Spring 2022 Regional Meeting Recap
We asked all 750+ members to vote on their region’s mascot. The top votes were transformed into seals by MCT2D designer, Larrea Young. Click to view in full detail and look for your seal’s appearance at upcoming events!
In April and May 2022, the Michigan Collaborative for Type 2 Diabetes held seven regional meetings across the state, providing a mid-year touchpoint for clinical champions and physician organization lead members. Over 220 members attended across the seven regions, with opportunities for networking, small group discussion, programmatic updates with member Q&A, and presentations from nephrology lead Michael Heung, MD, MCT2D director Caroline Richardson, MD, and MCT2D Quality Improvement Specialist Jake Reiss.
The meeting’s full presentation slide deck, including Dr. Heung’s presentation, are available to download now.
Dr. Michael Heung, nephrologist and nephrology lead for MCT2D, provided a clinical update on chronic kidney disease, screening and prevention strategies in primary care, and the benefits of SGLT2is and GLP1-RAs in slowing the progression of CKD. .
Dr. Caroline Richardson introduced a suite of point-of-care tools developed by MCT2D, including: Medications and CGM Coverage by Payer in Michigan 2022 Quick Reference Guide with information on copay discount and free-medication assistance programs, a lower carb diet log, and clinical dosing and decision aids. Jake Reiss provided a walkthrough of the MCT2D Data Dashboard.
Shalley, a member of the Patient Advisory Board, shared her experience navigating insurance coverage for GLP-1 RAs and why she decided to join the MCT2D Board.
Member Open Q&A
Here’s a sample of questions asked and addressed by members across the seven regional meetings.
How can we streamline the process for submitting prior authorizations?
We are planning an upcoming virtual event to share best practices on prior authorizations. We are hoping to host this in June and will be sharing additional details shortly. We will make sure that all clinical champions at the practices receive an invitation to attend this.
Prior authorization procedures vary between practices based on a number of factors including office staffing. Senate Bill 247 was signed into law on April 7th, 2022, and reforms the prior authorization process to do the following:
1.) Require an insurer to make available, by June 1, 2023, a standardized electronic prior authorization request transaction process.
2.) Require prior authorization requirements to be based on peer-reviewed clinical review criteria.
3.) Require an insurer to post on its website if it implemented a new prior authorization requirement or restriction or amended an existing requirement or restriction.
4.) Require an insurer to notify, on issuing a medical benefit denial, the health professional and insured or enrollee of certain information, including the right to appeal the adverse determination, and require an appeal of the denial to be reviewed by a health professional.
5.) For a medical benefit that is not a prescription drug benefit, an insurer shall notify contracted health care providers via the insurer's provider portal of the new or amended requirement or restriction not less than 60 days before the requirement or restriction is implemented.
6) For a prescription drug benefit, an insurer shall notify contracted health care providers via the insurer's provider portal of the new or amended requirement or restriction not less than 45 days before the requirement or restriction is implemented.
7) Prohibits an insurer or its designee utilization review organization from affirming the denial of an appeal unless the appeal was reviewed by a licensed physician.
8) For urgent requests, beginning June 1, 2023, the prior authorization is considered granted if the insurer fails to act within 72 hours of the original submission. For non-urgent requests, beginning June 1, 2023, the prior authorization is considered granted if the insurer fails to act within 9 calendar days of the original submission. After May 31, 2024, a non-urgent prior authorization is considered granted if the insurer fails to act within 7 calendar days of the original submission.
9) Requires an insurer to adopt a program that promotes the modification of prior authorization requirements of certain prescription drugs, medical care, or related benefits, based on the performance of the health care providers with respect to adherence to nationally recognized evidence-based medical guidelines and other quality criteria (i.e., BCBSM “gold carding” program).
What program resources are there for diet counseling?
MCT2D has developed a number of resources for patients on low carbohydrate diets, as well as recommending a number of outside resources. These resources can be found here: https://www.mct2d.org/resource-library-0/category/Low+Carb+Diet
We are in the process of developing additional patient facing resources which will also be available at that link once they are complete. MCT2D recommends that any clinician who offers diet counseling but who may not feel comfortable with low carb diets, take the free Diet Doctor CME training. Link: https://www.dietdoctor.com/cme. Additionally, MCT2D will be onboarding a low carbohydrate dietician who will run a discussion group for dieticians at participating practices who would like to talk about low carb diets and ask questions.
Do you have more info on how to get the meds covered? Is there any option for the patients with a carve out?
The MCT2D Medication Coverage Chart has information on coverage for the major payors in the state, both commercial and Medicare Advantage. We update this document quarterly to ensure that it is as comprehensive as possible. For carve outs, it is likely that some options in each medication class are covered, it is just difficult to find that information readily available online, and it is much more customizable by specific employer plan, so may be different from employer to employer. We are working to identify ways to provide more information on coverage for plans with a carve out, but have not yet identified a solution.
Coverage for CGMs
How can we get CGMs covered by insurance?
CGMs are covered by insurance in two ways- as a pharmacy benefit where the CGM is distributed through the pharmacy, and as a medical benefit where the CGM is distributed through a durable medical equipment (DME) vendor. Typically, pharmacy coverage is less restrictive and has fewer requirements, but patients who have pharmacy carved out and receive their pharmacy benefits through a pharmaceutical benefits manager (PBM) will typically have to follow the plan’s medical policy. We suggest starting with trying to confirm if a patient has pharmacy coverage for CGMs (you can check on the MCT2D dashboard to see if a BCBSM patient has a carve out) and if not, checking the criteria on our coverage tracker and determining if the patient meets the requirements to receive a CGM through the medical benefit.
If a patient does have pharmacy coverage with BCBSM, it will say “Yes” under Pharmacy Claims Data Available for November 2021. If they do not have pharmacy coverage with BCBSM, it will say “No” under Pharmacy Claims Data Available for November 2021.
We also suggest putting some of the onus to determine coverage back on the patient when feasible. Advise them to call their insurer and inquire if a CGM (specify either Libre or Dexcom) is covered for a patient with T2DM. If yes, great 🡪 then ask which one, and if it is covered at the pharmacy or by DME (and if so, which one) – verify if there are criteria that must be met. If not covered, ask if there are any circumstances that CGMs are covered on a plan. Offices could also build smart phrases around this so that if there is not time to cover it at the visit, this can be added to an after-visit summary or sent the patient as a portal message with the information following the visit.
We are continuing to advocate for expanded CGM coverage for type 2 diabetes at a statewide level. For anyone interested in helping with that advocacy, we have a project right now driven by policy engagement leadership at the ADA to get Medicaid to cover CGM for patients with Type 2 Diabetes. Please email ccteam@mct2d.org if you would be willing to speak to the ADA about the importance of these being covered.
Regarding deductibles, unfortunately there is little that we can do to get around this. As part of our advocacy on CGM coverage, we will ask for $0 copays. Please note the price differentials in CGMs as well- Abbott CGMs will be a lower out of pocket cost to patients who have not met their deductible in comparison to a Dexcom CGM.
CGM specific cost savings programs such as the ones offered by drug manufacturers for low income individuals, unfortunately do not exist. Abbott offers an introductory CGM program where patients may receive their first CGM for free, but that is the extent of such programs at the moment. MCT2D has partnered with the Office of Governmental Affairs at the American Diabetes Association to gather support and lobby Michigan Medicaid for coverage of CGMs for the individuals with Type 2 Diabetes.
What about CGM-specific cost savings programs?
CGM specific cost savings programs such as the ones offered by drug manufacturers for low income individuals, unfortunately do not exist. Abbott offers an introductory CGM program where patients may receive their first CGM for free, but that is the extent of such programs at the moment. MCT2D has partnered with the Office of Governmental Affairs at the American Diabetes Association to gather support and lobby Michigan Medicaid for coverage of CGMs for the individuals with Type 2 Diabetes.
What about cases where a deductible isn't met?
Regarding deductibles, unfortunately there is little that we can do to get around this. As part of our advocacy on CGM coverage, we will ask for $0 copays. Please note the price differentials in CGMs as well- Abbott CGMs will be a lower out of pocket cost to patients who have not met their deductible in comparison to a Dexcom CGM.
Other CGM Questions
Are there ways to streamline prescribing CGMs? It takes time and staffing, what if we don't have a diabetes educator?
Starting a patient on a CGM who has never used one before does require that the patient be trained on the system. This can be done by a provider, a nurse, a pharmacist or a certified diabetes educator.
As a part of prescribing the CGM for the first time, a practice may bill for startup and training. The CPT code for this is 95249 and is defined as “Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording. Bill only once during the time period that the patient owns the device.”
Ideal workflows for ongoing monitoring vary between practices depending on staffing.
It is common to have a nurse or care manager be in charge of facilitating CGM data sharing with the patient, downloading the data from the respective CGM systems (I.E. Libreview and Clarity) and uploading it into the patient's medical record before the visit with the provider. The cadence of review is patient dependent but is often only done in conjunction with clinic visits.
Review of CGM data may be billed for by your practice. This CPT code is 95250 and is defined as “Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified healthcare professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording. Do not bill more than 1x/month.”
Getting started with using CGM in your practice can seem daunting, but is actually very simple. The use of brand specific platforms such as Clarity and Libreview are free options that can be managed by any staff in your office including a provider, nurse, pharmacist or certified diabetes educator. Reps from the individual CGM companies provide free assistance to practices in setting up accounts and establishing their clinics. If you would prefer to speak with someone who is not at one of these companies, we at MCT2D would be happy to help you as well. To schedule a time to speak with us, please email Jake Reiss at jereiss@med.umich.edu.
CGM data isn't integrated into our EMR. What's a good workflow for accessing CGM data?
Getting started with using CGM in your practice can seem daunting. The use of brand specific platforms such as Clarity and Libreview are free options that can be managed by any staff in your office including a provider, nurse, pharmacist or certified diabetes educator. Reps from the individual CGM companies provide free assistance to practices in setting up accounts and establishing their clinics. If you would prefer to speak with someone who is not at one of these companies, we at MCT2D would be happy to help you as well. To schedule a time to speak with us, please email Jake Reiss at jereiss@med.umich.edu.
Yes this is an unfortunate limitation of the current systems. There are systems that are in the process of building CGM data integration such as the Glooko system as well as one directly from Abbott. The limitations with these is that the Glooko system is not compatible with Abbott Freestyle CGMs due to Abbott’s build of their own system, and Abbotts system is only compatible with their devices, and both cost money.
For the time being, the most common workflow is to have a nurse, or care manager be in charge of facilitating CGM data sharing with the patient and then download the data from the respective CGM system (I.E. Libreview and Clarity) and upload it into the patient's medical record before the visit with the provider.
The cadence of review is patient dependent but is often only done in conjunction with clinic visits. Review of CGM data may be billed for by your practice. This CPT code is 95250 and is defined as “Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified healthcare professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording. Do not bill more than 1x/month.”
We would also be happy to make a how-to guide on creating a profile in both Clarity and Libreview that we can share with the collaborative.
FEEDBACK FOR FUTURE REGIONAL MEETINGS
Thank you to all who participated in our first round of regional meetings. We appreciated your engagement and feedback after the event. Here’s a round up of suggestions for future sessions. We plan to incorporate many of your ideas as we plan for the October 2022 regional meetings. Hope to see you there!
General Suggestions
- Invite patients from advisory board
- Virtual Meetings- Note: BCBSM would like these meetings to take place in person
- More time for Q&A with presenters
- Have members email questions before meeting
- Vote on topics ahead of time
- Send discussion topics before meeting
- Have people bring favorite patient education tools
Topic Suggestions
- Cardiology presentation
- CGMs- Interpretation, integration
- Program Basics/Requirements
- Behavior change counseling
- More low carb diet content
- Case presentations
- Weight management
- Hypertension best practices
- Prior authorization help
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