The Impact of Medicare Expansion for Continuous Glucose Monitors on Health Plans

The diabetes management space is heading toward a shift as 1.5 million new Medicare beneficiaries are projected to soon gain eligibility for Continuous Glucose Monitors (CGMs).

The expansion, while promising for improved diabetes management, poses challenges for health plans in terms of costs, resource management and the need for effective strategies to work through the influx of first-time CGM users.

Masturzo

Arti Masturzo, MD, CMO of CCS, told Managed Healthcare Executive, before the local coverage determination (LCD) change, domestic spending on CGMs was approximately $8 billion. However, with the "widened pool" of individuals gaining access to CGMs, this figure is expected to double over the next 24 months.

The impact on Medicare Advantage plans, in particular, is expected to be significant with heightened operating costs, increased claims expenses and additional regulatory/reimbursement challenges from the Centers for Medicare & Medicaid Services (CMS).

Though the initial rise in CGM adoption could lead to increased costs for health plans, there are promises of positive health outcomes, Masturzo said.

"CGM provides real-time feedback on glucose levels, allowing for quicker adjustments to insulin dosages and lifestyle changes," she said. "Additionally, CGM can help identify patterns and trends in glucose levels, leading to more personalized diabetes management plans. This, ultimately, can help lead to better glucose control and a higher quality of life for those living with diabetes."

However, the influx of first-time CGM users brings challenges to health plans in terms of cost and resource management.

Turnaround time for approvals becomes crucial for member and provider satisfaction, potentially leading to road bunps over time, Masturzo said.

The key to offsetting these challenges is to ensure that CGM devices are used appropriately, with a focus on the right individuals, at the right time and for the right reasons.

Comprehensive education and support for new CGM users are important for long-term health and cost benefits.

To effectively manage the increased demand for CGMs, Masturzo suggests health plans must implement evidence-based education for healthcare professionals and streamline patient onboarding and ongoing member or patient education.

In addition, addressing social determinants of health challenges through strategic partnerships, such as with organizations like CCS, can help reduce silos and enhance the overall experience of CGM distribution, education and long-term adherence, Masturzo added.

"Proactive" identification of individuals likely to request a CGM and determining potential benefits involve efforts to identify those with uncontrolled A1C test measures and focusing on patients with diabetes facing other health challenges, she said.

Predictive analytics tools play a crucial role in identifying high-risk patient populations and assessing the likelihood of adherence to CGM devices.

The potential long-term benefits for health plans, including reduced downstream costs, improved member experiences and better overall outcomes, rely on the correct identification of members who truly benefit from CGMs.

Ongoing education and coaching for patients with diabetes are essential, recognizing the active day-to-day management required for this chronic condition.

In the complex healthcare landscape, coordinated, personalized and motivational engagement are key in creating upfront costs and achieving a positive outcome for health plans in terms of CGM coverage expansion.

"To drive long-lasting change for patients with diabetes prescribed a CGM, a tailored and coordinated approach to meeting the members where they are is critical," Masturzo said. "Established trust and a consistent human touch are vital in helping patients drive sustainable behavior changes that will improve their lives and make managing their diabetes less of a chore."