'We have to make it easy': Barriers hinder CGM access for some people with diabetes
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Key takeaways:
- Continuous glucose monitoring is fast becoming standard of care for many people with diabetes.
- Device cost, insurance status, race and socioeconomic status remain as barriers to CGM use.
For many people with diabetes, continuous glucose monitoring has become an indispensable tool to accurately monitor real-time blood glucose levels and track glucose trends over time.
Since it was first approved by the FDA for professional use in 1999, CGM has become standard of care for people with type 1 diabetes, with data demonstrating benefits for improved glucose management, health outcomes and quality of life. More recently, data have demonstrated those same benefits for people with insulin-dependent type 2 diabetes, whether prescribed multiple daily injection therapy or basal insulin alone. Emerging data suggest the technology’s benefits also extend to women with type 1 or type 2 diabetes who are pregnant or women who develop gestational diabetes. Experts note CGM may also be useful for those with diabetes not using insulin, people with prediabetes, and perhaps even people with obesity without diabetes, but more studies confirming these clinical indications are needed.
“A key component of diabetes is knowing and understanding your glucose levels,” Richard M. Bergenstal, MD, executive director of the International Diabetes Center, HealthPartners Institute in Minneapolis, told Healio. “CGM has, finally, made understanding and using your glucose levels possible, in a way that blood glucose monitoring never did. With CGM, all of a sudden, patients can visualize their real-time glucose, see that data. For clinicians, CGM is a whole new awakening to what glucose levels really are. An 8.4% HbA1c vs. a CGM glucose profile — these metrics are two completely different things. With CGM, clinicians’ eyes are opened. The engaging and understanding of glucose is what CGM has brought to the table.”
Despite compelling data showing how CGM use improves diabetes outcomes, many barriers that prevent CGM access remain, according to experts. At the American Diabetes Association’s first-ever Cost of Care Summit in 2021, researchers discussed study data that demonstrated CGMs provide “potentially life-changing benefits” for diabetes management; however, poorer, older and Black Americans have less access to the devices than others. The study also showed that Americans on Medicaid are the least likely to have access to a CGM than those with a commercial health insurance plan.
“CGM should be standard of care right now for people with diabetes who take insulin,” Irl B. Hirsch, MD, professor of medicine at the University of Washington School of Medicine in Seattle, told Healio. “Right now, we are far from that.”
Access, simplicity, action
Bergenstal said getting CGM into the hands of more people who could benefit most from the technology comes down to three pivotal issues: access, simplicity and action.
“CGM is approved for people with diabetes who take insulin, but who has access?” Bergenstal said. “That gets into equity — can you afford it? For providers, do they have access to the CGM data at their fingertips? In primary care, it is one thing to say we have CGM. It is quite another to say, ‘Where is the data?’ Searching for CGM data on the cloud may work for endocrinologists or diabetes care and education specialists, who do a great job. That is why we are working so hard to put models out there that integrate this CGM data right into the electronic health record.”
Access to CGM is widening. In April, Medicare expanded coverage of CGMs to include people with type 2 diabetes who are taking any type of insulin, as well as people with diabetes not taking insulin with a history of problematic hypoglycemia. The changes will make CGM available to potentially millions more people with diabetes.
Additionally, in 2021, Medicare permanently eliminated the requirement of four-time daily finger sticks with a blood glucose monitor to qualify for CGM coverage, considered by many an unnecessary barrier for Medicare beneficiaries that further delayed CGM access.
Still, data show many people who are eligible for a CGM do not have one, either because of access or affordability issues, Hirsch said.
“Not only where you live, but sometimes what insurance you have matters,” Hirsch said. “When we look at health outcomes in diabetes for the underserved populations and the inequities, and we see it here in Seattle, we have shown that HbA1cs are higher and technology use is lower when our patients come in, and then, 2 years into our program, things balance out. But it’s tough, and in the real world, it doesn’t work that way.”
Data from CGM reports can offer clinicians insight into a user’s day-to-day glucose profile to allow more tailored treatment. Yet the main barrier to analyzing CGM reports in the clinic is the ability to easily obtain them, according to Bergenstal.
To improve access, the International Diabetes Center partnered with Abbott on a pilot initiative beginning in spring 2020 to make FreeStyle Libre CGM data available at the point of care in select clinics. The goal was for clinicians to place an order in the EHR for a patient with diabetes who agreed to share their CGM data. In real time, data would then be transferred from Abbott’s cloud-based system, LibreView, via an EHR platform, allowing providers to automatically view CGM data in patients’ lab results and diabetes flow sheet. Data metrics would include time in the recommended glucose range and visual alerts for out-of-range values.
The ambulatory glucose profile is also integrated into the EHR in a PDF format, allowing clinicians to track the patient’s glucose trends over time and adjust treatment regimens as needed.
“No matter what we do, it has to be simpler, simpler, simpler,” Bergenstal said. “We have to make it easy. In primary care, it is all about workflow. Who is going to pull up the CGM data? Who will have it ready? How do you act on it? How do you bill for interpreting it?”
Bergenstal said after the successful pilot program, work continues across several diabetes centers to integrate CGM data into EHRs.
“We are making progress,” Bergenstal said. “It takes work, aligning with a CGM company that is willing to release their data and get it in the format that you want. It is possible, and we have done it, but that is one electronic health record and each company is different. We have demonstrated proof of concept that shows it is possible. This will happen, we just need to build the evidence.”
Hirsch said patient training can also help, particularly in busy clinics where time to review any CGM data may be limited.
“A lot of this you can do by training the patient,” Hirsch said. “It doesn’t matter which CGM, a patient can get all of their info on the app for the device, and maybe even leave the physician out of it. The patient can see time in range. Many physicians just look at the patient phone. That is not what I recommend, because the physician can get reimbursed by interpreting and going over CGM with the patient. But, for the providers seeing 30 patients a day, that is one option.”
Education is key
For CGM to become more widely adopted, Hirsch said education and training are vital for both health care providers and patients.
“CGM is no different from an SGLT2 inhibitor, a GLP-1 receptor agonist or a statin,” Hirsch said. “We need to do more educating of clinicians. This is not an over-the-counter product; this is still a medical tool requiring a prescription.”
Population education could be effective too, Hirsch said.
“For example, during the pandemic, when everyone was locked down, there was a surge of CGM use because it was being advertised on television,” Hirsch said. “Primary care physicians were contacting me and asking how to prescribe CGM, because their patients saw it advertised on television.”
It is also important to spread the word that any person with diabetes using insulin therapy should be eligible for CGM, Hirsch said, noting that for many providers, this is still new information.
“In the United States, 50% of adults with type 1 diabetes are cared for by primary care physicians, not endocrinologists,” Hirsch said. “That is the group that we know is less likely to prescribe CGM, because they are less familiar with CGM. Numbers are increasing, but they are still not where they should be. Educating family practitioners, nurse practitioners, all of these groups need to be familiar with CGM. Anyone using insulin is now eligible, usually with reimbursement, for CGM.”
Reference:
- American Diabetes Association. New Medicare requirements make CGMs more accessible. Available at: https://diabetes.org/tools-support/devices-technology/cgm-medicare-coverage-requirement-change-accessibility. Accessed May 11, 2023.
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