Advancements in Diabetes Technology: Coverage, Challenges, and Pregnancy Considerations

At an Institute for Value-Based Medicine® (IVBM) event held in Cleveland, Ohio, The American Journal of Managed Care^® (AJMC^®) spoke to 3 experts from Cleveland Clinic about diabetes technology benefits and challenges:

• Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, director of education and training in diabetes technology at Cleveland Clinic
• Kevin Borst, DO, director of the Endocrine Disorders in Pregnancy Center at Cleveland Clinic
• Kevin Malloy, PharmD, BCPS, pharmacy materials coordinator at Cleveland Clinic Akron General Medical Center

The interviews shed light on the advancements in diabetes care technology, particularly in automated insulin delivery systems and continuous glucose monitors (CGMs), which have been shown to facilitate better glucose management with reduced variability and hypoglycemia. The speakers also noted how insurance coverage has improved for these technologies, therefore offering patients more options for accessing these devices. However, challenges still remain, such as ensuring compatibility with pregnancy-specific glucose targets and addressing potential technical malfunctions.

Diana Isaacs, PharmD – Cleveland Clinic

AJMC: In what ways can technology improve care for patients?

Isaacs: It's been amazing, especially with automated insulin delivery with the [CGMs] working with insulin pumps. It's made it, I think, a lot easier to manage glucose levels; just less variability, less hypoglycemia, taking some of the burden off of just managing diabetes. So, it's definitely been very positive and very exciting, all the advancements.

AJMC: How are insurance changes making technology for patients with diabetes more readily available?

Isaacs: Overall, I think that we've seen a positive movement with insurance coverage for different devices. It used to be where a company might only prefer 1 specific type of a pump, for example, or 1 specific type of continuous glucose monitor. But now we are seeing that patients have more choices that more options are being covered.

Borst: It is difficult at times to get patients the technologies that they need. However, as these products are on the market longer and as there are more data available to support the use of these products, I've found that insurance coverage is improving.

Kevin Malloy, PharmD – Cleveland Clinic

Malloy: Speaking just here in Ohio, just last year, Ohio Medicaid prescription benefit plans have actually expanded CGM access to all patients regardless of insulin dependence, and that was a large change. From a federal standpoint, most people know Medicare expanded coverage to patients on just a single dose of insulin, which really expanded previous requirements where it was 3 or more administrations a day. So, even in just that short 1-year period, my practice has changed quite a bit in the patients we’re able to offer CGM to. I think there's still a ways to go in improving access to patients that are either not on insulin or patients that are not able to afford co-payments for these devices since they are still fairly expensive for those who have large deductibles and items like that that we're not able to defray, and unlike some medications, they don't have a lot of the patient assistance programs that are at our disposal. But, in general, it's really been quite a big expansion over the last several years.

AJMC: What is the difference between insulin pumps and CGMs and what are the pros and cons of each?

Kevin Borst, DO – Cleveland Clinic

Borst: An insulin pump is a delivery system for insulin, so this is something that insulin goes in and is administering insulin to a patient. A continuous glucose monitor is something just monitoring the blood glucose. The pros of an insulin pump vs just taking shots are many. The main one is you're able to fine-tune the dosing of the insulin a lot more precisely with a pump than you are with shots. During pregnancy, that's important because you're trying to achieve very stringent targets. So, if a patient needs 5.7 units of insulin, I want them to get 5.7, not 6, not 4. As far as continuous glucose monitoring goes, I think that this is a great option for many patients who are pregnant, in particular if they're taking insulin, because even if they're not on an insulin pump, they still have very stringent targets for what they need to do when they're pregnant. I think that, if nothing else, there's value in knowing for the patient and knowing what's going on with their blood sugars all the time. They're able to see what happens right after they eat something, for example, and sometimes that will lead to modification in diet or modification in behavior whenever they're actually able to see what's going on with their blood sugars at times that they would not normally be checking it.

AJMC: What challenges are there still with utilizing diabetes technology like CGM?

Isaacs: Especially in pregnancy, the challenge is that these automated insulin delivery systems aren't really designed for pregnancy in mind. The targets for pregnancy, for example, are fasting [blood glucose] under 95 mg/dL, and 1 hour postprandial under 140 mg/dL. We have one system that goes down to 100 mg/dL; the others have targets of 110 or 112 to 120 mg/dL. So the targets aren't quite exactly where we would like for pregnancy, but we still find ways to work with them, because they're often better than if we didn't have that technology at all, so those are some challenges. And there's always things that come up like that technology isn't perfect all the time, so knowing how to problem solve if the CGM stops working or the pump stops working, still having those basic survival skills are important because technology can fail at times.