CGM use increases with expanded insurance coverage for insulin users
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Health insurance policy changes that expand access to continuous glucose monitoring for adults with type 1 or type 2 diabetes can greatly increase uptake of the devices, according to a study published in Diabetes Technology & Therapeutics.
In December 2018, BlueCross BlueShield of North Carolina made a policy change to reduce prior authorization requirements for CGM and make devices available through the pharmacy benefit for almost all members with type 1 or type 2 diabetes using insulin. In an analysis of claims data, researchers found CGM uptake in the quarter after the policy change took effect increased immediately and continued to increase through December 2020.
“While CGM is now recommended as standard of care for patients on insulin who can use it independently or with a caregiver, coverage for CGM systems continues to vary across insurers,” Shweta Pathak, MPH, PhD, a senior health services researcher at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina, and colleagues wrote. “Coverage through the pharmacy benefit appears to expand access to these systems and has several advantages over coverage through the medical benefit, including decreasing costs of products through greater leverage in manufacturer contracting, more specific and timely claims data, decrease the administrative burden of manual prior authorizations, and increase member access through a more convenient site of purchase.”
CGM use increases after policy changes
Researchers collected administrative claims data from Blue Cross North Carolina from December 2016 to November 2020. Data were analyzed on a quarter-by-quarter basis, with the first quarter of the policy change beginning Dec. 1, 2018. Adults with at least one inpatient claim or two outpatient claims for a diabetes-related diagnosis or at least one outpatient claim with a diabetes diagnosis and a claim for a diabetes-related drug were included. All participants also had at least one claim for insulin use during any 365-day period. Use of CGM was defined as any prescription or medical claim for a CGM receiver, transmitter or sensor during a quarter.
There were 43,491 people with diabetes who used insulin that were included in the study, of whom 25.1% had type 1 diabetes and 74.9% had type 2 diabetes. At baseline, CGM was used by 18.8% of the type 1 diabetes group and 1.2% of the type 2 diabetes group. In the quarter before the policy changes from September to November 2018, 30.5% of those with type 1 diabetes and 2.6% of those with type 2 diabetes used CGM. In the next quarter after the new policy was implemented, CGM used jumped to 40% among the type 1 diabetes group and 6.6% among those with type 2 diabetes. At the end of the study period, 58.2% of adults with type 1 diabetes and 14.9% of those with type 2 diabetes were using CGM.
CGM use increases with all insurance types
Among adults with type 1 diabetes, 57.3% of those who were self-insured used CGM at the end of the study compared with a predicted 50.4% had the policy changes not happened. CGM used among adults with type 1 diabetes and full insurance was 61.8% vs. a predicted 44.5% without the policy changes, and CGM usage was 57.2% among those with marketplace or independent insurance vs. a 38.9% predicted usage without policy changes.
For adults with type 2 diabetes, CGM usage was observed in 17% of those with full insurance vs. a predicted 4.1% without the policy changes. Of adults with type 2 diabetes who were self-insured, 14% used CGM compared with a predicted 5.1% without the policy changes. Among adults with type 2 diabetes and independent or marketplace insurance, 15.5% used CGM vs. a predicted 4.1% without the policy changes.
“Given the utilization management criteria implemented along with this policy change restricted use of CGM to patients with diabetes who used insulin, the increase in CGM use reflects those that would benefit from the use of CGM devices and aligns with clinical guidelines,” the researchers wrote. “Additional work is needed to evaluate the impact of this change in trend on clinically relevant and patient-reported outcomes as well as medical spending to capture the full effect of this policy change. Furthermore, work is needed to measure the impact of additional use on diabetes outcomes in the real-world setting.”
Perspective
Back to TopOsagie Ebekozien, MD, MPH and Ann Mungmode, MPH
We congratulate Pathak and colleagues on this work to quantify the impact of policy changes and coverage requirements on CGM uptake for BlueCross BlueShield of North Carolina members.
This study confirms that policy changes can support increased CGM use by analyzing quarter-to-quarter data before and after a BlueCross BlueShield North Carolina policy change. Adjusted analysis showed increased CGM use compared to predicted estimates for people with type 1 or type 2 diabetes.
We agree with the summarized limitations, including challenges in separating the impact of the COVID-19 pandemic or the release of new technology during the study period. In the T1D Exchange, we appreciate the value of data, when actionized, to influence changes from local, clinic-specific settings to broad strokes of policy change in improving outcomes for people with diabetes. While this study highlights the impact of a commercial insurer policy change, we encourage other researchers to explore similar studies in other populations, like publicly insured populations or nationally (given varied state-to-state coverage).
We applaud Pathak and colleagues for this work and invite diabetes providers to not only contribute to policy advocacy but, as described in other studies, explore local-level process changes to improve CGM use.
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