costs & insurance
Seeking Reimbursement from Insurance Providers for Glucose Monitoring Devices
Health Guide October 16, 2006
Reprinted with permission from Amy Tenderich of www.diabetesmine.com.
We've been asking the question, "How soon will insurance providers start covering continuous glucose monitoring (CGM) devices?" But it seems the more accurate inquiry would be, "Why won't insurance providers 'reimburse' for CGM devices any time soon?"
There are some serious barriers in the way, as I've experienced personally in the last few weeks, submitting multiple claims for my DexCom supplies -- and receiving rejection after complicated rejection. Each "Explanation of Benefits" form from Blue Shield states a different reason for rejecting my CGM-related claims. Was the diagnosis info not clear enough? Was the HCPC (Healthcare Common Produce Code) incorrect or missing? Well, duh, this is new treatment technology, so no codes exist for it yet! Which is just the trouble, as it turns out.
To address this issue, the national Medicare Coverage Advisory Committee (MCAC) met in Baltimore on August 30. Despite the fact that the JDRF and Congress are both pushing hard for coverage soon, this meeting didn't go so well, according to diabetes industry consultant Kelly Close:
"Unfortunately, we felt like we had walked back in time about, oh, a quarter century. The committee did not make any decisions that will immediately undercut diabetes patients or the companies that sell goods or services to them. But several comments from Medicare panelists raised doubts about the need for one of the most important tools in diabetes management: home glucose monitoring. Frankly, we thought these battles had been won long ago... Never mind that the DCCT (completed in 1993), plus dozens of other studies since, have provided overwhelming evidence that near-normal blood sugars reduce the risk of complications... It appears, however, that this memo has not reached some Medicare officials."
[insert cry of consternation, plus expletive, here]
David Kliff, who observes the D-industry from a financial perspective on his Diabetic Investor site and newsletter, explains the obstacles to CGM coverage this way:
"The economic reality of diabetes management centers on two important factors, time and money... Some companies see the role of the educator and/or physician as being the knowledge enabler. With this approach, the patient merely gathers the information which is then transmitted to their educator or physician for analysis. (But) will the physician and/or educator have the time to analyze all this data and, if they do, how will they be compensated for their time? Third-party payers are already reluctant to pay for patient education; it’s a wonder that so many companies believe they will pay for data analysis."
The trouble with all these advanced glucose monitoring tools (and "smart" pumps and the like), Kliff explains, is that they provide almost too much information -- too much for the patient to utilize unassisted, anyway. Think up to 288 glucose readings a day, and complicated trend graphs that require a trained eye to interpret.
In covering the AADE (American Assoc. of Diabetes Educators) conference this summer, Kliff noted: "This is the hidden issue with CGM, as valuable as this data is especially when combined with insulin and food intake, analyzing the data is a time-consuming process. In a clinical setting when patients have the assistance of physicians and educators, this isn't an issue. However, in the real world all this information can be overwhelming... Based on the products displayed on the AADE exhibit floor, it’s quite clear that increasing patient knowledge has taken a back seat to gathering even more information."
So we've got two principal barriers here:
1) officials' lack of understanding about the value of new glucose-monitoring technology to patients' long-term health (and thus long-term healthcare costs)
2) the costly time required for professionals to analyze CGM data; Who will pay?
So far, it seems only a few "extreme" patient cases have managed to garner coverage for CGM technology -- where the patient suffered severe hypoglycemia unawareness and was landing in the ER every other week. There, the insurance provider could see an immediate, short-term cost savings in their own interest. The long-term for us "middle of the road" patients is going to be a much harder sell.