Diabetes care in five states is under the microscope; results are mixed

The Center for Insulin-Dependent Diabetes Access is monitoring Medicaid coverage for diabetes and has reported on coverage in five states — California, Colorado, New Jersey, Texas, and Washington — chosen for their diversity in size, geographic location, and anticipated range of policies. The center was created by the Juvenile Diabetes Research Foundation and funded by an unrestricted grant from the Medtronic Foundation. It is staffed by health policy experts from Health Strategies Consultancy LLC.

Health Strategies president Dan Mendelson tells State Health Watch it is important to look at diabetes treatment because Medicaid is heavily focused on children and diabetes is a significant childhood illness.

The most vulnerable

"Those who are covered are the most vulnerable in not accessing care properly," he points out. "They rely on doctors who historically are more responsive to matters of reimbursement."

Center staff noted in their report that they are concerned that diabetes coverage can fall victim to state efforts to cope with budget problems, and coverage limitations can be a particular concern for the more intensive insulin management services, which are more expensive and typically are targeted toward Type 1 diabetes.

Barriers to the best treatment

"Some states have set up barriers to kids getting what the government says is the best treatment for them," Mr. Mendelson declares.

For that reason, the center is monitoring policies that define accessibility to and reimbursement for Type 1 diabetes management treatments and supplies in select Medicaid programs. Specific services for the monitoring include insulin and insulin syringes, blood glucose monitors, testing strips, lancets, insulin pumps (with corresponding infusion sets), and diabetes education and/or case management programs.

Ensure access to care

"As states continue to try to find new ways to control Medicaid spending, it is vital that we keep an eye on diabetes programs to ensure that access to care is not unnecessarily limited," Mr. Mendelson says.

"This initial report outlines the levels of Medicaid reimbursement for various diabetes services and supplies in five states. It raises a red flag about potentially restrictive practices in Texas and California, and also stresses the importance of diabetes disease management programs in guaranteeing access to care while saving money," he points out.

Since state data on the number of Medicaid beneficiaries with diabetes are limited, the center says it is unclear how many patients with diabetes are eligible for Medicaid benefits. However, because Medi-caid provides health benefits to the most needy patients, Medicaid policy plays an important role in terms of patient access for all chronic conditions, including diabetes care, the report says.

The center says it is "conceivable that denying supplies and services to diabetics in the short-term may lead to long-term conditions requiring expensive treatment and management.

"Therefore, ensuring access to diabetes services is critical to successful management of the condition, and could even save state Medicaid funds in the long-term. By identifying both positive and negative Medicaid policies and programs in terms of beneficiary access to Type 1 diabetes services, the center can create strategies to encourage states to adopt best practices in terms of diabetes programs and policies. We also can identify harmful policies that stakeholders should attempt to overturn," the organization notes.

Policies haven’t been updated

In the five states studied, the report says, Medicaid programs have specific coverage policies for all the diabetes products and supplies researched, but those policies have not changed significantly over the past few years.

Another important factor in terms of patient access to diabetes treatment and supplies is how much state Medicaid programs pay for such services, the report says.

Reimbursement for diabetic supplies through Medicaid generally is adequate for the purchase of generic products.

However, payment rates are often inadequate to support the purchase of brand-name supplies or high-cost devices with added features. Because Medicaid does not allow beneficiaries to pay the difference between the Medicaid allowance and a charge, beneficiaries only can procure high-cost items if the provider or supplier is willing to accept the Medicaid payment.

"There is some evidence," the center says, "that Medicaid beneficiaries have reduced access to care, at least partly caused by lower reimbursement as compared to private insurance, but the impact in terms of access to diabetes equipment and supplies is less clear."

Other points brought up in the report include:

• Insulin and insulin syringes are covered in all five target states and neither requires prior authorization. Restrictions on the frequency and size of insulin refills are left to a prescribing physician’s discretion. The number of prescriptions allowed for insulin syringes in a specific time period is not restricted, although the number of syringes available per prescription often is limited.

• Blood glucose monitors are covered in all five states. While some states require beneficiaries to receive prior authorization before obtaining a monitor, no states have brand restrictions. The reimbursement amount for monitors varies by state; it generally is high enough to cover standard monitors, but inadequate to cover the market price of monitors with additional features such as automatic recording and monitoring features or computer connectivity. There also are differences in how often beneficiaries are permitted to obtain new monitors.

• All states that were researched cover testing strips without prior authorization. In some states, the amount dispensed per script is restricted by a quantity limit (for example, four boxes a month in Texas), while in other states, beneficiaries receive a certain quantity per script with no limit on the number of scripts per period of time (New Jersey).

• All states cover lancets without prior authorization; and in each state, the amount per script is limited.

• For those states with information publicly available, prior authorization is required for reimbursement of insulin pumps, with the criteria for approval varying. In California, for instance, prior approval for an insulin pump is granted when there is documented frequent and severe glycemic excursions requiring visits to a physician, emergency department, or hospital; demonstrated ability to self-monitor glucose levels four or more times a day; and motivation to achieve and maintain glycemic control. New Jersey does not have specific criteria, but does require prior authorization. Texas requires the following minimum documentation of medical necessity: any wide fluctuations in blood glucose before mealtimes; any dawn phenomenon where fasting blood glucose level often exceeds 20 mg/dL; day-to-day variations in work schedule, mealtimes, and/or activity level that requires multiple insulin injections; and a completed and signed home health DME/medical supplies physician order form.

• Four of the five target states have or recently had a disease management program for diabetes; New Jersey is the only state without either program. None of the four states with programs have anything specifically for Type 1 diabetes. California’s pilot program was specifically for Type 2 diabetes, while those in Colorado, Texas, and Washing-ton were intended to cover all types of diabetes. California and Washington have moved beyond the pilot stage and include diabetes disease management in their range of provided services directed toward high-cost cases.

Some state policies surprising

"Both Texas and California have coverage policies that are surprising," Mr. Mendelson explains. "We had to dig to get the policies and it’s hard for a doctor or patient to figure out how to get around them. People are surprised to see that some of these policies are in place and some legislators have told us they’re interested in addressing them," he adds.

According to Mr. Mendelson, states adopted many of the policies reviewed in the survey for reasons of short-term cost control. But he says there is no evidence that they will control costs in the long term. Mr. Mendelson says it has taken time for a consensus to develop in the medical community on the best treatment protocols for juvenile diabetes, and it will take a bit longer for Medicaid policies to catch up to the treatment consensus.

[More information is available on the Health Strategies web site: www.healthstrategies.net. Contact Mr. Mendelson at (202) 207-1310.]