On this episode of danatech Talks, a special series from The Huddle: Conversations with the Diabetes Care Team, Dana Moreau is joined by Amy Hess-Fischl, MS, RD, LDN, CDCES, to explore the real-world challenges of prescribing diabetes technology. Amy shares practical strategies for navigating coverage pathways, documentation requirements, denials, and affordability, while offering workflow tips to help providers streamline access for their patients. This episode was supported by educational grant funding from Abbott. Explore the latest in diabetes technology as well as trainings and resources on danatech: danatech l Diabetes Technology Education for Healthcare Professionals Listen to the first episode of our danatech Talks diabetes technology series: https://thehuddle.simplecast.com/episodes/basics-diabetes-technology-for-health-care-professionals
Dana Moreau
Welcome to danatech Talks, a special series from ADCES's The Huddle, Conversations with the Diabetes Care Team, powered by ADCES. I'm Dana Moreau of danatech, and in this series, we delve into the latest in diabetes technology, bringing you expert insights, clinical strategies, and the innovation shaping patient care today. So whether you're new to diabetes technology or looking to take your expertise to that next level, Dana Tech Talks is your go-to source for real-world knowledge.
Our guest is member Amy Hess-Fischl, CDCES. And today we're talking about something that sounds really simple, but can feel surprisingly complicated. Actually prescribing diabetes technology out in the real world. CGMs and insulin delivery devices are more accessible than ever, but the path from decision to patient actually having it in hand or on body, that's where things tend to get a little bit messy. So let's break this down.
Amy, before we dive into this very important conversation, can you tell us a little bit about yourself, your role, and how diabetes technology prescribing fits in your own day-to-day work?
Amy Hess-Fischl
Absolutely, Dana. As you said, Amy has Fischl. I'm a diabetes care and education specialist at the University of Chicago. So a large, urban, outpatient endocrinology clinic working with both Peds and adults. And I've been there for 19 years, diabetes care and education specialist for 26. Yes, I started when I was 10. And thinking about kind of that evolution of how prescribing has changed, you And so right now, we are lucky because again, I work with nurses. We have a pharmacist in clinic that help us kind of navigate some of this, but I know that many people don't. And so I like to stay on top of what do I need to do in case all the wheels fall off and I don't have someone to help me. And so I think that as a diabetes care and education specialist, yes, I have these people to help me. But I am kind of that first line of defense working with people with diabetes. And so I wanna prepare them even before that. We had this really nice collaboration of, okay, I know what to do in case I don't hear from someone. yeah, I'm still really working with them and saying, all right, let's talk about, A, what is it you want? It has nothing to do with me, it has to do with you. So what is it you want? And then let's kind of break down where we need to go to find coverage. So that's kind of what I do, you know, again, with every single patient.
Dana Moreau
And that's fantastic. And actually, it sounds like the team you have is lucky to have you because not everybody's got someone who helps play that role. So let's go and start at the beginning here. The moment you decide or your team decides a patient would benefit from technology, when you identify someone who could potentially benefit from a CGM or an insulin delivery device, what's your first step?
Amy Hess-Fischl
I'll just change your question just a little bit that it is not really my decision. You know, again, I really think that certainly the standards of care say, yes, everyone should be offered technology. And I wholeheartedly agree that. Then it comes down to the person with diabetes. What's their readiness? Can we find a way to use this? I think that we all know that if someone isn't willing to do it on their own.
If they aren't the ones that making that decision, we're going to have an uphill battle that they're just going to keep pushing off like, no, I didn't want to use it. And they want them to of deflect. And so I think that we really have to have that buy-in from the person. So it is their decision on what specifically they're going to choose. Then from there, we have to identify how are we going to get coverage. And I think that if we break it down,
The easiest one to talk about is insulin delivery devices. Because again, let's use the resources we have available to us. when I think of every single one of the pump companies, all of those sales representatives are the most important person that I can connect my patient with. Because they are going to be able to give them the seamless way of identifying coverage, cost, and is there another alternative payment plan and then where we need to get it? So I like starting the easiest, is the easiest one to find out coverage and cost and all of that because someone else is helping. And I really strongly encourage that if a diabetes care and education specialist does not have a relationship with the pump companies, please, please, please do that. Why are we making our lives harder? Again, really make sure that you're aligning with them because that's what they're there for.
Yeah, again, and I think that really has made my life so much easier pump wise.
Dana Moreau
That's great. But CGM, not so much.
Amy Hess-Fischl
And I think that, and I don't want to downplay the sales roles for those CGM folks. And in fact, I just received an email from one of the CGM companies of the over-the-counter side. So we'll talk about that in a little while, but I know that there are resources as well. So if you have a good relationship with your CGM folks, by all means. But when we think of CGM, it depends on the coverage plan that the person has and the state that they live in. So I think this is where it gets a little trickier because you then have to really understand states of the patients that you are working with, again, and what are their rules. We know that type 1 diabetes coverage is no problemo, but when we think of anyone else that's not on insulin, then we need prior authorizations and where do we go? A DME versus a pharmacy plan. And so that's where we do sometimes need to do a little more homework, but we know that Zane Atak has all of that information for us too. And I was just at a conference over the weekend and someone was recommending it. Like, yay, I'm like so excited. Yeah, we need you promote that more. And I think that, again, knowing the resources that are available to you, because yeah, it was a lot easier. I was talking to a patient yesterday that 25 years ago when I started, yeah, it was like the no-brainer, like, here we go, go to the pharmacy, this is what you need. Now it's like, hmm, A, B, C, D, E, F, G, you know? And so I think that it really comes down to, we do need to do a little more investigation of the resources that are available because one size doesn't fit all. And that's where it gets confusing, because it's like, who needs a prior off? Who doesn't? And we need as many tools as possible to help. And the companies are going to be the best place to do that if you don't have the staff to be able to kind of investigate, which most people don't. So I think that's why, again, I like to be a little more self-sufficient that, yes, I have those resources and they can do that. And I can turf it off to them and say, here, I need you to do this. But I think that it's really important that as diabetes care and education specialists, we know where to go to get this information. Talking to the companies, are going to be the best way because they've already done their homework. They've already said, hey, this plan in Illinois is what's covered or in Indiana or Texas or Louisiana. So I think we need to make sure that we are relying a little bit more on these companies to be able to help us because they're selling these products and it's to their advantage to help us.
Dana Moreau
Exactly. Getting a little more specific here, when we're thinking about writing the prescription, are you the one entering the prescription or you have workflows that are built into your team overall?
Amy Hess-Fischl
It depends on whether I'm seeing the patient alone or if I'm seeing them in conjunction with the physician. So usually if I'm seeing them alone, then yes, I'm entering the prescription and then pending it off to the provider. You know, I guess it just depends on kind of how busy my day is as well that we do have a semi a quasi workflow that, you know, again, especially if a patient is calling in, you know, the nurses handle it or they'll reach out to the diabetes care and education specialist, identify what we're looking for, and then they're writing the prescription, pending it to the doctor. So we have a lot of different ways. We're really, I think for everybody listening, working on a workflow is a really efficient way to do it. And I think we're in the process of doing that as well, even though we are a really big organization, but we have 27 endocrinologists, so everyone does their own thing. And so I think it's...
Yeah, again, having a workflow is helpful. you know, thinking of that workflow of, patient wants X. Have we identified where we need to go? You know, then are we putting it through? Does it require a prior authorization? And then identifying is a DME or pharmacy that it's going to be going to, and then the person picks it up. And whether they come back to be trained by us or the company, of course, all the pumps, I'm going to just say to the audience, use the companies. They might hurt me. But I'm very protective of diabetes self-management training hours, because again, we only get two of them per year for most patients. And so I think that having the button pushing and things done by the company is the most efficient way for us to use our time, because we really want to do the problem solving. We want to help with those outcomes for patients, not necessarily anybody can push buttons. So I think that it's important.
Unless, unless you're one of those lucky people that can have a contract from these companies and get paid through your organization to do that. It's just a lot of big organizations still.
Dana Moreau
Hey, well you said something earlier, you're talking about DME versus pharmacy benefit. Yes. How do you, for those who are new to this, determine whether a CGM or an insulin pump goes through DME or pharmacy?
Amy Hess-Fischl
You know, this is the eternal question because with commercial pay, it's kind of a poop shoot, you know, that we don't know what it's going to be, you know, unfortunately that, you know, because again, every plan makes their own requirements. So we can easily say that some state-based coverages and Medicare typically may require it to go through a DME. And that's where having that relationship with your tech representatives can kind of help you to better discern that. Yeah, I mean, the other way is, sure, if you have a patient that is savvy, and I hate making them do this, but call the company and find out. I mean, if you have a couple hours to kill, by all means, give them a call and find out. But I think that the most efficient and easy way is talk to the pump companies, talk to the CGM company, find out, all right, I have X. what do I need to do? And in fact, a lot of their websites even allow that, and of course, Dana Tech does too, that you can be like, all right, I have this, I have this, what do I do? I wish I had like a cut and dry answer for you, Dana, because there isn't. I think that we have to work with each person. But like I said, for the most part, Medicare, we're going to be going through a DME for the most part, just because of the requirements. But I think that this is where we have that heavier lifting on our part to help the person with diabetes understand that there are a lot of pieces to this puzzle before we even start. So again, like, all right, we're not starting this tomorrow. Let's give it a little time to figure out where we need to go. I know I sound like a broken record, but I do think that should be our primary resource to help us to tease out where we need to go.
I mean, in fact, I was talking to one of the pump companies yesterday. You know, they're putting together a new kind of statement of medical necessity saying, hey, now we have it all together. could be an SMN or a pharmacy benefit. And so, you you can have all of them together and we'll work out the details. And so I think that I like being able to say, call my rep and he'll help with that assignment of benefits because it's so confusing.
Dana Moreau
I mean, you clearly work for a large organization. Does everyone have that type of access to rep?
Amy Hess-Fischl
You know, yes, you know, I think that's the little known fact that they are available to everyone. If you are prescribing a product to your patients of theirs, that you need to reach out. In fact, you go to annual ADCS conference, you know, talk to these companies and say, hey, I live here. They'll be like, let me get in touch with the person that covers that territory. So I think that that's sometimes this misconception of so many diabetes care and education specialists that don't work in large organizations. Because again, it's not just meant for large organizations. Yes, bigger numbers, I get it. But they are meant to help everyone in their territory. And that is something that every single diabetes care and education specialist should be relying on and really creating that relationship and saying, I want this to happen, help me.
If you want to increase those numbers in my territory, come on now. We need to work together. know, again, can you give me some free samples? What can you provide for me? Because that's what they do.
Dana Moreau
That's great. let's move on and talk a little bit about the dreaded denials. Have you ever had one that made you kind of rethink your documentation or kind of forced you to, you know, change language? And what tips do you have for other people who are dealing with this?
Amy Hess-Fischl
great question and yes, we've had plenty of denials and it does always come down to documentation. And I think that we don't have to reinvent the wheel. There's verbiage that we can put into all of our documentation to make sure that we never get a denial. And I think that it's really important, again, I know I keep saying it, but all the companies, like this is what needs to be in your, you know, that this person is CGM, for example. Again, this person is injecting insulin at least once a day. Again, all of these things that will, that's not in the documentation. It doesn't show that this is warranted. Then we know that it's gonna be a denial. And you know that the companies are going to, they're very, they're sticklers. And unfortunately, while we sometimes get a little fast and loose with how we're documenting things, and I don't mean it like, you're blatantly not putting something in, you know, they want the verbiage to be exact. Because again, you know, most of these people that are looking at the documentation, you know, they're looking for words. And so I think that, again, every single one of the companies like here, this is what needs to be in your documentation to get this covered. This is for a pump. This is what needs to be said. You know, again, it all comes down and electronic medical records have made it so much easier that you had a smart phrase, you know, again, put that smart phrase and say smart phrase requirement, say CGM required, CSII required or AID required, whatever you wanna put in your smart phrase. So I think that, again, making sure that we don't have to keep reinventing the wheel, but I have to say we had so many denials and all, I love my patients because they're like, you are not gonna believe what happened, and it's like, my gosh. And then you look back at the documentation like, oops, my bad.
Dana Moreau
Okay, so let's say we get through that part of the process, right? We've got coverage and it's approved. But then there's other issues that come up. So let's talk about addressing some of the patient concerns. And number one that I always go to is affordability. So when a patient says, great, I'm covered, but I'm really worried about the cost, how do you respond and what are you thinking about?
Amy Hess-Fischl
I'm always thinking about cost. I think that regardless of what socioeconomic status my patient is in, I'm very aware. Just because I think it's affordable doesn't mean anybody else will. And I think that we have to step back. And so that's always first and foremost, even before we even go down this road. What I see specifically, and let's just talk specifically about continuous glucose monitoring. Because again, that's where we tend to see and I hear people saying, my gosh, you know, this is going to be $230. You know, again, I just can't do this, you know, a month. And then we have to look at, is there a way to make this more affordable? And again, yesterday I had a patient that she fit in one of the patient assistance programs. So again, I think that we, as diabetes care and education specialists, do need to be aware of all of the ways that we can make this more affordable, regardless of the person that's sitting in front of us.
Data Tech has a great, it's a wonderful resource. have to say that I was looking, was showing my patient yesterday, I was just like, look at this. And it's like, she already knows what needs to be done, but these are things that I don't feel that people are aware of. And I think that when we think of competencies, again, this fits very nicely in competencies, diabetes care and education specialists. This is a competency that we need to be reassessing our knowledge base when it comes to technology. We can't have our heads in the sand anymore. Again, this really is something that's part of DSMES. And I think talking to the person even before we get there. But again, getting back to, all right, we found the most affordable continuous glucose monitor for you. How do we make this fit? And I think that depending on a lot of factors, depending on is somebody type 1, is somebody type 2, do they have a high degree of hypoglycemia.
Do they have hypoglycemia unawareness? Can we get away with intermittent use? I think that we have to also acknowledge that, let's talk this through. Let's see what fits for you. Another patient yesterday that is type two and he's on a basal insulin and he's like basal plus, like he'll take one extra insulin dose sometime during the day. He would rather just say, my numbers look pretty solid. Again, I'm not having hypoglycemia.
As long as I keep on keeping on with what I'm doing and I'm not deviating or doing something weird that's going to increase my risk of hypo, I'm going to just wear a CGM like every other month, or I'll use it for 15 days and then I'll take 15 days off. That I can, for affordability sake, I can make that work a little bit better. So again, if we're just talking about coverage of the ones that have alarms, that's much easier for people, but I think we have to meet them where they are.
And even the same with insulin pumps. I think that affordability is a big deal. And that's where I do rely on these companies and say, is DME or pharmacy a better benefit? It is about the coverage. And that's what I love about the assignment of benefits that go on. Even before we know what's going to be covered, they're looking at all of that stuff for the person with diabetes to better fit in their needs. I think that then looking at
Is there kind of a payment plan that we can also do with pumps? So we have lots of options, but I think that it's really important that we understand the landscape and what is available, because it's changing. Again, there are some requirements that we have to also look at, and those also may be different depending on who we're talking to.
Dana Moreau
I love how holistic your perspective is here and I think it emphasizes the importance of a role like yours in the organization and the DCES to be quite honest. So I appreciate how you look at it from every single angle. That's not always usual.
Amy Hess-Fischl
No, thanks, Dina. When I'm looking back over my career as a diabetes care and education specialist, we have to evolve. I mean, we know that centers are closing, and so we have to prove our value, and we have to show that we are providing positive outcomes. And so this is one really great way, because it's about patient satisfaction. It's about, again, patient-centered care. We have to really focus on that, and this illustrates that more than anything, because again, sure, we could say, I want you on this. That's never gonna work. It's never worked. You know, it's like, what do you want to do? What are you willing to do? Because if it's coming out of their mouths, they're gonna be more apt to follow through with it. And then, hey, if at first it doesn't succeed, let's try again. You know, and that's really important.
Dana Moreau
Let's touch on something you mentioned earlier, and that's kind the EMR. So you talked about smart phase or praise, smart praise. But do you have any other tips for working effectively with the EMR to make this easier on everybody?
Amy Hess-Fischl
It depends on the EMR that people are using. But I am a huge fan of smart phrases, just because again, you can do the majority of your documentation and then obviously individualize. So if someone isn't utilizing smart phrases, I think that you need to take a close look at kind of your day to day. We tend to say the same things over and over again. So kind of truncate that into a smart phrase and then you can, have little asterisks and then add in stuff. But I think that other EMRs do have ways that you can look at outcomes. You can look at the number of people that have type 1 hypoglycemia unawareness, all depending on how the diagnoses are entered. So that's really what the bigger issue is. Identify kind of coverage plans. So I think it really depends on how much into the weeds EMRs can provide a lot of data.
But if we're just talking down and dirty documentation, that's where Smart Phrases creating the same notes, making sure that we're standardizing. Because if we're standardizing what we're saying, then the documentation is what needs to stand alone, especially when it comes to coverage. And so I think that we do need to make sure that we're standardizing a lot of the verbiage that we're using. So that's the biggest piece when we think of EMR.
Dana Moreau
Coming to a close here, let's do a little bit of a reflection question. If someone listening today has been hesitant to prescribe diabetes technology, what would you say to them?
Amy Hess-Fischl
I would say do your homework and you're not alone. I think that we need to acknowledge that there are so many resources that are available. Don't feel so overwhelmed because again, the CGM companies, the pump companies are all there for you to use. If you do not have someone in your back pocket that you can call, find out who you can. There is always someone in your territory that is providing resources on their products. Remember, they want to sell their products. Have them sell you on their products. Have them help you to do that. And that is going to be the biggest change that anyone can make. Make sure that you're leaning on these companies to give you more information. And make sure that you're looking at danatech.
Dana Moreau
Exactly. And actually, I'm going to add a plug for ADCS near communities of interest here. If you do work alone and you don't have access to a lot of resources, you probably want to join our technology COI because there's so many people waiting to answer any questions or help you learn how to prescribe or kind of ease some of the challenges you face. again, if you're not a member, big call.
Amy Hess-Fischl
one, know, is strength is in numbers. Take a look, find out if you have DAPs in your vicinity, who are they? Reach out to them. I mean, you're not competing with each other. I mean, we have enough people with diabetes that, you know, again, learns from each other in your area. Find other diabetes care and education specialists throughout, you know, even in a 25, 50 mile radius. Because again, you're all dealing with the same things within your region. So by all means, you know, we are a big community. Make sure that you are tapping
that we're all tapping each other for this information.
Dana Moreau
That's really important. Amy, thank you so much for joining us today.
Amy Hess-Fischl
My pleasure, Dana.
Dana Moreau
So remember, prescribing diabetes technology isn't just about writing the order. It's about building systems that make access possible. Thank you to Abbott for supporting this episode. You've been listening to Dana Tech Talks, part of the funnel conversations with the diabetes care team. To explore more resources and guides that have been mentioned in today's discussion, visit danatech.org. And until next time, thanks for tuning in.
The information in this podcast is for informational purposes only and may not be appropriate or applicable for individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.