The diabetes management landscape is on the brink of transformation, with 1.5 million new Medicare beneficiaries poised to gain eligibility for Continuous Glucose Monitors (CGMs).
Challenges for Health Plans
While this expansion offers promise for enhanced diabetes management, it brings challenges for health plans. These include concerns about costs, resource allocation, and the need for effective strategies to handle the influx of first-time CGM users.
Financial Implications
According to Dr. Arti Masturzo, CMO of CCS, prior to the local coverage determination (LCD) change, domestic spending on CGMs stood at around $8 billion. With a larger pool of individuals gaining access to CGMs, this figure is expected to double in the next 24 months.
Tip: Fill out this form to check if you or a friend qualify for Glucose Management Devices.
Impact on Medicare Advantage Plans
Medicare Advantage plans, in particular, are anticipated to experience significant effects, including increased operating costs, higher claims expenses, and additional regulatory and reimbursement challenges from the Centers for Medicare & Medicaid Services (CMS).
Promising Health Outcomes
Despite the initial rise in CGM adoption potentially leading to increased costs for health plans, the potential for positive health outcomes cannot be overlooked.
CGMs offer real-time feedback on glucose levels, facilitating quicker adjustments to insulin dosages and lifestyle modifications. Furthermore, they help identify patterns and trends in glucose levels, leading to more personalized diabetes management plans and improved glucose control, ultimately enhancing the quality of life for individuals with diabetes.
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Resource Management Challenges
Nevertheless, the surge in first-time CGM users presents resource management challenges for health plans. Quick approval turnaround time is crucial for member and provider satisfaction but may face roadblocks over time.
Effective Solutions
The key to mitigating these challenges lies in ensuring appropriate CGM device usage. This involves targeting the right individuals, at the right time, and for the right reasons. Comprehensive education and support for new CGM users are pivotal for long-term health and cost benefits.
Strategies for Health Plans
To effectively manage the growing demand for CGMs, Dr. Masturzo recommends that health plans implement evidence-based education for healthcare professionals and streamline patient onboarding and ongoing member or patient education.
Addressing social determinants of health challenges through strategic partnerships can reduce silos and enhance the overall CGM distribution experience.
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Identifying Beneficiaries
Proactively identifying individuals likely to benefit from CGMs, especially those with uncontrolled A1C test measures and other health challenges, is essential.
Predictive analytics tools play a critical role in identifying high-risk patient populations and assessing the likelihood of adherence to CGM devices.
Also, read about the Potential of Precision Medicine in Diabetes Care
Long-Term Benefits
The potential long-term benefits for health plans, including reduced downstream costs, improved member experiences, and better overall outcomes, depend on the accurate identification of members who truly benefit from CGMs.
Patients who have diabetes really need to have ongoing education and coaching because diabetes is a chronic condition that requires active care on a day-to-day basis.
Creating Positive Outcomes
In the complex healthcare landscape, coordinated, personalized, and motivational engagement are key in managing upfront costs and achieving a positive outcome for health plans in terms of CGM coverage expansion.
Dr. Masturzo emphasizes the importance of a tailored and coordinated approach to meeting members where they are, establishing trust, and providing consistent support to help patients make sustainable behavior changes in diabetes management.
