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Role of Blood Glucose Self-Monitoring in Medicare Patients with Type 2 Diabetes

Posted: Thursday, October 12, 2006

The Centers for Medicare and Medicaid Services is questioning whether or not Patients with Type 2 Diabetes benefit from self-monitoring of their blood glucose and should they pay for monitor and strips.

Medicare currently pays for up to 100 glucose testing strips per month for diabetics who use insulin, and up to 100 strips every 3 months for those not using insulin. Higher amounts are covered if the physician provides written documentation of need. In 2003, the most recent year for which data are available, the program paid more than $908 million for glucose testing strips.

Among current “problem areas” are skilled nursing facilities and home health agencies that perform multiple daily glucose tests on type 2 diabetic patients without any adjustment of medication dose based on the results. Inappropriate marketing of glucose testing to Medicare beneficiaries has also become a problem. “The question is how often to test, should we be testing, and are changes being made to improve the disease?”

At the hearing, a series of presenters summarized the current literature addressing the relationship between the use of both fingerstick monitoring and continuous glucose monitoring, and clinical outcomes in patients with type 1 and type 2 diabetes. At the end of the day, panel members were asked to answer a series of questions regarding the role of self-monitoring of blood glucose (SMBG) and glycemic control in patients with diabetes.

One question was: “How confident are you that an increased frequency of outpatient glucose monitoring translates to decreases in chronic complications (specifically cardiovascular morbidity and mortality) in Medicare-age patients (older than 65 years) with diabetes?” The overall average response of the 12 panelists—comprising 7 voting members and 5 nonvoting guests—was 2.67 on a scale of 1 (“very unconfident”) to 5 (“very confident”). One nonvoting guest panelist was an endocrinologist; none of the voting members were.

Other questions addressed the degree to which data on hypoglycemia generated in populations with type 1 diabetes can be extrapolated to those with type 2 (overall scores were 2.92 for insulin-using type 2 patients and 1.92 for non-insulin-using type 2 patients), and whether the optimal frequency of SMBG in Medicare-age patients with type 2 diabetes is known in terms of strips per day, strips per week, or continuous monitoring (overall average was 1.83).

Ms. Yutzy, diabetes nurse-educator at Mercy Medical Center, Baltimore. said in her presentation “If the committee were to consider recommending reductions in Medicare coverage for diabetes needs, it would do a great disservice to the nearly 7 million Medicare beneficiaries with diabetes. … Instead, I hope the committee's questions were asked to help determine how to optimize current coverage,”.

Dr. Steve Phurrough, of the agency's Coverage and Analysis Group, stated in an interview following the hearing, “This meeting has nothing to do with whether we're going to reimburse for anything. … The purpose of this meeting was to have the discussion about what's best for the adult type 2 Medicare diabetic. A whole host of people think that any monitoring might not benefit the diabetic population aged 65 and older who develop type 2 diabetes and have no complications. Should we be monitoring them at all? It's a question for scientists, not a question of whether we're going to pay for it. So remove from your mind any thoughts that we're going to make payment decisions based upon this committee.”

According to MCAC's charter, its role is to advise CMS “on whether specific medical items and services are reasonable and necessary under Medicare law.”

The meeting had opened with two speakers who outlined how few of the available data directly address the relationship between glucose monitoring and clinical outcomes in general, and in the Medicare-age population in particular.

Dr. Elizabeth Koller, of CMS's Office of Clinical Standards and Quality, led off with a summary of the data from several prospective trials including the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), both considered benchmark studies in demonstrating the value of intensive glucose management for patients with diabetes.

Studies that did look at older type 2 populations, such as the UKPDS, the Veterans Affairs Cooperative Study, and others, still failed to show a direct correlation between intensive blood glucose control—achieved via frequent glucose monitoring—and cardiovascular outcomes, she noted.

Source: Diabetes In Control: Family Practice News Volume 36, Issue 19, Page 1,4 (01 October 2006)

 
 
 
 
 
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