The Case for CGMS and Medicare Covered Patients
There is a heck of a blog out on March 12, 2014 by Bennet Dunlap in the blog space “your diabetes may vary” (http://www.ydmv.net/) concerning overall emergency room visits by diabetics with hyperglycaemia and hospital admissions. It is frightening and it draws off of a paper published by JAMA online titled “National Estimates of Insulin-Related Hypoglycemia and Errors Leading to Emergency Department Visits and Hospitalizations” (Geller, Shehab, Lovegrove, & et al., 2014). The statistics and meanings are remarkable. I hope you will see it as I see it and maybe it will give us a renewed source of energy to advocate for Medicare coverage for CGM’s .
First let me state I am not able to read the Geller article for good reason. I am not a member of JAMA (Thank goodness, I think) and without that membership this article can only be read in summary or one can gain read access for $30 for 24 hours. The reason is that this article was only published on March 10, 2014 so overtime it will enter the public domain, but it may take a couple of years , or it may never enter the public domain especially given the incredible discussion it is generating. Time will tell. For the time being this article is going to generate the authors a bunch of money and some serious notoriety so it is going to be a purchase only document for a few years yet. Ok so long / short I have only read the summary and commentary about the summary. To my knowledge no one in the diabetic community has yet to rent the article for a full reading. But who know someone will and I am going to keep trying to get my hands on it. It is a cool serious article.
Ok so enough about what we do not know, this is the part that is striking. The authors used the “National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project) and a national household survey of insulin use (the National Health Interview Survey)” (Geller et al., 2014), to examine insulin related admissions to emergency rooms from January 1, 2007 thru December 31, 2011 (Geller et al., 2014). (Just a note the “National Electronic Injury Surveillance System” is one seriously important national database) Anyway this is what was found. During that two year period, there were 97,648 visits to Emergency Departments (ED) for insulin-related hypoglycemia and errors (IHEs) (Geller et al., 2014). Again a big thanks to Bennet Dunlap for putting the following pieces together.
So this represents about 50,000 ED visits per year. Now remember most IHE’s never make it to the emergency department. I am not in this statistic because I refuse transport to an emergency department several times in my lifetime and most of us who have ever had a low and someone called 911, refused transport. Likewise, I was 48 last evening so I treated. Neither of these would have been recorded in the 97,648 number. Anyway, so this 97,648 is the number of people who show up in the ED because of insulin-related hypoglycemic events. So these are the worst of the worst. Anyway, nearly one third of these patients (varying from 26% to 36%) ended up being admitted to the hospital (Geller et al., 2014). In addition “severe neurologic sequelae were documented in an estimated 60.6% %) of ED visits for IHEs, and blood glucose levels of 50 mg/dL” (Geller et al., 2014) and lower.
Ok so a side track what does ‘sequelae’ mean? A ‘sequelae’ is a an “aftereffect of disease, condition, or injury or a secondary result” ("Merriam-Webster sequelae," 2014). This secondary piece of information means that some neurological after affect was noted in about 60% of people who hit the ER with a blood glucose level of 50 mg/dL or below. How many of us have wondered and some of us have said out loud we wonder about the neurological effect of being low for an extended period of time. Anyway, 60% is a large number but before we jump off the deep end, this 60% may include some disorientation all the way to being unable to be revived. The summary of the study links all of this together. So it may be just really short term in duration, but it is noted.
Ok so back to the story. This is the crux of the finding and I believe our call to action. This study also examined the issue of age related visits to the emergency department and admissions to the hospital. The authors found that “insulin-treated patients 80 years or older were more than twice as likely to visit the ED (rate ratio, 2.5; 95%) and nearly 5 times as likely to be subsequently hospitalized (rate ratio, 4.9) for IHEs than those 45 to 64 years. The most commonly identified IHE precipitants were reported reduced food intake and administration of the wrong insulin product” (Geller et al., 2014).
Now a jump back to what Benet Dunlap pointed out, which is that Medicare will not cover the use of CGM’s in this population. Diabetics, even those who have been on long term CGM therapy before entering the Medicare system cannot routinely obtain coverage for CGM’s yet this population (as it ages) is the most likely to end up with hospital stays as a result of hypoglycemic events. Further hypoglycemic sequelae is a major issue in this population. Want to do something? Take this information and push congress people to change the law. Denying people the opportunity to use CGM puts them at harm for these issues. Just so it is understood these people are likely the least able to afford a CGM and they are the most likely to miss meals because of lack of funds or foul insulin dosing.
One of the issues of Medicare not paying for CGM’s is the cost of the devices and supplies. Well there is a group that also categorizes things. Such a study existed was completed and they found "The mean costs for hypoglycemia visits were $17,564 for an inpatient admission, $1,387 for an ED visit, and $394 for an outpatient visit” (Quilliam, Simeone, Ozbay, & Kogut, 2011). This was also quoted by Bennet Dunlap so I didn’t find it. According to Dunlap this means that from January 1, 2007 thru December 31, 2011, Medicare spent at least “$640 million a year” for hospital and emergency room visits by seniors age 80 and above (2014). As Dunlap points out, that is one heck of a lot of CGM purchases. Need to make a down payment it is available (2014).
Want to hear something else that is crazy tunes? During this two year period:
“Stimulants, including amphetamines and methamphetamine, were involved in 93,562 ED visits.” (Drugabuse.gov as quoted by Dunlap, 2014).
That means that during this period there were 93K Emergency room visits occurred for Stimulate overdose as compared to 97K for diabetic lows. Wow, we have a national war on meth abuse, with millions of dollars in policing, jails, guns, judges, juries, attorneys and yes hospital costs. Yet we as a country cannot spare money for CGM’s for people over age 64. Any idea why? Yeah me either.
It is time to change the law, or force Medicare to adopt the common sense, lifesaving step of paying for CGM’s. Yes now would be a good time to call your Congressperson and Senators office. In fact it is well past time. I wrote mine this morning.
Dunlap, Bennet. (2014). Meth. or Insulin. Blog Post Retrieved from http://www.ydmv.net/2014/03/meth-or-insulin.html?utm_content=buffer11839&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer
Geller, A. I., Shehab, N., Lovegrove, M. C., & et al. (2014). National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Internal Medicine. doi: 10.1001/jamainternmed.2014.136
Merriam-Webster sequelae. (2014). from Encyclopedia Britanica http://www.merriam-webster.com/dictionary/sequela
Quilliam, Brian J., Simeone, Jason C., Ozbay, A. Burak, & Kogut, Stephen J. (2011). The Incidence and Costs of Hypoglycemia in Type 2 Diabetes. American Journal of Managed Care, 17(10), 673-680.