Addressing Barriers to Health Care Delivery Through Advocacy
By Ambika P. Ashraf MD, FAAP, FNLA
Diabetes is the epitome of "an ounce of prevention is worth a pound of cure." That was the driving force behind our division's advocacy efforts that led to a change in Medicaid coverage requirements for continuous glucose monitors (CGM) for children with type 1 diabetes.
The Division of Pediatric Endocrinology and Diabetes at UAB, located at Children's of Alabama, caters to the majority of children with diabetes in Alabama. Multiple studies in children with type 1 diabetes have confirmed that intensive glucose control reduces the rate of diabetes complications. Traditionally, patients with diabetes check blood sugars at least four times per day. The glucometers require frequent, painful finger pricks to get a drop of blood for testing. In addition, middle-of-the-night checks are often needed to catch dangerously low/high sugar levels.
CGM provides real-time, numerical and graphical information every five minutes and allows patients with diabetes to monitor blood glucose with a reduced patient burden. CGM use can improve glucose control while reducing the frequency of hypoglycemia, lowering hemoglobin A1C, improving time in the range of goal blood glucose and ultimately helping to prevent acute and chronic complications related to diabetes. These devices can be especially helpful to patients with social determinants of health that prevent them from adequately self-monitoring their blood glucose.
In 2019, our clinic's baseline CGM use rate for all patients with diabetes was 22 percent, while the national average based on the Type 1 Diabetes Exchange Quality Collaborative was 48 percent. Of the approximately 2,000 children and adolescents with type 1 diabetes at Children's, around 45 percent of patients had Medicaid insurance. In our commercial insurance population, 50 percent of our total patient population used CGM. In contrast, our coverage rate for those insured by Medicaid was 17 percent, mainly due to the restrictions on coverage of CGM. At that time, Alabama Medicaid required patients to have "severe hypoglycemia" for coverage of CGM, which led to significant inequity between patients with private insurance vs. Medicaid insurance.
Drs. Jessica Schmitt and Mary Lauren Scott initiated a quality improvement project to address disparities in CGM access based on patient insurance. They used plan-do-study-act cycles to reduce the baseline disparity by 10 percent. The interventions targeted improving provider understanding of requirements for CGM coverage, weekly emails to providers detailing the percent of their patients using CGMs, assisting patients with meeting documentation requirements and inserting CGM samples obtained using the Kaul Pediatric Research Institute grant funding. Even though the percentage of patients who had CGM samples inserted in the clinic went up, we realized we could not get continued CGM supplies without meeting the Medicaid criteria.
In 2020, we petitioned Alabama Medicaid to change the CGM coverage policy, specifically to reverse the demonstrated hypoglycemia requirement to provide CGM technology for our patients with type 1 diabetes. All of my colleagues, especially Drs. Jessica Schmitt, Mary Lauren Scott, Margaret Marks, Joycelyn Atchison and Michael Stalvey helped me petition Alabama Medicaid. We explained that the cost of the CGM will be offset by decreased emergency room visits and admissions for diabetic ketoacidosis, hyperglycemia or hypoglycemia. While the yearly cost of CGM per patient may appear high, preventing one patient from having an admission for diabetic ketoacidosis can cover the complete out-of-pocket cost for two to five patients to use a CGM for a year. After months of effort, this became a reality on January 1, 2021, when Medicaid approved CGM use for children with type 1 diabetes who had proof of four blood sugar checks per day. They eliminated the severe hypoglycemia requirement. With the continued effects of our interventions, by late March 2021, the disparity between Medicaid vs. private insurance decreased to 12 percent.
Currently, our sustained weekly CGM use in our clinic for all patients is 81 percent and for patients with Medicaid insurance is 75 percent. This increased use of CGM resulted from our team's commitment to our patients and our responsibility to improve the quality of life and long-term outcome. We are grateful to Alabama Medicaid for recognizing this opportunity to improve the care of patients with type 1 diabetes and reduce disparities.
Ambika P. Ashraf MD, FAAP, FNLA serves as the Director of the UAB Division of Pediatric Endocrinology and Diabetes and the Medical Director of the Children's of Alabama Pediatric Endocrinology Clinics.