Snapshot
- Medicare Expansion: CMS now covers CGMs for millions with diabetes starting 2023.
- Cost & Clinical Benefits: CGMs significantly reduce A1C levels, saving health plans monthly.
- Managing New Users: Over 1.5 million new beneficiaries will qualify for CGMs.
- Success Strategy: Health plans should offer ongoing education, engage potential high spenders, and collaborate closely with primary care providers.
CGM expansion is coming. How can health plans prepare to maximize their value to members?
Arti Masturzo, MD
Chief Medical Officer, CCS
In April of 2023, CMS announced expanded Medicare coverage for continuous glucose monitors (CGMs), a game-changing personal device for the millions of people living with diabetes — and the 1.3 billion, including up to half of all Black and Latinx residents in the United States, who are projected to be living with the condition by 2050.
Industry leaders have applauded the expansion, citing research that ties CGM use to significant reductions in A1C levels (up to 1.5 points in some populations) and associated cost savings of several hundred dollars per member per month for health plans, largely due to fewer avoidable hospitalizations, long-term care needs, and other Medicare Part A expenses.
The research indicates that health plans, providers, and people with diabetes can all look forward to long-term clinical and cost benefits from broader CGM adoption. However, there are some shorter-term issues to consider as these devices start to become more popular.
Analysts anticipate that at least 1.5 million new Medicare beneficiaries will become eligible for CGMs, which will put pressure on health plans to manage an influx of first-time users and deepen their chronic care management relationships with members. Plans will be facing increased costs related to the distribution and use of these devices, as well as increased demands on their time and resources as new and existing CGM users start engaging more fully in their own care.
Plans will need to have a better idea of who is likely to request a CGM, what benefits they might gain from it, and how to engage with these individuals in a coordinated, personalized, and motivational manner so they can mitigate the upfront costs of coverage expansion and achieve long-term ROI via reduced downstream costs, better member experiences, and better overall outcomes.
Three strategies for health plan success in an expanded CGM environment
To achieve their clinical and financial goals, plans will need to combine advanced analytics technologies with fundamental competencies in building relationships with their members.
Identify and engage the cohort sitting right behind the top 20% of high spenders
To control costs, health plans naturally look first to their highest spenders: the 20% of members who are the most clinically complex and utilize the most expensive services.
But they shouldn’t be the only ones in the spotlight. Plans should also consider how to identify and engage the members who may be doing well today but are likely to be moving up into that high-spending 20% cohort tomorrow by thinking about innovative ways to uncover signals in clinical, financial, and socioeconomic data that might indicate adherence challenges or gaps in care that don’t always show up in traditional analytics methods until it’s too late.
For example, irregular reorder rates of diabetes supplies or medications can indicate trouble with self-management long before a member ends up in the emergency room with a major blood sugar issue. This type of person may benefit from CGM use — as well as any applicable socioeconomic and educational interventions — to simplify their daily routine and keep them from becoming more medically complex in the future.
Provide continued CGM education and coaching post-onboarding in order to optimize utilization
Even with a CGM to provide constant support, diabetes can lead to cognitive and emotional fatigue and a gradual slide away from healthy habits. This can reduce the value of CGM devices and potentially set members up for disease progression.
It’s important for health plans not to view the onboarding process as a one-and-done activity. Instead, they should establish a cadence of regular touchpoints that include ongoing education and coaching to keep members on track.
These interactions should not only include device-centric troubleshooting, but should also serve as opportunities to collect robust, personalized data on a member’s clinical and non-clinical challenges, such as affordability issues and other barriers to accessing optimized diabetes care services so plans can provide appropriate interventions.
Working with a partner to provide these capabilities can be an economical way for health plans to gain the scope and scale necessary to manage the expected influx of CGM users who will need these services.
Engage the primary care community in coordinated, data-driven diabetes care
Primary care providers deliver the vast majority of diabetes-related care, including prescribing CGMs and working directly with their patients to ensure proper adoption and adherence. Given the added pressures on physicians and challenges specific to physician burnout, it is imperative that they have the education and support they need.
Plans will need to provide actionable guidance for primary care providers who may not be familiar with the technology yet. Plans should also examine how CGM use will fit into broader value-based care initiatives that reward providers for high-quality care and better outcomes, especially as benefits accrue over time.
Establishing strong data connections and providing population health management insights to primary care providers, as well as offering ongoing education to providers and resources for connecting members to applicable services, will be important for closing the feedback loop and extracting value from CGM devices.
Overall, health plans should be looking forward to the opportunities of bringing CGMs to more people, but they also need to be cognizant of how this sea change will impact the way they manage members and their costs. As CGMs start to reach broader populations, plans will need to design effective, personalized, and predictive interventions that help members stay one step ahead of costs and clinical complications.
