In an August 2015 interview by the Juicebox Podcast’s Scott Benner, Dexcom CEO, Kevin Sayer, answered this CGM/Medicare question. He said that Medicare sees the CGM as a “safety” device and therefore ineligible for Medicare coverage. Sayer said that they were working on making the CGM eligible for Medicare coverage.
It’s interesting to note that the G5 released in Europe this summer contained a label that stated it could be used to make treatment decisions. This may be the situation required by Medicare to make CGMs eligible for coverage. I’m sure that there’s an asterisk and footnote that says if your physical sensations call into question the Dex reading then a fingerstick is called for. In any case I think that Dexcom and the FDA will need to finesse this.
I think using the CGM and fingersticks as a symbiotic system should permit CGM coverage. Most CGM users report a decrease in strip usage. That should be enough for Medicare to make the case. Fingersticks are a legitimate basis for treatment decisions but they don’t provide the all the time visibility of a CGM. That fact combined with hypoglycemia unawareness should be weighty enough for Medicare. CGMs save lives and diminish ER visits.
so is there any competition when it comes to cgms, or are they all just covered by insurance? why is there competition when it comes to strips- isn’t that something that is pretty much all covered by insurance?
I doubt there is much room for competition outside the insurance market for a CGM. What I’m talking about is the bigger picture but has allowed all cost to run away from anything reasonable Throughout our healthcare system. The entire system we have depends on insurance covering everything so there is not a lot that we can actually do to change that very easily but it is also a large part of the reason why costs have gone crazy.
I don’t know the solution. I just imagine that if insurance had never started covering cgm the prices would have to be within reach to ordinary people… Or else they wouldn’t sell…
Your religion prime strips are dirt cheap because they don’t contract with insurance companies… They charge what they cost to make them, plus their profit margin… That’s it… And if they weren’t affordable nobody would buy them.
I buy my own strips out of pocket even though I have insurance to cover other strips just because I hate how corrupted the whole system is, I can afford them, and I don’t want to contribute to the price gouging that is rampant in the medical industry when I can avoid it.
Relion CGM’s!! I like that idea. My Relion meter seems to be just as accurate as my FreeStyle meter. Relion is a very good brand, with reasonable prices. I bet the other meter companies hate Walmart!!
I suspect they recognize a sector of the market in which people don’t have insurance or just don’t want to mess with it and just want purchase low cost strips without messing around with the whole game…
There is a reason why Walmart is one of the most profitable businesses in the world. They think outside the box.
what’s their excuse then for not covering OmniPod, it is the coding (disposable issue), too. Everything is 'precautionary" i.e., preventive until it’s NOT. Most preventive care is not only encouraged but covered. This is the same thing yet on-going. Makes no sense! I’m happy to hear there are true advocates for trying to getting this passed. I would imagine seniors are some of our most vulnerable.
I love relion prime strips. I use them between bolus times to track trending since I don’t use a CGM. They are very close to my countour next which links to my pump. I have fought with my insurance company and lost. 150 strips a month is all they cover and then I still have a copay. I have ordered some strips on line as well for just as cheap as my copay. One does whatever works for them.
The whole profit motivated medicine is mistaken. How much is your life and the lives of your loved one worth to you? Nothing else is worth as much. where’s the competition if one says, “die or give me everything”? Another absurdity of profit motivated medicine is, a doctor is personal and you can’t switch them for better prices. Also when one gets sick and is in desperate need of medical care one cannot advertise, accept resumes, conduct interviews and then negotiate for the best deal because that is not what medicine is. It’s like a tree, it grows and blooms and from the bloom grows a fruit. But a bear in the woods did not come from a growing tree. By watering the fruit tree one may get a more moist fruit. But the bear in the woods does not become jucier by watering a fruit tree because bears don’t grow on trees they are mammals.
A little additional research on my part showed that some insurance plans actually do cover relion prime-- so I’ll correct myself there. However that doesn’t change the real point— that the vast majority of relion’s market are out of pocket customers, which is why they price their products at rock bottom prices in order to sell.
In contrast, if the vast majority of your product is paid for by insurance, the price is invariably much, much higher. Why? Because the insurance industry doesn’t directly care what the products they pay for cost-- because they can simply increase their rates to maintain their profit margin. Think about your household budget— would you care if a roll of toilet paper cost $50 each if you had the ability to just effortlessly increase your household income to adjust for that added cost? No, you wouldn’t. So there is no downward pressure in the pricing in that example… In the real world where we can’t adjust our income effortlessly we have to buy products that are priced reasonably and appropriately or else we’d go broke---- but in the insurance model this doesn’t hold true at all…
It is the worst system ever devised and makes no economic sense whatsoever… It’s akin to paying thousands of dollars in deductible in order to replace a $2 light bulb with your homeowner insurance… Insurance companies get obscenely rich while driving the prices of products we need to survive out of our reach and forcing our entire society to be completely dependent on them from birth to death. But As a society we just keep being herded along into this trap and it drives me absolutely crazy. I hope that makes at least a small amount of sense to anyone but me.
that makes sense. but can’t the government negotiate for lower prices for the medicare/medicaid program? then different cgm companies would have to compete for the government’s business.
One path is for Dexcom to submit the relevant data to the FDA allowing the Dex to be used to make treatment decisions (actually a scary thought given the variability I have seen, btw!). Of course, if the algorithm were improved or modified in some respect to increase accuracy, that would be better. This path may be more likely with the next generation of sensors and SW updates, but will be expensive for Dex to aquire the data.
The other path is to create a law that directs Medicare to cover CGMs. Again, a tough row to hoe, but one that we, as diabetics, can have an impact on.
Many of you have contacted your Federal representatives. I applaud you. We need to keep up the messaging, thank those who have co-sponsored and encourage those who haven’t seen the light to open their eyes.
One microcosm of this that I find rather alarming is the (to me) bizarre phenomenon of health insurance for pets. Inevitably this will mean an inflation of vet service prices, putting those services out of range of people who don’t have the insurance, thus increasing pressure on everyone who has a pet to obtain insurance and onward in an escalating spiral. The whole thing seems wonderfully advantageous to the insurance companies.
But it’s also important to recognize that health care doesn’t behave anything like a normal market, a fact that has long been recognized in economics but seems to make little headway among politicians, simple-minded policy makers and media pundits. It’s notoriously the realm of Market Failure. Fine example of that here:
In D-land we’re talking about a kind of specialized sub-category of this, but in general the problem is that as a healthcare “consumer” you’re not in the same position as someone shopping for a TV. Price may be far from the primary consideration, quality is a very high consideration but very hard to determine (Yelp reviews?), and the fact that very abstruse and difficult expertise is required for treatment decisions (“Wait, Dr Radiologist sir, I think you’re reading that CAT scan wrong!”) etc etc. make it about as inelastic as a market can get. There may be restricted or localized sub-zones where it can function more like a normal market–test strips, for instance, which aren’t much different from other OTC drugs and treatments. But because of that general inelasticity there are SO many areas where price gouging and outright scams can occur, because if people need something to stay healthy, or even to stay alive, they’re going to have little choice but to pay whatever the supplier demands.
So I’m sympathetic to the idea that insurance coverage can lead to inflated prices, but I also think that price inflation pressures are built into the nature of the market. Quack treatments have always been a huge problem for the same reason–something that used to be insanely out of control (“Drink healthy radium water! It cures everything!”) before the FDA, not that it has eliminated the problem. And there are certainly treatments that are justifiably expensive, way out of the range of non-millionaires, that insurance makes accessible by spreading the cost over a larger population. Obviously a huge topic but I think the nature of the beast is such that you have to have some kind of strong regulatory structure built into it because it just doesn’t operate by the same rules as other kinds of goods and services. One way to do it is the German model, where you have insurance companies but they are strongly regulated as to their profit margins, salaries and so forth, and the government is a player when it comes to negotiating prices with pharmaceutical firms–something we’ve stupidly nixed over here.
Thoughtful-- thank you. You are absolutely right that comparing more elastic demand with much less elastic demand for healthcare is prone to some real flaws but that doesn’t make it useless to understand basic concepts…
I think ultimately the best way out of this mess is (over a long stretch of time) people need to ween themselves off insurance altogether for all but the unexpected extraordinary high costs that they might unexpectedly incur---- insurance works quite well in that form— just like your automobile insurance and homeowners, life insurance, etc… It is good at insuring against the unexpected.
But when we need insurance all the time to cover our routine healthcare costs, from dentist visits to ongoing prescription meds, to cgms, etc— the results we are seeing is runaway costs and a totally disfuntional market.
It’s not just as simple as regulating the insurers profit margin— because it can be set in stone, as long as they can maintain it effortlessly by changing their rates, the end consumer still suffers…
You are right supply and demand aren’t the same in healthcare, but the pendulum has swung way too far in the opposite direction to the point that the prevailing model and mindset is almost completely “it doesn’t matter what something costs because nobody could ever afford it and somebody else pays for it” and I believe this has and continues to lead us in a very bad direction.
I don’t have it right at my fingertips but I read a recent study about a different way to put market forces to work that didn’t involve dumping everything on the consumer a la “Hey, go shopping for the best deal on that emergency throat cancer surgery!” which is essentially what was going on in the article I linked. Something that was actually implemented and found quite effective, a comparison between two different hospital systems, one using it and one not. Details are hazy–but I liked it because it was a quite different way of thinking about the problem that seemed to get at the real essence of it. I’ll try to find it and come back when I have a moment…
Richard I share your concerns. I’m one of those Medalists that experiences hypo and hyper unawareness. I check my bg at least 9 times every day, more if I’m driving running errands, because up to the point where I can’t support myself and end up on the floor, I have no symptoms of lows. I check myself before I get in the car because I don’t want to be driving with a 36 bg.
Medicare promotes itself as supporting preventative medical services yet continues to deny coverage for more than 1 hour a year for CDE appointments, along with the continued denial of CGMs and supplies. I’ve been in a Medicare survey for the past 2 1/2 years. Three times every year all of my medical appointments, labs and prescriptions are recorded along with my comments on the quality of healthcare I’m receiving. I have one final appointment/interview that will occur next February or March. Each time I’ve been interviewed I have specifically commented on the limited Medicare coverage for diabetes management/supplies. My comments are recorded but I have no idea if they’re even read.
Thanks Janis. There are many medalists in the Facebook group who have said they have hypo unawareness, like you and I. It seems that we are more apt to have that problem after we have been T1 for a very long time. Medicare may not be aware of that, or even understand the possible consequences of that problem.
