Innovation in Diabetes Care Technology: Barriers to Reimbursement
Institute Report
Jul 30, 2020

About the Report

The clinical and financial burdens placed on the healthcare system by growth in chronic diseases has spurred the search for new care models that generate greater healthcare value, such as those leveraging digital medicine products. Initial studies have shown that improved access to and optimal use of diabetes digital medicine products — for example, continuous glucose monitors (CGMs) and connected insulin delivery devices — can have positive clinical, psychosocial, and economic impacts on people with diabetes and the healthcare system that serves them.

A critical need for digital medicine products has simultaneously grown during the COVID-19 pandemic, as patients receive healthcare services at home. The importance of these products is highlighted by CMS’s easing of requirements for access to CGMs during this period. However, to obtain and utilize these products stakeholders face several challenges like navigating the current reimbursement landscape. As more digital medicine products become available and enable a new era of care, modernizing the reimbursement paradigm will facilitate their seamless integration into the healthcare system and their optimal use.

Report Summary

This report explores the current coverage and reimbursement paradigm for digital medicine products, which was largely codified before digital devices became prevalent, and examines possible barriers to access and use. Modernizing the reimbursement landscape across the U.S. healthcare system can aid in optimal access to and use of these new, and increasingly used, devices. Challenges exist in the form of coverage differences between insurance types such as commercial and Medicare. Additionally, healthcare providers and other stakeholders face challenges regarding reimbursement for time spent using these products and their expertise advising patients. Specifically, significant time investment is required for healthcare providers (HCPs) to train themselves on how to use these technologies, initiate patient use, and support the ongoing needs of patients that may not be reimbursed.

At its conclusion, the report presents short and long-term solutions that offer opportunities to better integrate digital medicine products into the U.S. healthcare system. Changes in policy to reimburse for HCP time and expertise may help optimize use of diabetes digital medicine products in the longer term. For example, the healthcare system could benefit from the development of new CPT codes to allow for HCPs to be reimbursed for training on the use digital medicine products and for patient coaching and counseling. Modifying current CPT codes to allow for more frequent remote analysis and interpretation of diabetes digitally collected data, modifying coding frequency, and expanding eligibility to the wider clinician team involved in care could similarly encourage adoption.

Key Findings

For people with diabetes, gaining access to critical devices and supplies can be complex and requires navigating multiple coverage components of their insurance plans.

Potential Impacts from the Current Reimbursement System

  • For key products, such as continuous glucose monitors (CGMs), connected insulin pens, hybrid closed-loop systems, and smartphone applications, transitioning from commercial insurance to Medicare, as an example, impacts coverage requirements, and the same types of products may or may not be covered.
  • From a health system perspective, variations in coverage between federal, state, and commercial payers may have an impact on health disparities, as access to technologies can vary based upon insurance type.
  • In order to respond to the rapid advancement of technology and new, emerging paradigms of care, there is a need to re-evaluate the current system of reimbursement to allow for a more flexible and modernized approach.

Healthcare providers play a critical role in integrating technology into the healthcare system, and the ways in which they educate, personalize, and coach diabetes patients can have a direct impact on the uptake and outcomes of digital medicine products.

Key Plays and Roles of the HCP Care Team

  • Providers need to ensure they have knowledge about current diabetes digital medicine products, stay up to date on recent advances, and are aware of changes and nuances of reimbursement systems, but investing this significant amount of time is costly.
  • While CPT codes do exist for digital medicine, these do not fully cover HCPs to support PwD in managing their diabetes with digital medicine products nor do they reimburse for their time initiating these products with patients or training them.
  • In order to support the uptake of digital diabetes products, policies could be adapted to restructure the current reimbursement system such as by introducing new CPT codes to account for healthcare provider time and expertise.
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