Phil Galewitz

Do Painless Glucose Monitors Really Help Most Diabetes Patients?

by Phil Galewitz | Mar 30, 2021 | Blog, Health & Wellness, Health Literacy, News, Public Health | 0 comments

In the nation’s battle against the diabetes epidemic, the go-to weapon being aggressively promoted to patients is as small as a quarter and worn on the belly or arm.

A continuous glucose monitor holds a tiny sensor that’s inserted just under the skin, alleviating the need for patients to prick their fingers every day to check blood sugar. The monitor tracks glucose levels all the time, sends readings to patients’ cellphone and doctor, and alerts patients when readings are headed too high or too low.

Originally Published in Kaiser Health News

Nearly 2 million people with diabetes wear the monitors today, twice the number in 2019, according to the investment firm Baird.

There’s little evidence continuous glucose monitoring (CGM) leads to better outcomes for most people with diabetes — the estimated 25 million U.S. patients with Type 2 disease who don’t inject insulin to regulate their blood sugar, health experts say. Still, manufacturers, as well as some physicians and insurers, say the devices help patients control their diabetes by providing near-instant feedback to change diet and exercise compared with once-a-day fingerstick tests. And they say that can reduce costly complications of the disease, such as heart attacks and strokes.

Continuous glucose monitors are not cost-effective for Type 2 diabetes patients who do not use insulin, said Dr. Silvio Inzucchi, director of the Yale Diabetes Center.

Sure, it’s easier to pop a device onto the arm once every two weeks than do multiple finger sticks, which cost less than a $1 a day, he said. But “the price point for these devices is not justifiable for routine use for the average person with Type 2 diabetes.”

Without insurance, the annual cost of using a continuous glucose monitor ranges from nearly $1,000 to $3,000.

Lower Prices Help Propel Use

People with Type I diabetes — who make no insulin — need the frequent data from the monitors in order to inject the proper dose of a synthetic version of the hormone, via a pump or syringe. Because insulin injections can cause life-threatening drops in their blood sugar, the devices also provide a warning to patients when this is happening, particularly helpful while sleeping.

People with Type 2 diabetes, a different disease, do make insulin to control the upswings after eating, but their bodies don’t respond as vigorously as people without the disease. About 20% of Type 2 patients still inject insulin because their bodies don’t make enough and oral medications can’t control their diabetes.

Doctors often recommend that diabetes patients test their glucose at home to track whether they are reaching treatment goals and learn how medications, diet, exercise and stress affect blood sugar levels.

The crucial blood test doctors use, however, to monitor diabetes for people with Type 2 disease is called hemoglobin A1c, which measures average blood glucose levels over long periods of time. Neither finger-prick tests nor glucose monitors look at A1c. They can’t since this test involves a larger amount of blood and must be done in a lab.

The continuous glucose monitors also don’t assess blood glucose. Instead they measure the interstitial glucose level, which is the sugar level found in the fluid between the cells.

Companies seem determined to sell the monitors to people with Type 2 diabetes — those who inject insulin and those who don’t — because it’s a market of more than 30 million people. In contrast, about 1.6 million people have Type 1 diabetes.

Helping to fuel the uptake in demand for the monitors has been a drop in prices. The Abbott FreeStyle Libre, one of the leading and lowest-priced brands, costs $70 for the device and about $75 a month for sensors, which must be replaced every two weeks.

Another factor has been the expansion in insurance coverage.

Nearly all insurers cover continuous glucose monitors for people with Type 1 diabetes, for whom it’s a proven lifesaver. Today, nearly half of people with Type 1 diabetes use a monitor, according to Baird.

A small but growing number of insurers are beginning to cover the device for some Type 2 patients who don’t use insulin, including UnitedHealthcare and Maryland-based CareFirst BlueCross BlueShield. These insurers say they have seen initial success among members using the monitors along with health coaches to help keep their diabetes under control.

The few studies — mostly small and paid for by device-makers — examining the impact of the monitors on patient’s health show conflicting results in lowering hemoglobin A1c.

Still, Inzucchi said, the monitors have helped some of his patients who don’t require insulin — and don’t like to prick their fingers — change their diets and lower their glucose levels. Doctors said they’ve seen no proof that the readings get patients to make lasting changes in their diet and exercise routines. They said many patients who don’t use insulin may be better off taking a diabetes education class, joining a gym or seeing a nutritionist.

“I don’t see the extra value with CGM in this population with current evidence we have,” said Dr. Katrina Donahue, director of research at the University of North Carolina Department of Family Medicine. “I’m not sure if more technology is the right answer for most patients.”

Donahue was co-author of a landmark 2017 study in JAMA Internal Medicine that showed no benefit to lowering hemoglobin A1c after one year regularly checking glucose levels through finger-stick testing for people with Type 2 diabetes.

She presumes the measurements did little to change patients’ eating and exercise habits over the long term — which is probably also true of continuous glucose monitors.

“We need to be judicious how we use CGM,” said Veronica Brady, a certified diabetes educator at the University of Texas Health Science Center and spokesperson for the Association of Diabetes Care & Education Specialists. The monitors make sense if used for a few weeks when people are changing medications that can affect their blood sugar levels, she said, or for people who don’t have the dexterity to do finger-stick tests.

Yet, some patients like Trevis Hall credit the monitors for helping them get their disease under control.

Last year, Hall’s health plan, UnitedHealthcare, gave him a monitor at no cost as part of a program to help control his diabetes. He said it doesn’t hurt when he attaches the monitor to his belly twice a month.

The data showed Hall, 53, of Fort Washington, Maryland, that his glucose was reaching dangerous levels several times a day. “It was alarming at first,” he said of the alerts the device would send to his phone.

Over months, the readings helped him change his diet and exercise routine to avert those spikes and bring the disease under control. These days, that means taking a brisk walk after a meal or having a vegetable with dinner.

“It’s made a big difference in my health,” said Hall.

This Market ‘Is Going to Explode’

Makers of the devices increasingly promote them as a way to motivate healthier eating and exercise.

The manufacturers spend millions of dollars pushing doctors to prescribe continuous glucose monitors, and they’re advertising directly to patients on the internet and in TV ads, including a spot starring singer Nick Jonas during this year’s Super Bowl.

Kevin Sayer, CEO of Dexcom, one of the leading makers of the monitors, told analysts last year that the noninsulin Type 2 market is the future. “I’m frequently told by our team that, when this market goes, it is going to explode. It’s not going to be small, and it’s not going to be slow,” he said.

“I believe, personally, at the right price with the right solution, patients will use it all the time,” he added.

Vaccination, American Style: A “Crazy Quilt” of Policies

by Phil Galewitz | Mar 25, 2021 | Alaska, Blog, California, Coronavirus, Florida, Mississippi, News, North Carolina, Pennsylvania, Public Health | 0 comments

Kaiser Health News

In North Carolina, the nation’s leading tobacco producer, any adult who has smoked more than 100 cigarettes in their lifetime can now be vaccinated against covid.

In Florida, people under 50 with underlying health conditions can get vaccinated only if they have written permission from their doctor.

In Mississippi, more than 30,000 covid vaccine appointments were open Friday — days after the state became the first in the contiguous United States to make the shots available to all adults.

In California — along with about 30 other states — people are eligible only if they are 65 or older or have certain health conditions or work in high-risk jobs.

How does any of this make sense?

“There is no logical rationale for the system we have,” said Graham Allison, a professor of government at Harvard University. “We have a crazy quilt system.”

Jody Gan, a professional lecturer in the health studies department at American University in Washington, D.C., said the lack of a national eligibility system reflects how each state also makes its own rules on public health. “This hasn’t been a great system for keeping, you know, the virus contained,” she said.

The federal government bought hundreds of millions of doses of covid vaccines from Pfizer, Moderna and Johnson & Johnson — as well as other vaccines still being tested — but it left distribution largely up to the states. Some states let local communities decide when to move to wider phases of eligibility.

When the first vaccines were cleared for emergency use in December, nearly all states followed guidance from the federal government’s Centers for Disease Control and Prevention and restricted use to front-line health workers and nursing home staffs and residents.

But since then states have gone their own way. Some states have prioritized people age 75 and older, while others have also allowed people who held certain jobs that put them at risk of being infected or had health conditions that put them at risk to be included with seniors for eligibility. Even then, categories of jobs and medical conditions have varied across the country.

As the supply of vaccines ramped up over the past month, states expanded eligibility criteria. President Joe Biden promised that by May 1 all adults will be eligible for vaccines and at least a dozen states say they will beat that date or, as in the case of Mississippi and Alaska, already have.

But the different rules among states — and sometimes varying rules even within states — created a mishmash. This has unleashed “vaccine jealousy” as people see friends and family in other states qualify ahead of them even if they are the same age or have the same occupation. And it has raised concerns that decisions on who is eligible are being made based on politics rather than public health.

The hodgepodge mirrors states’ response overall to the pandemic, including wide disparities on mask mandates and restrictions for indoor gatherings.

“It’s caused a lot of confusion, and the last thing we want is confusion,” said Harald Schmidt, an assistant professor of medical ethics and health policy at the University of Pennsylvania.

As a result, some Americans frantically search online every day for an open vaccine appointment, while vaccines in other states go wanting.

The assorted policies have also prompted thousands of people to drive across state lines — sometimes multiple state lines — for an open vaccine appointment. Some states have set up residency requirements, although enforcement has been uneven and those seeking vaccines are often on the honor system.

Todd Jones, an assistant professor of economics at Mississippi State University near Starkville, said the confusion signals a need for a change in how the government handles the vaccine. “The Biden administration should definitely be thinking about how it might want to change state allocations based on demand,” Jones said. “If it does become clear that some states are actually not using lots of their doses, then I think it would make sense to take some appointments from these states to give to other states that have higher demand.”

Jagdish Khubchandani, a professor of public health at New Mexico State University, said no one should be surprised to see 50 different eligibility systems because states opposed a uniform federal eligibility system.

“Many governors don’t want to be seen as someone who listens to the federal government or the CDC for guidance,” he said. Florida Gov. Ron DeSantis, a Republican, has boasted of ignoring the CDC advice when he opted to make anyone 65 and older eligible beginning in December.

“There is a lot of political posturing in deciding eligibility,” Khubchandani said.

To be sure, governors also wanted the flexibility to respond to particular needs in their states, such as rushing vaccines to agricultural workers or those in large food-manufacturing plants.

Jones said the decision to open vaccines to all adults in the state may sound good, but Mississippi has one of the nation’s lowest vaccination rates. Part of that is attributed to hesitancy among some minority communities and conservatives. “It’s good news everybody can get it, but there doesn’t seem to be a whole lot of demand for it.”

Jones, 34, was able to go online for a shot on Tuesday and was vaccinated at a large church a short drive from his home on Thursday morning. “I was very happy,” he said.

Published courtesy of KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Access to Opioid Addiction Treatment Opens Up in COVID-19 Crisis

by Phil Galewitz | Jun 8, 2020 | Blog, Coronavirus, News | 0 comments

Opioid addiction isn’t taking a break during the coronavirus pandemic.

But the U.S. response to the viral crisis is making addiction treatment easier to get.

Under the national emergency declared by the Trump administration in March, the government has suspended a federal law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Patients can now get those prescriptions via a phone call or videoconference with a doctor.

Addiction experts have been calling for that change for years to help expand access for patients in many parts of country that have shortages of physicians eligible to prescribe these medication-assisted treatments. A federal report in January found that 40% of U.S. counties don’t have a single health care provider approved to prescribe buprenorphine, an active ingredient in Suboxone.

A 2018 law called for the new policy, but regulations were never finalized.

“I wish there was another way to get this done besides a pandemic,” said Dr. David Kan, chief medical officer of Bright Heart Health, a Walnut Creek, California, company. It has recently started working with insurers and health providers to help addicted patients get therapy and medications without having to leave their homes. He said he hopes the administration will make the changes permanent after the national emergency ends.

For years before the emergency regulations, Bright Heart — along with several other telemedicine counseling providers — began offering opioid addiction treatment and counseling via telemedicine, even if they couldn’t prescribe initial medication for addiction. Patients can renew prescriptions for drugs to deal with withdrawal symptoms, get drug-tested and meet with counselors for therapy.

When Nathan Post needed help overcoming a decade-long drug addiction, he went online in 2018 and used Bright Heart Health to connect to a doctor and weekly individual and group counseling sessions. He said the convenience is a big benefit.

“As an addict, it was easy to have excuses not to do stuff, but this was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he said.

Post, 38, a tattoo artist who recently moved from New Mexico to Iowa City, Iowa, was addicted to Suboxone, the drug he was prescribed in 2009 to deal with an addiction to opioid pills.

Officials with the insurer Anthem said using Bright Heart’s telemedicine option has helped increase medication-assisted treatment for members with opioid drug abuse issues from California and nine other states from 16% to more than 30%. While fewer than 5% of Anthem patients seeking addiction treatment use telemedicine, the company expects the option to become more common.

Bright Heart Health officials say one barometer of the effectiveness of the care is that 90% of patients are still in treatment after 30 days and 65% after 90 days — far higher than with traditional treatment.

Several insurers — including Aetna, and Blue Cross and Blue Shield companies like Anthem across the country — have begun covering the telemedicine addiction service.

Dr. Miriam Komaromy, medical director of Boston Medical Center’s Grayken Center for Addiction, said there are some downsides to virtual care.

“I think therapists and providers do worry whether it provides the same level of engagement with the patient and whether it’s possible to gauge someone’s sincerity and level of motivation as easily over a camera as in person,” she said.

But she predicted telemedicine service will grow because of the tremendous need to broaden access to mental health and addiction counseling. “Too often the default is no counseling for patients,” she said. “This gives us another set of tools.”

Patients can also have trouble finding a doctor who is eligible to prescribe medication to help treat addiction. Physicians are required to get a federal license to prescribe Suboxone and other controlled substances that help patients with opioid addictions and can write only limited numbers of prescriptions each month. Many doctors hesitate to seek that qualification.

A few small studies have found that patients are as likely to stay with telemedicine treatment as with in-person care for drug addiction. But no studies have determined whether one type of therapy is more effective.

Telemedicine does have its limits — and is not right for everyone, particularly patients who require more intensive inpatient care or who lack easy internet access, Komaromy said.

Premera Blue Cross and Blue Shield officials said they are partnering with Boulder Care, a digital recovery program based in Portland, Oregon, to help customers in rural Alaska. “Telemedicine is a unique way for someone to go through treatment in a discreet manner,” said Rick Abbott, a Premera vice president.

While telemedicine has been growing in popularity for physical medicine, some people may still be reluctant to use it for drug addiction.

There are also concerns that allowing providers to prescribe controlled substances without meeting patients in person could increase the risks of fraud.

“There is a fear around this that there may be some rogue providers who make a lot of money off addiction and will do it stealthily on the internet,” said Dr. Alyson Smith, an addiction medical specialist with Boulder Care. “While that is a small risk, we have to compare it to the huge benefit of expanding treatment that will save lives.”

Smith said she doesn’t notice a big difference in treating patients for drug addiction in her office compared with on a video screen. She can still see patients’ pupils to make sure they are dilated and ask them about how they are feeling — which can determine whether it’s appropriate to prescribe certain drugs. Dilated pupils are a sign of patients suffering from withdrawal from heroin and other drugs.

Dr. Dawn Abriel, who treated Post and previously directed a methadone clinic in Albuquerque, New Mexico, said she can diagnose patients over video without issue.

“I can pick up an awful lot on the video,” particularly a patient’s body language, she said. “I think people open up to me more because they are sitting in their homes and in their place of comfort.”

In West Virginia, one of the states hardest hit by the opioid addiction epidemic, Highmark, a Blue Cross and Blue Shield company, started offering telehealth addiction coverage with Bright Heart Health in January. Highmark officials say a lack of providers, particularly in rural parts of the state, meant that many of the insurer’s members had difficulty finding the help they need.

Dr. Caesar DeLeo, vice president and executive medical director of strategic initiatives for Highmark, said the insurer was having problems getting customers into care. Only about a third of members with addiction issues were receiving treatment, he said.

“We needed to address the crisis with a new approach,” DeLeo said. “This will give people more options and give primary care doctors who do not want to prescribe Suboxone another place to refer patients.”

DeLeo said patients will also be referred to Bright Heart in hospital emergency rooms.

Dr. Paul Leonard, an emergency doctor and medical director for Workit Health, an Ann Arbor, Michigan, company offering telemedicine treatment and counseling programs, said many patients who turn to ERs for addiction treatment get little help finding counseling. With online therapy, patients can sign up while still in the ER.

“We’ve built a better mousetrap,” Leonard said.

Telemedicine addiction providers said they and their patients are getting more accustomed to virtual care.

“There are always times you wish you could reach out and hold someone’s hand, and you can’t do that,” said Boulder’s Smith. “But we feel like we are more skilled at a virtual hand-holding and really connect with people and they feel well supported in return.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.