October 10, 2013 - This Thursday, Oregon’s Health Evidence Review Commission will hear concerns from physicians and other providers about a proposed limitation on Medicaid reimbursement for test strips for patients with Type 2 non-insulin dependent diabetes patients.
“No cost evaluation has been done or at least provided for review,” says Southwest Portland endocrinologist Andrew Ahmann, M.D., and president of the Oregon/Southwest Washington chapter of the American Diabetes Association. “In other words, patients who don’t use monitoring, don’t get strips and providers who don’t believe in it and don’t review the results shouldn’t be ordering strips. Preventing those who need and properly utilize strips from getting them will save no money at all as it reduces payment for clinic visits, and may create more emergency room visits, and complications.”
Judy Fry, R.N., Certified Diabetes Educator and advocate, worries that by reducing test strip availability for patients means that self-testing will also decrease, as the HERC is recommending only one test strip per week. “One test strip per week does not give us enough data to respond in any way that helps us treat our patients.”
Both Fry and Dr. Ahmann express the concern that a reduction in test strips is outside of the expected standards of care. This policy would undermine many years of working to educate patients with diabetes about the importance of self-monitoring so quick steps can be taken if blood sugar levels get either too high or too low.
“The HERC’s recommendations around proposed use of strips in those with Type 2 diabetes who are not treated with insulin is inconsistent with good diabetes practice, particularly in settings where appropriate diabetes education and adherence to progression of pharmacologic therapy to attain appropriate glucose goals are employed,” notes Dr. Ahmann.
Providers such as Dr. Ahmann and Diabetes Educator Fry point to recently published clinical literature suggesting non-insulin-treated Type 2 diabetes patients experience clinically meaningful improvements in glycemic control as compared to patients not using SMBG (Harashima S, Fukushima T, Sasaki M, Nishi Y, et al. Self-monitoring of blood glucose improves glycaemic control in oral hypoglycaemic agent (OHA)-treated type 2 diabetes (SMBG-OHA study) Diabetes Metab Res Rev 2013;29:77-84).
“By restricting access to self-monitoring, the HERC proposed criteria may reduce the quality of patient care, because it may discourage or prevent medically necessary testing by requiring patients to submit an appeal or pay for testing out-of-pocket. Even for those patients that fall within the proposed coverage criteria, many may not bother to obtain coverage,” said Fry.
Dr. Ahmann and Fry also note that several exceptions will be included in this new proposed Medicaid coverage criteria, including allowing coverage for at least one test strip per day for newly diagnosed patients; patients changing treatment regimen; patients with unexplained or new onset of hyperglycemia; and patients with recent history of hypoglycemia.
“Having patients monitoring once weekly is useless, as there is no way that once weekly monitoring would do anything to reduce high blood sugar,” said Dr. Ahmann.
Additionally, these providers worry that not only is patient safety at risk, but also there is a lack of evidence to support this change. Says Dr. Ahmann, “The scientific literature on the topic of self-monitoring for blood glucose levels is poor, inconsistent, and clinically irrelevant to a large degree. Combining various studies with different design, different primary outcomes and many other variables does not allow the usual level of evidence attributed to the methods applied in this discussion.”
Says Gary Puckrein, Ph.D, and president and chief executive officer of the National Minority Quality Forum notes that almost one in 10 Oregonians are living with diabetes. He is concerned about the disproportionate effect that could happen to minorities with diabetes, and that the proposed guidelines do not coincide with the Oregon Legislature’s most recent actions.
He adds, “In the most recent regular legislative session, the Oregon Legislature passed legislation declaring a diabetes emergency and requiring the Oregon Health Authority, by February 1, 2015, to report to the Legislature on the prevalence of and costs related to pre-diabetes and diabetes in Oregon, and on the development of a strategic plan to address pre-diabetes, diabetes and diabetes-related complications. This clear acknowledgement by Oregon legislators of the need for additional information to support such a change in policy is buttressed by the recent announcement from the Patient-Centered Outcomes Research Institute (PCORI) of a three-year, $2 million grant to the University of North Carolina Chapel Hill to assess the impact of different approaches to self-monitoring of blood glucose.”
Thursday afternoon, the HERC committee will be asked by Dr. Ahmann and the Oregon Diabetes Educators to delay consideration of this coverage change in light of two upcoming studies that are not yet complete, the Patient Center for Outcomes Research Institute and the Oregon Diabetes Cost Reduction study.
Adds Fry, “As a person with diabetes, I and my doctor need to be the ones deciding when I test. Life influences my diabetes and how it is controlled.”