62% to 50%, which correlates to a 0.5% increase in A1c.³⁴

Discontinuing coverage for CGM in individuals who have achieved optimal glycemic control is analogous to discontinuing coverage for an antihypertensive medication when individuals achieve their blood pressure targets. A call for CMS to update the CGM continuation policy is necessary. The update should be evaluated in an evidence-based manner, evaluating and relying on primary literature as well as national guidelines. This will ensure quality care can be provided to all members.

Addressing Racial and Ethnic Minority and Socioeconomic Disparities

Expanding access to CGM and other diabetes technologies within the Medicaid diabetes population is particularly important given that racial and ethnic minority groups are disproportionately impacted by T2D prevalence, suboptimal glycemic control, and poor clinical outcomes.³⁵ Recent CMS data show that a larger proportion of the Medicaid population is Black or Hispanic compared with the overall US population.³⁶ In addition, a lower socioeconomic status is strongly associated with both higher disease prevalence and poorer clinical outcomes.^37-43 Because the majority of Medicaid beneficiaries have incomes below the poverty line, this population is at increased risk for developing debilitating and costly diabetes-related complications.⁴⁴ Although it is clear that racial and ethnic backgrounds and lower socioeconomic status are major contributors to health disparities, the occurrence and effects of implicit bias must also be considered. Results from recent studies have revealed significant differences in the use of CGM and other technologies between White individuals and individuals from other racial and ethnic minority gruops.^45-48 Ebekozien et al reported racial and ethnic disparities in the use of diabetes technologies among more than 48,000 adolescents and adults with type 1 diabetes (T1D) who were enrolled in the T1D Exchange Quality Improvement Collaborative.⁴⁹ Investigators observed notable racial and ethnic disparities in the percentage of individuals using these technologies (57% Black individuals, 69% Hispanic individuals, and 83% White individuals).⁴⁸

One Health System’s CGM Initiatives

MetroHealth System is a public, safety net health system serving northeast Ohio. The health system includes 22 community medical facilities with more than 1 million outpatient visits annually serving mainly low-income, underserved patients. The patient population treated by the health system is composed of the following patient demographics: insurance type includes 37.6% with Medicaid, 27.3% with Medicare, and 11.3% self-pay; age groups include 35.8% ages 45-64 years and 23.2% ages 65 years and older; and ethnicities include 35.8% Black and 51.9% White. Nearly 20% of patients seeking treatment within the health system are living at or near the federal poverty line. MetroHealth had 4 pharmacy specialists (3.2 full-time equivalents [FTEs]) embedded in primary care clinics focused on diabetes management until summer of 2023 when it expanded to 7 pharmacy specialists (6.2 FTEs). Additionally, starting in the fall of 2020, 3 pharmacy specialists (3 FTEs) in a telemedicine clinic incorporated diabetes management into their existing clinic of anticoagulation and anemia services.

As CGM access improved within Ohio, particularly through Ohio managed Medicaid payers, the pharmacy specialists at MetroHealth took a uniformed approach to offer CGM to all individuals with diabetes and Medicaid as part of their routine for baseline diabetes management. The conversation included explaining the technology and potential benefits, showing demo devices, and offering to send in a prescription to the pharmacy. The pharmacy specialists integrated discussions related to CGM with patients with diabetes and covered under Medicaid as an opportunity to use technology as another tool to help in the management of their diabetes. By offering CGM to all Medicaid patients, it helped to avoid implicit bias from the pharmacist specialists.

Owing to successes by the pharmacy specialists with integration of CGM, one of the pharmacy specialists and a postgraduate year 2 ambulatory care pharmacy resident continued to work across disciplines to break down barriers to integration of CGM into the clinics. This work led to a pilot program at MetroHealth System to integrate CGM at the primary care level. As more and more individuals with diabetes were transitioning from self-monitoring of blood glucose to CGM, several challenges and barriers were identified. First, the software needed to download the CGM readers was not accessible through the health system. Second, many primary care providers (PCPs) were not familiar with the different CGM devices, how to interpret the Ambulatory Glucose Profile, and how to determine drug therapy changes based on the information. Finally, nursing staff also lacked familiarity with and knowledge of CGM to assist with the necessary startup and training for patients.

Addressing a Critical Need

Despite the increased access to CGM resulting from changes in the CMS eligibility criteria, prescribing CGM continues to be low in primary care. Results from a survey conducted by Oser et al found that only 46.6% of the 632 PCPs surveyed have seen a patient with a CGM and 38.6% have never prescribed a CGM device.⁴⁹ Investigators concluded that PCPs are interested in using CGM for patients with diabetes but often lack the resources to implement use of this diabetes technology in their practices. As seen at MetroHealth System, which provides care to approximately 60,000 patients with diabetes, only 3,500 patients were using CGM (as of July 2023). There is a critical need to improve the access of CGM to patients as well as awareness, confidence, and expertise in using CGM among primary care clinicians.

To help to address these challenges, one of the pharmacy specialists worked with information services to allow security access to download the software needed to upload the CGM readers during appointments. This allowed the pharmacist or PCP to access and review the data including the ambulatory glucose profile to make clinical decisions regarding diabetes treatment. Next was to address the knowledge gaps for providers and nurses related to CGM. To assist with this, many of the pharmacy specialists provided in-services, continuing education sessions, and panel discussions. Although this was beneficial for early adopters, it was not sufficient to result in routine use of CGM within the primary care setting. PCPs often approached the imbedded pharmacy specialists with questions and requested additional resources for CGM.

Program Goals

As a result, one of the pharmacy specialists and a postgraduate year 2 ambulatory care resident created a pilot program to assist with CGM use in primary care clinics. The long-term goal of MetroHealth’s primary care CGM integration program is to seamlessly incorporate CGM use for diabetes management at the primary care level. To determine the effectiveness of the program development, a survey was administered prior to the implementation and 2 months after to assess pre- and post-confidence levels among PCPs and nursing staff. The hypothesis is that providing in-clinic training to PCPs and staff, as well as having weekly on-site support by an expert, PCPs and staff will develop increased awareness of and confidence with prescribing and using CGM sensors. Once CGM use is integrated into the primary care setting, its use will become routine. At the completion of the program, the pharmacists involved in this integration initiative plan to publish results and a tool kit that would facilitate greater use of CGM at the primary care level.

Training and Implementation Toolkit

Essential to the program’s training and implementation was an extensive toolkit developed by several of the pharmacy specialists that provided all of the information PCPs and staff would need to integrate CGM use into their practices. The toolkit includes a comprehensive manual with written instructions for setting up accounts to access the CGM download cloud software (LibreView, Dexcom Clarity), application of sensors/transmitters, app setup (for smartphones), reader upload, and ambulatory glucose profile report interpretation. Additionally, the manual provides a general overview of CGM and helpful tips for product ordering, insurance coverage, adhesive solutions, and patches. In the front of each manual are reader upload cords. Finally, a series of short, targeted educational videos with accompanying PowerPoint presentations serve as ongoing education and provide the following:

• An introduction to CGM, including an overview of the features and technical specifications of the various CGM systems (FreeStyle Libre 2, FreeStyle Libre 3, Dexcom G6, and Dexcom G7), sensor adhesion/removal solutions, average prices, and general insurance coverage.

• Detailed descriptions of each CGM device, including indications for use, phone compatibility, and common drug interactions that can affect sensor readings; step-by-instructions for connecting the device to a smartphone or handheld reader; and other device-specific information.

• Instructions for downloading and interpreting CGM data using the Ambulatory Glucose Profile and information about remote monitoring, billing codes, and integrating CGM into clinic workflow.

A short series of questions is presented at the end of each video that allows viewers to assess their understanding of the information presented. Pocket cards were also created to give PCPs immediate access to frequently used information including average glycemic goals at %TIR based on A1c goal, CGM drug interactions, insurance coverage, and product ordering. Production of the manuals and pocket cards were grant funded.

Impact and Utility of CGM in Clinical Practice: Patient Experiences

The use of CGM provides patients with essential information that helps providers (PCPs, pharmacists, endocrinologists, etc.) identify problematic glycemic patterns. CGM also improves patients’ understanding of their diabetes and how food, exercise, and other factors (eg, illness and stress) impact their daily glycemic control. Unfortunately, affordability and lack of awareness about CGM remains a problem. The following patients’ cases (from MetroHealth System) illustrate how these barriers can impede patient care.

PATIENT CASE 1

K.A. is a 74-year-old Hispanic female with T2D. Her preferred language is Spanish. She is enrolled in the Medicare fee-for-service insurance plan. She was diagnosed with T2D 18 years ago and is currently treated with dulaglutide (Trulicity) 4.5 mg weekly, insulin glargine U100 (using the Lantus Solostar pen) 52 units each day, and insulin lispro (Humalog) 8 units before each meal. Her most recent A1c was 9.8%, which had remained above 9.0% since the fall of 2021. The patient was consistent in monitoring her blood glucose twice daily; however, this was not frequent enough to make accurate insulin dosage adjustments. Although the patient was eligible for a CGM device, she would have to afford the out-of-pocket cost for the sensors at approximately $200 every 90 days. Periodically, the pharmacy specialist provided the patient with 1 or 2 sample sensors, which she wore before upcoming clinic visits. This enabled pharmacy specialist to review her ambulatory glucose profile and make appropriate changes to her insulin regimen.

During the last time the patient wore a sample sensor, no medication adjustments were made. However, K.A. explained that the glucose patterns generated by the CGM sensor prompted her to modify her eating, which explains the gradual improvements in her glycemic status (Figure 1). This illustrates how CGM can improve glycemic control by helping patients understand and modify their health behaviors. If given the opportunity to have access to affordable CGM use, it is likely she would make further improvements in her glycemic status while minimizing the risk of hypoglycemia.

FIGURE 1.

Daily Glucose Profile From Ambulatory Glucose Profile

PATIENT CASE 2

R.J. is a 75-year-old male with T2D. The patient is enrolled in the Medicare fee-for-service plan. He was diagnosed with T2D 14 years ago and was treated with metformin extended release (Metformin ER) 1,000 mg twice daily and sitagliptin (Januvia) 100 mg once daily. His A1c was 5.6%, a decrease from his previous A1c (6.7%) obtained 6 months prior. R.J. is nonverbal and accompanied by a nonfamily caregiver.

Approximately 4 months after the A1c (of 5.6%), the patient contracted COVID-19 and was admitted to the hospital. This was the first time the patient and his caregiver were made aware of the patient’s elevated glucose; however, the patient was not discharged on insulin therapy. R.J.’s first visit with the pharmacy specialist was 2 months after his hospital discharge. At the first visit, the patient did not bring any self-monitoring of blood glucose records. An in-office test showed that his glucose was 300 mg/dL, and he had no symptoms of severe hyperglycemia. The pharmacy specialist ordered laboratory tests and requested that the patient complete them the same day and schedule a follow-up visit in a week with the pharmacy specialist. Importantly, a CGM could not be prescribed at the visit because insulin therapy was still a requirement for eligibility.

Although the pharmacy specialist made weekly calls to remind the patient to get a laboratory A1c test and schedule a follow-up appointment, the patient was not seen until 1 month later. At that visit, the pharmacy specialist learned that the patient had gone to the emergency department 3 times for hyperglycemia during that 1-month period. With the updated laboratory results, his A1c was greater than 15%. He was started on insulin with a prescription for a CGM.

If the patient would have been able to start a CGM at the previous visit, the patient, caregiver, and pharmacy specialist likely could have identified his rising glucose levels and may have been able to start insulin sooner. A CGM at discharge would likely have avoided the emergency department visits. Although cost will always be an issue when prescribing a medication or medical device, in this situation, the cost of using the FreeStyle Libre 3 sensor ($62.25 wholesale acquisition cost per sensor, $124.50 per 28-day supply) was only approximately $50 more than performing self-monitoring of blood glucose 2 times daily ($72.96 wholesale acquisition cost for one 50-count box of One Touch Ultra 2 test strips plus lancets). The cost difference is far outweighed by the costs incurred by the avoidable emergency department visits.

Recommendations for Best Practices

Based on our experiences in integrating CGM in PCP practices, we have developed recommendations for best practices in primary care settings. Core recommendations are summarized in Table 1.

TABLE 1.

Core Recommendations for Best Practices

Make CGM available to all patients with diabetes regardless of their therapy.

Integrate ambulatory glucose profile reports into EMR software.

Utilize the EMR. ◦SmartSet, PowerPlan, etc. for CGM ordering, billing, documentation, and patient education.

Provide additional and ongoing education for clinicians and nurses.

CGM = continuous glucose monitoring; EMR = electronic medical record.

MAKE CGM AVAILABLE TO ALL PATIENTS WITH DIABETES

As demonstrated in numerous studies, use of CGM improves glycemic control in all patients with diabetes, regardless of their therapy. For individuals treated with antihyperglycemic medications that directly cause hypoglycemia (eg, insulin and secretagogues), CGM enables more accurate insulin adjustments and is effective in avoiding severe hypoglycemia.^1-18 For individuals treated with insulin, noninsulin, or no medications, CGM use provides valuable feedback that prompts patients to make effective changes in their health behaviors that improve glycemic control and help mitigate other risk factors (eg, overweight/obesity and cardiovascular disease).^10,12,16,17 For geriatric patients, CGM facilitates daily glucose monitoring in those with possible dexterity issues and cognitive deficits.⁵⁰

Moreover, the ambulatory glucose profile report allows clinicians to quickly and easily analyze CGM data in a systematic fashion to understand current glycemic status and to monitor the impact of adjustments to therapy in both T1D and T2D in real time.⁵¹ CGM also enables clinicians to make informed decisions about medication regimens for patients with various health conditions and treatments that affect glucose levels, such as during chemotherapy⁵² or during a short course of steroids.⁵³

INTEGRATE AMBULATORY GLUCOSE PROFILE REPORTS INTO ELECTRONIC MEDICAL RECORDS

Upgrading current electronic medical record (EMR) software to allow seamless access of the Ambulatory Glucose Profile reports would eliminate the need to log in and use multiple systems to retrieve and document data. Moreover, building alerts into EMR software that notify clinicians of extreme hyperglycemia or hypoglycemia would provide an additional layer of safety for patients and improve overall management of diabetes. Until these upgrades are made, we recommend designating one “practice” within Dexcom Clarity or LibreView for an entire health system. This would allow clinicians and staff to access the data even if they are floated to a different clinic or if a patient needs to be seen by a different provider.

USE THE EMR SMARTSET COMPONENTS FOR BILLING

Providers may be able to use order sets or other order panels in their EMR to add billing codes for CGM startup and training (Billing Code 95249) and CGM data review/interpretation (Billing Code 95251). Some EMRs may also allow for reminders to enter billing codes by tracking the last time a code was billed and alert providers when the 95251 code has not been billed within a specified number of days. This will inform payers as to when CGM is being used by patients and providers. Because many pharmacy specialists are often at the forefront of providing diabetes management, they should be included as billable providers for this code (95251).

PROVIDE INITIAL AND ONGOING EDUCATION FOR CLINICIANS AND NURSES

Health systems should develop initial and ongoing education for providers and staff. Nurses are integral to assist in the startup and training education needed for patients. The toolkit provides the essential content needed to initiate CGM in primary care practices, and health systems should consider developing similar materials. Primary care offices should also consider developing a pocket card resource as discussed earlier to support clinical and administrative decision-making. Additionally, provider education and training should include strategies for overcoming implicit bias. Lower use of CGM and other diabetes technologies has been observed among racial and ethnic minorities and people of lower socioeconomic status.^47,54-56 It has been hypothesized that implicit bias associated with patients’ racial or ethnic characteristics and/or socioeconomic status may be a key contributor to these disparities. Although implicit bias can influence clinical decision-making when determining the appropriateness of a CGM for a given patient, it can also affect the quality of patient-provider communications. An early study by Fiscella et al found that physicians are more likely to take a more directive, less participatory approach with less-educated patients.⁵⁷

Summary

The increasing prevalence of diabetes is a major public health concern and places a significant burden on US health systems. Individuals enrolled in state Medicaid programs are at high risk for suboptimal glycemic control and poor clinical outcomes. Although use of CGM has been shown to improve glycemic control, reduce HCRU, and lower health care costs, Medicaid insurance coverage of CGM has been inconsistent between states. This is a call to expand insurance coverage (Medicare, Medicaid, and private payers), modifying eligibility to allow all patients with diabetes (including those on intensive insulin therapy, nonintensive insulin therapy, and noninsulin therapy) to have affordable access to CGMs to aid in the management of their chronic disease state.

In addition to the needed coverage changes, many primary care physicians have been slow or do not have the tools to integrate this technology into their practices. Health systems need to provide additional education and resources to their providers and nursing staff to aid in the integration of this technology at the primary care level.

Funding Statement

Abbott funded the development and writing of this work.