Video How to Best Incorporate CGM into the Managed Care Pharmacy Practice Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Error loading media: File could not be played 00:0000:0000:0000:00 How to Best Incorporate CGM into the Managed Care Pharmacy Practice Overview TranscriptChapters Click here to view the program Back to Symposium Hello and welcome to this presentation. That was a great overview. We just heard from Sioux Cornell and now I'm going to be talking about how to best incorporate see GM into the managed care pharmacy practice. My name is Diana Isaacs and I'm an endocrine clinical pharmacy specialist and I'm also the C. G. M. And remote monitoring program coordinator at the Cleveland clinic, endocrinology and metabolism institute. So for starters let's go ahead and talk about C. G. M. Cost and access. So we know see GM can have a higher price tag. Even the lowest cost option which has a disposable transmitter is still around $120 per month without insurance. So many people want to be able to use their insurance plans to be able to pay for it. And historically insurance plans were limiting access to people with type one diabetes. However, now there's really a lot of robust data showing the benefits in people with type two diabetes. And because of this we have seen Medicare as well as other insurance plans expand to now include people with type one and type two diabetes. However, there are some additional requirements. So for example, with Medicare, it requires a person to be on multiple daily injections of insulin or insulin pump therapy. You have to show that the insulin treatment regimen requires frequent adjustments. That that data is going to be used to tie, trade or adjust insulin doses. There also needs to be ongoing visits to assess adherence to using the device and Medicare only covers non injunctive see GM. So that would be the C. G. M. S. That are classified with non injunctive indication um Which includes ever since. And lee brae as well as decks come devices. Um It means that they can be used to make treatment decisions without having to confirm with a finger stick. Now commercial insurance is very planned specific. One of the nice things though about commercial insurances, the coverage often goes through the pharmacy benefits. Now there were some really I think great changes recently to Medicare that have improved access to see GM. So as of july 18th CMS no longer requires beneficiaries to perform the four times a day blood glucose test to qualify for C. G. M. And that was quite the hurdle because you know keeping a log of checking four times a day. Many times people. One of the reasons they want to use C. G. M. S. So they don't have to do all of those finger sticks. But perhaps the real kicker was the fact that Medicare was only Covering three test strips a day. So it's like how are people even supposed to do this for finger stick? So that was a challenge. And it's definitely a big win that that has been removed. Also one other change was that insulin was changed from injections two administrations which might not seem like a big deal. But we do have inhaled insulin which can be a good option for some people. And now that can be included if someone's using inhaled insulin that can be included as part of their administrations to be able to qualify for C. G. M. Now what about Medicaid access? That is a little different depending on your state. And I really like this diagram because it outlines very nicely what do different states cover. And so the green means that they cover type one and type two diabetes, You'll notice some states are yellow meaning they still only cover type one diabetes. And then blue means pediatrics only. So we are seeing this shift. You know, there's a lot of momentum for more type two diabetes across the country. Something else just to be aware of with Medicaid plans are that some require some additional requirements like documented hypoglycemia unawareness Or evidence of severe hypoglycemia showing glucose levels below 50. And many still do require those finger stick logs of the four times a day, at least 30 days of data. So those are sometimes some additional hurdles to getting it covered. Now what are some other barriers to see GM access? So a big one is it can be hard for clinics and health systems to know the right process of how to get C. G. M. Covered. So for example with some plans it goes through the durable medical equipment and others that goes through pharmacy benefits and those are really two very different processes and so it's not always clear based on the insurance. And so also each clinic really needs to think about well who in the clinic is going to fill out the paperwork because there is certain paperwork for DME or even when it goes through the pharmacy benefits, there's still gonna be prior authorization paperwork and someone needs to fill that out. And then an additional thing is just because it's covered by insurance Does't mean it's free or even affordable for patients. So for example, we know with Medicare, you know, many patients may have a 20% coinsurance and then if they have a supplement they may not have anything but there's varying amounts or some people have high deductibles. And so that kind of plays a role into the cost and what someone can afford. So I call this the vicious cycle. And unfortunately I see this play out too often where you know the prescriber is in the patient agree. All right, let's go ahead and start C. G. M. And the prescription is sent to the pharmacy because often that's the easiest way to do it. You can describe it, send it to the pharmacy, right? And so you know, it asked for prior authorization and so the prior authorization paperwork is filled out by the office and it gets rejected and everyone is disappointed and then we assume, okay, it wasn't covered. We couldn't get it. But actually all along it was supposed to go to the D. M. E. And so we kind of falsely thought it wasn't covered when really the patient could get it. We just we didn't know the right way to where to send it. So we want to break that was just like a now when it does go through DME there are certain additional requirements that are needed. And one of them is called a certificate of medical necessity for Maura CMn form. And this has a lot of basic data you know like the patient's name their their prescriber, their physician um you know what diagnosis they have and it needs the physician's signature a tip here is that if this is linked to the electronic health record a lot of this information could be auto filled and auto populated to really streamline the process. Now also though chart notes are typically needed. Um The last for example the last two notes and then you know in the past we needed glucose logs which we should not need any more for Medicare but for some other companies or for some other plans you know that sometimes is still needed. So how can we streamline this process because it's not always the most straightforward and this unfortunately can be a barrier then the patient's getting and starting their C. G. M. So there are some companies now that are really trying to address this and make it better for everyone involved. And one of the examples is a company called Parachute health and they provide all digital ordering and basically they can work in a couple different ways. One is just going to the website and entering in the information. But also it can be paired with that electronic health record where someone can order it directly through there it goes to parachute. And what they do is they are able to help identify the correct DME company to use based on the person's insurance. And that is really helpful because otherwise you could try to send to one company and they say oh we don't work with this plan and then you have to send it back and you kind of end up going back and forth. Also they can help take care of prior authorization. They can automate that process and route and and really streamline that process as well. And then they also can report on some metrics, you know based on you know the suppliers, the products, the physicians for ongoing savings and adjustments. So we are seeing more companies like this trying to really address this problem. Now there's also some creative solutions so you know based on someone's plan right? They may have this coinsurance, this deductible, they may have this cost. But there are some other things we can use. And I wanted to share a quote from the 88 standards of care that says you know use of professional C. G. M. Or intermittent see GM use can be helpful in identifying and correcting patterns of hyper and hypoglycemia and improving a one C levels in people with diabetes on non insulin as well as basil insulin regimens. So why am I sharing this with you? Because these are options to still use GM. That's not using it all of the time. So professional C. G. M. Is actually owned by the clinic and essentially lent out to the person with diabetes on a short term basis. Typically anywhere from 7 to 14 days depending on the device that's used. And often you know this can be this is often actually a covered insurance benefit. Often we see plans covering this 2 to 4 times per year. And this can be a great option for patients to be able to see their data and the health care team to see their data. But also the intermittent use of personal C. G. M. So a person doesn't necessarily need to wear a sensor all of the time they can wear it. Maybe they wear one a month or maybe they were just one before each you know each doctor's visit. So those are ways that we can still benefit from C. G. M. Even if it's not being worn all of the time. So I also just wanted to share some of the discount programs because there are certain patient assistance programs out there and each program has some things to offer which can be great especially when starting someone on C. G. M. Uh If there is a delay going that DME route that can often take a few weeks and so they can get started on it and not have a delay or if there's a new cost issue, being able to take advantage of one of these programs can really really be able to help. So uh for example with the freestyle lee brae, they have a manufacturer program where the sensors, the two sensors are not more than $75 per month. And there's also uh my freestyle program where someone can get started with a free sensor and a reader and that's for commercially insured patients. And then many offices do have samples that they're able to take advantage of. Now dex come has especially offered patient assistance during Covid where they provided a discount up to two shipments of 90 days of decks com G six supplies, which that would include a transmitter and then nine sensors because each sensor is a 10 day wear. So that offers a cost savings. And then there's also copay savings for people with commercial insurance to be able to reduce the cost. And I'd encourage you to come back to these because with all these savings programs, you know, they can change over time. But I think it's so great to see that each, you know, each company is offering something. So ever since also has one that's the implantable C. G. M. Where you know that's a cost savings per 90 days and also cost savings per year on the sensors And the Medtronic also has a discount. So one of the things with Medtronic is that with the non they are they do not have the non injunctive indication. So that was sometimes a barrier for some of my Medicare patients to be able to continue use. And that was a problem because their sensor goes with their insulin pump and it allows it to automate insulin delivery and by patients not being able to use that sensor and having to maybe switch to a different sensor that was really affecting the quality of their care. So, Medtronic did something about it and they have a program where patients can actually get a heavily discounted number of sensors, Five sensors per month for $60. And then there's also a discount on that transmitter so that I have really my patients have benefited from that programme. So that's accessing CGM. But once someone has CGM, I think there's so much we, as pharmacists can do to support them and ensure that they have optimal use. And this again, is taken from the 88 standards of care and says when prescribing see GM devices robust diabetes education training and support are required for optimal see GM device implementation and ongoing use and to illustrate this, I want to share with you a real life example about how simply wearing the device does not automatically translate to health benefits. This was a patient of mine who had been provided with a C. G. M. But was not given any education about glucose targets really about anything other than you know where the C. G. M. In this case it's intimately scan so scan the sensor and so she had been wearing it for three months and this is her report. And even if you're not an expert and looking at reports, hopefully you can see that that that A G. P. Is really not in that range. She actually was only in the target range 2% of the time and the rest of the time was above it and in fact 87% of the time over 2 50. But I think the sad part here is that she didn't know that was a problem. She didn't know that this wasn't her goal. And how sad is that? Because had she known that she could have reached out to us, she could have reached out to her doctor to her team to let them know so that we could adjust her regimen. We could do something about it. And so this just demonstrates we've got to provide that education so people can have good outcomes. Also there are certain times where we still want people to do finger sticks. Yes. Many of our devices now our factory calibrated and do not require finger sticks to be able to use but there are certain times when a finger stick is still indicated and so with certain devices like you can see in the image here if you see that drop of blood that means it's a time where someone should confirm with a finger stick before treating. Also any time a person's symptoms don't match the number. So for example it's telling a person that they're running low but they feel fine they should confirm or if the opposite situation is happening it's better to be safe than sorry. Also if using for a non FDA approved indication such as pregnancy it's better to be checking some finger sticks and then also any device that does not have that non injunctive indication should be confirming with finger sticks to make treatment decisions. So if in doubt check it out. But also what this means is your patients need a prescription for test strips. This is so important because I have seen some plans say well this patients using C. G. M. So we don't they don't need test strips but that is not true at this point in time with our current technology people need test strips and they absolutely still should have access to them. Now. Also there can be challenges with alarms and the settings. So there's a lot of ways we can customize these devices and I think as pharmacists there's so much we can do to support people in doing this so that they don't get annoyed with the alarms. So what we want to do is we really want to set the high and the low alerts To something that's going to make sense and be useful that people can act on. So for example, we don't just want to set a high alert at 1.80. So it's pretty much going off every single time a person eats. There could be a person who is heavily motivated where 1 80 could work. But for most of my patients were making it much higher or in some cases we're turning it off because they don't need to be bothered by that ringing too, you know too much. And also that can affect quality of sleep. So we don't want to do that to. Also there is the opportunity for data sharing where data can be shared with clinics, it can be shared with loved ones. And so coming up with a plan to decide who should data be shared with. So someone feels the most comfortable And then a very common thing or comment that comes up is you know, how do I what do I do? My sensor fell off early. How do I keep it on? There are so many great products out there that can help people to keep their sensors on. I mean right 14 days is a long time to keep something on and especially you know in the summer when it's hot it's more likely to come off. So these are some of my recommendations for products that can really help there are products that can go underneath like skin tack to help it adhere better and then there's a lot of fun products that can go over it. Um There's even there's fun designs and colors and sparkles or you can do clear whatever the person prefers. But I see let your patients know about this, see if you can offer it to them because that will just help them have the optimal use and then you don't need to be replacing sensors early. If a sensor does fall off early though the manufacturers are great about replacing those. So in summary you know insurance coverage has been expanded to include more people with type one and type two diabetes. And the requirements are becoming less stringent which is positive. It's a very positive thing in the diabetes world, ongoing communication with prescribers and health systems as well as third party platforms can really help streamline the ordering process for C. G. M. And help facilitate prior authorizations to make it a smoother process for everyone and help our patients to easily access the C. G. M. Devices. And then finally there's so many ways that managed care pharmacists can help with C. G. M. Optimization through the initiation process that education and troubleshooting to really ensure optimal use and maximum benefits. So thank you so much for attending this presentation today Published October 19, 2021 Created by Related Presenters Diana Isaacs, PharmD, BCPS, BCACP, CDCES, BC-ADM, FADCES, FCCP Endocrine Clinical Pharmacy SpecialistCGM and Remote Monitoring Program CoordinatorCleveland Clinic Endocrinology and Metabolist Institute
