As technology improves, increasing CGM access requires education, community support
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In 1999, the FDA approved the Medtronic MiniMed as the first continuous glucose monitor for people with diabetes. In the 25 years since that approval, use of diabetes technology has gradually increased.
Photo by Ray Burgett. Printed with permission.
“In the beginning, there were all sorts of barriers, both because there wasn’t coverage and because the devices were harder to use,” Anne L. Peters, MD, a Healio | Endocrine Today Editorial Board Member and professor of clinical medicine at the Keck School of Medicine of the University of Southern California, said in an interview. “For instance, the FreeStyle Libre 3 and the Dexcom G7 are so much easier to use [now]. Having a device that’s one tiny plastic circle that doesn’t require that you put on a transmitter, that easily goes to a phone or a reader has made it so much easier for my patients to use CGM.”
Private and public health insurance coverage of CGM has increased in recent years. In 2023, Medicare eased its requirements and began covering CGM for all Medicare recipients with type 1 or type 2 diabetes who require insulin.
“We’ve seen a progressive transition over the last 5 years with more and more states making it easier for people with diabetes to get CGM,” Osagie Ebekozien, MD, MPH, CPHQ, chief medical officer at T1D Exchange, told Healio | Endocrine Today. “Private insurance has, for the most part, been favorable to CGM. Medicare changes were a big win. With Medicaid, we’re seeing more of that transition toward increased coverage over time. That’s been one of the biggest drivers to reducing barriers.”
As innovations in CGM technology have become more available to many, studies of how CGM is used in real-world settings have made providers who treat diabetes aware of other barriers to access, according to Shivani Agarwal, MD, MPH, associate professor of medicine at Albert Einstein College of Medicine and senior director for health equity at Montefiore Medical Center in the Bronx, New York.
“The research field mixed with insights from the clinical field is changing how endocrinologists approach CGM in terms of trying to provide more access to more people,” Agarwal told Healio | Endocrine Today.
Disparities by age, race and ethnicity and other sociodemographic factors remain. For example, both users and providers may find CGM data difficult to understand. The diabetes community needs to shift its focus from simply using CGM to having strategies in place to use CGM more effectively, according to Richard M. Bergenstal, MD, executive director of the International Diabetes Center, HealthPartners Institute in Minneapolis, who laid out this concept as part of a roadmap to effective use of CGM published in Diabetes Spectrum in 2023.
“There’s awareness, there’s much better devices than 10 to 15 years ago, we have simpler ways to look at the data and it is less scary [for patients] because you’re hearing about it more,” Bergenstal told Healio | Endocrine Today. “We’ve got a good track record for building [CGM] use, but we haven’t put the time in to the workflow and the implementation to say we have effective use.”
Inequities in access
Some barriers to CGM use have lessened in recent years, but access has not been equal.
In a study published in Diabetes Technology & Therapeutics in 2021, Agarwal and colleagues found 28% of Black and 37% of Hispanic young adults with type 1 diabetes used CGM compared with 71% of white young adults.
CGM use also differs by where people live. In a study published in Diabetes Care in 2023, researchers found children living in small rural towns had a 31% lower likelihood of using CGM than those from urban areas, and children living in isolated rural towns were 49% less likely to use CGM.
“Effective uptake of CGM gets more optimized when you are in a practice with diabetes care and education specialists and physicians that are well versed in the most updated CGMs and options,” Ebekozien said. “For people with diabetes living in rural areas, irrespective of race and ethnicity or income, where you’re receiving care and who you are receiving care with does have a significant difference.”
Older adults are also less likely to use CGM than younger adults, Ebekozien said, as some older people may not be comfortable using newer technology.
Lack of familiarity with or access to technology in general can be a barrier to using CGM for younger adults as well. Much current diabetes technology requires owning a smart device, which could be a barrier for people with limited financial resources, Agarwal said.
“The way that these devices have been engineered is they are all reliant on apps on smartphones, and the automated insulin delivery systems rely on the CGM to have apps on smartphones to be their receivers,” Agarwal said. “That’s a problem. That’s introducing inequity from the beginning.”
Insurance coverage also remains a barrier for some people, according to Agarwal. Medicare’s recent expansion of CGM coverage has helped increase the number of older adults who can receive a CGM, but Medicaid coverage of the devices varies from state to state. Commercial insurance plans also have their own requirements for CGM coverage, some of which lead to delays in initiation.
“Sometimes there’s a lengthy prior authorization procedure to even get the device. That can be a huge barrier,” Agarwal said. “Sometimes just to maintain the device, there’s prior authorization procedures every 6 months. Some people may be able to start CGM and not continue it.”
Increasing awareness in primary care
Lack of education can also be a barrier. Primary care providers need more education on CGM so they can explain the advantages to patients and help them acquire devices, Agarwal said.
“There’s huge education campaigns that need to happen, while also instituting those systems of support in prescription management and authorization,” Agarwal said.
Many patients do not understand how to use the data generated by the technology to improve health outcomes, Bergenstal noted.
“Right now, a lot of people use [CGM] as a glorified glucose meter, meaning ‘I don’t have to poke my finger, but I can see my blood sugar,’” Bergenstal said. “The real value is, how much did [glucose] go up after the meal, what food are you eating, did you change your food? A lot of people intuitively understand that, but with a little instruction, they understand it a lot more.”
And many PCPs also are not fully taking advantage of the data, Bergenstal said. Although endocrinologists are now familiar with using an ambulatory glucose report to inform treatment decisions, many PCPs lack that same knowledge. Peters agreed and said some PCPs send CGM tracings to an endocrinologist for interpretation due to a lack of training and time.
“A lot of PCPs haven’t been interpreting blood glucose monitoring data,” Peters said. “A lot of people are on multiple daily insulin injections. They aren’t an easy subset to treat.”
Bergenstal said three key aspects are needed for PCPs to analyze CGM data. First, PCPs need to have a system and a team in place to be able to access data. Second, the data presentation must be simple enough for providers to interpret. Finally, providers need to understand what actions to take in response to suboptimal CGM readings.
“They appreciate that [CGM] brings a lot more data,” Bergenstal said. “But now you’ve got to teach them some simple tools to use it.”
A framework that allows PCPs to connect remotely with specialists for guidance on caring for people with diabetes — such as the Extension for Community Healthcare Outcomes (ECHO) Diabetes model — can improve CGM use at the primary care level, Ebekozien said.
“This is something we need to continue to explore,” Ebekozien said. “A lot of people, even outside of rural areas, receive care from primary care. Primary care in the city vs. an endocrinology tertiary center in the city have widely different access [to CGM resources].”
Building an equity roadmap
Before 2023, the diabetes community did not have a comprehensive plan for the effective use of CGM, Bergenstal said. To combat this issue, Bergenstal wrote a roadmap to examine how CGM has changed diabetes care and how providers can get more out of the technology.
The roadmap ended with five goals he described as the “diabetes quintuple aim”: reducing patient burden, reducing cost, improving quality, reducing clinician burden and increasing equity of optimal care delivery. The equity piece was important because CGM equity is at times forgotten by stakeholders, Bergenstal said.
“It was a no-brainer that the end should be that those who could benefit have access to CGM,” Bergenstal said. “People don’t always think about that, it’s just easier to prescribe it to those you are seeing and who you think will benefit. But that’s not fair, because [all] people will benefit if they are given a chance.”
Improving CGM equity was a focus for Ebekozien in 2023 when he wrote an article published in the same issue of Diabetes Spectrum as Bergenstal’s roadmap. Ebekozien’s plan centered on achieving CGM equity by reducing disparities at every level of care.
“We need to think about the individual perspective first: As an individual, how aware are they of the benefits of CGM and how to optimize the experience,” Ebekozien said. “Then, we need to move on ... to an interpersonal level between a provider and a patient, a diabetes educator and a patient, an administrator or insurance claims, a pharmacy representative or any of the other people that make critical decisions along that roadmap. Those interactions, those decisions, that teaching, that education, all of that plays a role in reducing barriers.”
Beyond individuals and providers, Ebekozien said, institutions must review their policies and ensure they are promoting CGM equity, CGM manufacturers must ensure their devices are easy to use for people unfamiliar with technology, and health insurers should provide coverage for all people with diabetes who require insulin and eliminate unnecessary barriers that may slow the device initiation process.
“That roadmap wants us to think about issues around barriers not just in a simplistic way, but to think about how there are multiple layers,” Ebekozien said. “It will be critical that we address not just one layer but address a lot of layers.”
Leveraging community resources
Diabetes providers are looking within their own communities for ways to build trust with people hesitant to use CGM. Peters said building trust begins with understanding your patient population and employing a support staff that can connect with those people.
“My staff is all similar to the patients,” Peters said. “They’re from the local community, they all understand them, they speak the same language. There’s trust.”
Community health workers could be a key part of increasing CGM access, Agarwal said. She is leading an ongoing study examining the impact of adding community health workers — trained as diabetes technology specialists — to the diabetes care team. The specialists will introduce technology to the patients, assist with prior authorization and prescription concerns and ensure patients receive proper training on their device. The community health workers will follow each patient for the first 6 months of CGM use.
“It’s a viable model because community health workers are usually from the communities that patients live in,” Agrawal said. “There’s a kind of automatic trust that happens with those community health workers that are different than the health care provider.”
For people living in rural communities, providers should take advantage of the ability to share CGM data remotely, Ebekozien said. In a study published in JAMA Network Open in 2023, adults used CGM as part of a virtual endocrinology clinic. Those with type 1 diabetes decreased HbA1c from 7.8% at baseline to 7.1% at 6 months, and those with type 2 diabetes reduced their HbA1c from 8.1% at baseline to 7.1%.
Reducing financial barriers
Addressing financial barriers requires filling some research gaps, Bergenstal said, including whether CGM will benefit people with prediabetes or people with type 2 diabetes who do not require insulin.
“We need the studies, we can’t just complain that it’s not covered,” Bergenstal said.
His institution is formally assessing the clinical efficacy of CGM compared with finger-stick blood glucose monitoring. In November 2023, HealthPartners received funding to expand the study to analyze whether CGM may help ease the economic burden of diabetes care. Bergenstal said he is hopeful that the expanded study will have an impact in increasing insurance coverage of CGM.
“Out-of-pocket cost is one thing that may weigh against CGM,” Bergenstal said. “You say it may cost more than poking your finger. But we think that by having CGM guiding your insulin therapy, you’re going to have fewer emergency room visits for hypoglycemia... you’re going to recover from illness better. Financial distress is broader than out-of-pocket costs. We’re hopeful that CGM is going to show that those [financial] barriers went down as well.”
Bergenstal said the end goal of the diabetes community should be to provide CGM to all people who may benefit from it.
To do that, researchers and providers must reach out to underserved populations themselves to make sure they have the opportunity to use diabetes technology, Agarwal said.
“CGM has become a standard of care in diabetes management,” Agarwal said. “It is imperative for scaling of any of our interventions to reach populations who might not otherwise get it.”
- References:
- Agarwal S, et al. Diabetes Technol Ther. 2021;doi:10.1089/dia.2020.0338.
- Aleppo G, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.36876.
- Bergenstal RM, et al. Diabetes Spectr. 2023;doi:10.2337/dsi23-0005.
- Ebekozien O. Diabetes Spectr. 2023;doi:10.2337/dsi23-0002.
- Stanford Medicine Children’s Health. The ECHO Diabetes Model. Available at: www.stanfordchildrens.org/en/service/echo-diabetes/echo-diabetes-model. Accessed Jan. 11, 2024.
- Tilden DR, et al. Diabetes Care. 2023;doi:10.2337/dc23-1564.
- For more information:
- Shivani Agarwal, MD, MPH, can be reached at shivani.agarwal@einsteinmed.org.
- Richard M. Bergenstal, MD, can be reached at richard.bergenstal@parknicollet.com.
- Osagie Ebekozien, MD, MPH, can be reached at oebekozien@td1exchange.org; X (Twitter): @ebekozien
- Anne L. Peters, MD, can be reached at annepete@med.usc.edu.
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