Consensus Conference on glucose monitoring, patient input needed!
Emily Coles has this discussion running and I think it will be a hot topic (or I hope it is). The link to her post is:
https://forum.tudiabetes.org/topics/consensus-conference-on-glucose-monitoring-patient-input-needed
She is seeking comments related to a pending FDA conference to generate a combined system of test strip management by Federal Authorities. I hope she gets many comments. I for one hope the conference works because the current system is dysfunctional to say the least. Today I want to comment on one part of the 4 part discussion. Medicare strip management and surveillance. This ought to be a hot portion of the discussion.
The current Medicare policy on testing management (I say testing because the issue must include CGM usage to be effective) is outrageously bad. To me the topic needs to be addressed in 3 parts:
1. CGM usage: It is crazy that current Medicare rules prevent coverage for CGM’s. Since it prevents coverage of CGM’s and supplies, that means that as diabetic’s age they are effectively ageing out of using CGM’s. Take my case. On my current arrangement I am on Medicare with a strong private secondary insurer that is not a traditional Medicare supplement. At present Medicare will not cover my CGM but my secondary Insurer will. So my provider files its claim to Medicare (who rejects it) and then with my secondary insurance who pays it according to its rules. In a few years however that goes away. I will be losing my secondary coverage and that will effectively end my usage of the CGM.
But before you say oh poor rick, this is happening to every Medicare diabetic. Effectively Medicare recipients are economically barred from using CGM’s since Medicare is not providing coverage, the traditional supplements will not provide coverage and a typical diabetic cannot afford the cash price. Under the present rules I will have been using a CGM for 13 years when this occurs and it won’t matter. The same is true for current Medicare recipients; they cannot get CGM coverage no matter how bad their situation. It is simply prohibited and is termed unproven technology. So my first recommendation:
Include CGM for Medicare coverage of CGM’s as an overall approach to blood sugar management.
2. The second part is the one that makes me so angry and that is strip consumption restrictions for diabetics. At present this is the published understanding of the ADA regarding Medicare rules for test strip reimbursement
“Beneficiaries with diabetes who use insulin may be able to get up to 300 test strips and 300 lancets every three months. Beneficiaries with diabetes who don’t use insulin may be able to get up to 100 test strips and 100 lancets every three months. If your doctor says it is medically necessary, you can get additional quantities of testing supplies. Additional documentation is required. [Note: See information below about the National Mail-Order Program for Diabetes Testing Supplies]” (Americna Diabetes Association 2014).
So I am not a big fan of this policy, but I get it. Selling black market test strips is an awful practice and Medicare cannot just be left hanging without accountability. So here is my suggestion:
Expand the current limits to 5 test strips per day for insulin dependent diabetics and 3 per day for non-insulin dependent diabetics. In addition make the prescription provider universally responsible for collecting and maintaining the logs. In addition standardize the log requirement at one month of test data for every 6 months. Also allow a behavior period where after submittable of 5 years of required data, the log requirement is dropped so long as the number of test strips and the provider remains the same or the number of test strips declines.
With the exception of the 5 year amnesty program and the increased number of strips that is all common practice today but it is not the universal practice. All I am asking is that the practice be made universal and that the burden be placed universally on the pharmacy not the doctor.
3. Establish gray market tracking of test strip sales in order to curb abuse. At present Medicare does not know where gray market sales of test strips originate. It is assumed it is Medicare, and it may be, but no one knows for certain. I think that if it were known if Medicare is supplying the balk of the gray market test strips then more commonsense test strip management could prevail. So here is my third recommendation which I imagine will cause some loud protests but is necessary:
Force manufacturers to produce coded test strip packaging only for Medicare use and prevent pharmacies from using non Medicare specific test strips to fill Medicare orders. Also make it illegal for Medicare test strip recipients to sell test strips to another individual.
So here is my thought, Medicare is the largest test strip buyer in the country by far. So create specific packaging so it can be determined with some certainty where gray market test strips originate. Penalize any gray market sellers of Medicare provided test strips that are found and penalize people who sell their strips with the threat of prosecution. Notice I did not say prosecute those who give strips away. Let’s face a reality we all hoard stuff and when we have to much we usually give it away. This provision I am hoping for is about sellers not donators.
Now no doubt what would happen is that gray market providers would repackage their Medicare provided test strips and continue to sell them. But it might increase their cost to the point where they refrain from doing it. Also the threat of criminal prosecution of Medicare recipients who sell Medicare provided test strips might stem the flow. Ultimately the aim should be to remove these ridiculous monthly test strip limits imposed by Medicare, suggested by me and hated by almost all Medicare diabetics.
So why might people be upset with this arrangement. Well for one it would, with some minimal work, give Medicare a way to backtrack individual strip resellers. I can hear the Civil Libertarians and the conservatives both complaining about the loss of privacy. No doubt scaring older citizens into thinking there is unjust government intrusion. But hey these gray market sales are a legitimate threat to Medicare provision of diabetic supplies, this is one where Medicare recipients, like myself, need to take one for the team.
Some readers of this blog will agree, some will disagree and frankly I understand. We all want unlimited test strip provision with the consent of our doctors. At least that is what I want. But those days are over. The gray test strip marketers have caused the need for radical reform. I hope the conference Emily is speaking of in her post will adopt these three items with regard to Medicare and test strips.
References
American Diabetes Association (2014). "Medicare." Retrieved July, 24, 2014, from: http://www.diabetes.org/living-with-diabetes/health-insurance/medicare.html.
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