As CGM technology continues to evolve, it's important that those working with people with diabetes understand the different devices available and how to help people find the best fit for them. Celia Levesque, an advanced practice provider for the Department of Endocrine Neoplasia and Hormonal Disorders at M.D. Anderson Cancer Center in Houston, TX, joins The Huddle to discuss the latest updates in the world of CGM technology, as well as advances that she would like to see in the future and how to help people with diabetes find the device that best fits their needs.
Resources
For more information about CGM options, visit danatech.org.
To view all CGMs currently available, visit our find & compare CGMs page: CGM l Compare CGM Features l danatech (diabeteseducator.org)
Will insurance cover a CGM? Find out with our free CGM insurance lookup tool at: CGM Insurance Coverage Look-Up Tool (diabeteseducator.org)
Interested in training on the devices mentioned in this podcast? Visit our danatech device training page for current and future training events.
dana moreau:
Hello and welcome to ADCES's Podcast, “The Huddle: Conversations with the diabetes care team”. In each episode we speak with guests from across the diabetes care space to bring you perspectives and updates that elevate your role, inform your practice and hopefully ignite your passion. I'm your host today, Dana Moreau, and I oversee Danatech. Not familiar with Danatech? Let's fix that. Danatech is an online resource from ADCES. It was developed to teach all healthcare professionals more about diabetes technology devices and best practices. Find articles, tools, training, and even some free continuing education opportunities at danatech.org. On today's episode, we're talking about a very hot topic. It's all about continuous glucose monitors or CGMs. And honestly, with all the changes we've seen in this past year, we're going to be pretty hard pressed to cover everything there is to talk about in the allotted time. But my guest today, Celia Levesque, and I are going to try our hardest. Celia is an advance practice provider for the Department of Endocronioplesia and Hormonal Disorders at MD Anderson Cancer Center out of Houston, Texas. Celia treats patients with hyperglycemia and diabetes who also have cancer, and she frequently prescribes diabetes technology for her patients. Welcome Celia!
celia_levesque:
Thank you. I'm glad to be here.
dana moreau:
Before we kinda jump into this podcast and the core topic, Celia can you tell us a little bit more about you, your background, your work, and why this topic is important to you?
celia_levesque:
I'm an advance practice nurse. I'm a clinical nurse specialist and a family nurse practitioner and I treat diabetes and its related complications in patients with cancer. And we usually see the patients that have very high A1cs. We're not seeing the patients who are well controlled. They don't get referred to us. So all of my patients are very complex. They undergo surgery, chemotherapy, radiation, tube feeding, TPN, all sorts of things. And so we're always having to adjust therapy. Most of our patients are on insulin, and we use a lot of technology, insulin pumps and censors.
dana moreau:
And talking about this topic, we have seen a lot of changes in the CGM world this past year with so many FDA approvals heading our way. Can you tell us a little bit more about what you see happening in the CGM industry right now, and what this means for patients with diabetes?
celia_levesque:
Yes, I think overall censors are getting smaller and more accurate and easier to use, which is key. And then insurance is covering them better, so as people learn more and more about family members and friends wearing it then they're asking for it. But then we also present it to all the patients who may want to wear it. Even patients that aren't on insulin, we offer it to them if they want to wear one, because I think that is valuable. Even if they don't wear one every single day, they may wear one periodically.
dana moreau:
And some of the specific features that we're seeing on these newer devices, so clearly we've seen the Dexcom G7 that was just released, what last week I think in the United States, and the Libre 3, and even the Eversense. What are some of the changes that you might be seeing by device that will be helpful for people using them or looking to start them?
celia_levesque:
I'll start with the newest one first and then work my way backwards. But the Dexcom G7 was just released to the pharmacies on February 17, so it's very recent. Overall it's smaller, so it takes up less space on the body and it's a lower profile. It only has a thirty-minute warmup period compared to two hours from the previous Dexcom G6. The mart is better, so the accuracy is better. It's 8.2 compared to the G6 of 9. And the transmitter is built into the center, where as before, with a G6 you would have to carry a transmitter from censor to censor for 90 days, and if you lost it, then you would have to wait 90 days to get it out of the transmitter if you accidentally threw it away. Also the packaging size is smaller, and so I think the footprint is easier, and I know that sounds trivial, but as a person with diabetes and you have to carry lots of things with you, size does matter, and the smaller the better. And then also, the cost is going to be less for the people who don't have insurance covered. So maybe they're not on insulin and the insurance won't pay if they're not on insulin, then I was quoted a price of about eighty dollars a month. That would be for three censors. Don't hold me to that, but that's what I was told.
It is approved by Medicare, so that's good whereas most of my patients personally have Medicare. And one other good thing I think is new about Dexcom G7 is that before you had to take it off for a CT scan and now you can actually wear it with the CT scan as long as the CT scan is not directly over the censor. But if you had to say what's the downside of the Dexcom G7? It's not compatible with the automated insulin delivery devices, not just yet. Although I think the companies are working on it.
dana moreau:
Okay. And it does sound like again, they are looking into and moving towards being compatible with those same insulin delivery devices. They just…
celia_levesque:
Correct.
dana moreau:
don’t look like they have any timeframes on the horizon just yet, correct?
celia_levesque:
Not yet. I know Tandem said probably later this year, but they have to get FDA approval for that, so that's just whenever they decide it's okay to be compatible. So yeah,
celia_levesque:
And then the freestyle Libre 3 is smaller also and its insertion is much easier. So instead of two boxes, and you put the two pieces together and then separate them and then use it, it's only one box. And so it's pretty easy to insert. But the biggest difference between the Libre 3 and the previous versions is that it's continuous, so you don’t have to scan to see your reading and you don't have to scan a certain amount of times per day to get a full report. And I think that's nice. Instead of every five minute update, like some of the other censors, it's every one minute and then you can have followers. And the mard is better too, so it's seven point nine compared to the Libre to at nine point three. But if you had to say, what's the downfall? It's not covered by medicare and it obviously is not compatible yet with the automated insulin delivery devices. Although I think the companies are working on that, so I think in the future you may see it talk to insulin pumps, and then you know be compatible with other devices.
dana moreau:
Now, the one thing I remember somebody else asking was about receivers. Are receivers still options with both the Dexcom G7 and the Libre 3 now?
celia_levesque:
With receivers, you can get one with the Dexcom G7, but the Libre 3 does not have a receiver.
dana moreau:
Okay
celia_levesque:
So you have to have a smart phone and you have to have a compatible smart phone. So I always tell my patients before I send a prescription, I make them pull out their phone to see if they have the app on their telephone before I go and have them pick up something and then find out it's not compatible. Then that would be really bad. Then they paid for something that they can't use.
dana moreau:
That makes sense.
celia_levesque:
And then the ever Eversense E3, what's new about that is they have FDA approval for six months wearing now and then you don't have to calibrate as often. Used to be you had to calibrate twice a day, but now you calibrate twice a day for 21 days and then it's daily after that. And it's now covered by medicare.
dana moreau:
There might be people who are listening who are not as familiar with the Eversense as the other options. What's different about the Eversense than the other two CGMs that you mentioned.
celia_levesque:
It's implanted into the arm and then you put a transmitter over it after it heals for a few days. And it's rechargeable every day. So you would take it off, so if you're going to be having an MRI or cat scan or x rays, you just remove the transmitter and set it aside in a safe place and then have your testing and then put it back on. But it’s implanted by a professional that's trained. It's not compatible with any automated insulin delivery devices. So that's a downfall, but I'm hoping that it will eventually talk to insulin pumps, because then that would be fabulous and you wouldn't have as much downtime on censors. And you know when it's the most inaccurate time of the center is the first day. And so you have less first days with the Eversense.
dana moreau:
Yeah, those 24 hours can be fun.
celia_levesque:
And what's new about Medtronic is that it's covered by Medicare now.
dana moreau:
Oh, that's interesting.
celia_levesque:
Yeah. It wasn't before. It is now.
dana moreau:
Okay, great. Again, it sounds like there are just a ton of new features and functionality available on the CGMs that will make them a different experience and hopefully a better one for many people. But of all of these features that we're seeing right now, what are the ones that you are personally most excited by and think will have the biggest effect on patient management and care?
celia_levesque:
I think if it's easy to use and the patients know how to use it and it's affordable to them. I have a patient I just saw the other day who had only had an A1c and one blood sugar by lab. And so he saw me for the first time, and since I didn't have any data on him, I was like “well, let's put you on a censor and if you really like it, I'll prescribe it”. So, I gave him a starter one and he went home and he saw what caused his blood sugars to go up, and he made all these changes in his diet. And I did start him on a GLP1 because he had newly diagnosed type 2 diabetes. But he kept texting me pictures. He was so excited about it, and when I called him to refill his GLP1 for the second month, he just was beaming about how much this just revolutionized his life and changed his life. And I hear those stories all the time.
dana moreau:
Yeah, and I think it's that old adage “if you can't measure it, you can't manage it”. So when people actually get to see what they're eating or what they're doing affects that blood sugar, they’re gonna take more hopefully corrective steps to doing things that make sense for them and their management overall. So as a healthcare practitioner and a user of some of these devices, is there anything new that you haven't seen yet but you really hope the manufacturers might address in the future?
celia_levesque:
Yes, lots of things. I wish they would address the tests to make them compatible with CT scans and MRIs and x-rays, and things like that. And any interfering substances, if they could make it to where you don't have to worry about vitamin C supplements and, you know, acetaminophen, and other things like that. So if they could fix those kind of things. Also if they could make it interchangeable with other devices. So like, I would like to have people shop for the pump that fits their lifestyle the best, and the one they like the best with the censor that they like the best. And so that you can pick pump A with censor C, and you get to pick what you want and have them talk to each other. And then, obviously, if they can afford to use it. So if insurance would then cover it, or at least if the companies made it affordable for cash paying patients, and a lot of them are already doing that as far as cash prices. So the Libre 3, If you don't have any insurance covered, you can call Libre and get a coupon for two censors for 75 dollars. And the new Dexcom G7, I was told it was going to be 80 dollars a month. And Medtronic has a cash program where the censors are 60 dollars for a box of censors which lasts one month, and then the transmitter, which is good for a year, is a hundred and eighty dollars. So that's pretty affordable to most patients. And then Eversense, if you're cash paying, then they have a discount, but I actually honestly don't know how much it costs to have one implanted if you didn't have insurance, but it is covered by insurance.
dana moreau:
So it sounds like again, the manufacturers are working to make these more accessible and affordable. But still, I mean how easy or difficult is it to obtain one of these? I mean type 1 versus type 2? What are still some of the hurdles to being able to access a CGM if you need one?
celia_levesque:
A lot of the commercial insurances will just pay if you have the diagnosis of diabetes. Although, in the past month I have seen a few insurance companies want me to do a prior authorization, so that's like a change that I've seen in the past month. But medicare covers if you only have one injection a day, so you don't have to be on multiple daily injections with a sliding scale, adjusting your insulin at every meal. If you just have one shot a day, it's covering it for now. I don't know if they'll change that, you know, in the near future, but it doesn't look like it because it's actually getting better and better covered. And I think if you're checking your blood sugar a lot, because I do have some patients that come to me and they have type 1 diabetes and they're checking ten or twelve times a day by finger stick, it would be actually less costly to be on a censor if you're going to check your finger that many times.
dana moreau:
A hundred percent.
celia_levesque:
I do find that patients that I don't start them on the censor, they already come to me on the censor is that they'll go to the pharmacy and they'll pay a high price for their censors. And what they don't realize is that the local pharmacy is not even trying to bill their insurance and it's usually Medicare patients, and I'll go well “how much are you paying for your, let’s say Libre?” And I know in my head it should be two for seventy five or less with insurance. And they're like “well, I pay $120 month,” or “they asked me for two hundred and something.” And then I go “you realize you're paying more than the cash price?” And then I tell them about it and they're like “why didn't anybody tell me?” So I would like for anybody that's listening to please talk about cost before you have the patient go pick it up. And I always say talk to me if it costs you more than that much money, let me know and then I'll send it to one of the suppliers. So a lot of times the mail order companies will bill the insurance, whereas the local pharmacies won't.
dana moreau:
Oh that’s a great tip. Um. So given all the options currently available, what should a diabetes care and education specialist or other healthcare providers really focus on to help individuals choose a CGM if they're looking for one?
celia_levesque:
I think if you kind of compare, like what do they want in the future? So if they want to wear an automated insulin pump, then they're going to have to have a compatible device. So if they want the medtronic, they'll need to pick the medtronic censor. If they want tandem control IQ they're going to have to pick the Dexcom G6 and not the G7, and so they have to know that. But if the patient doesn't want to do that, then you might look at what does the insurance pay for? I had a patient message me back, and they said they wanted one brand, and so I sent a prescription for it. And then they message me back the next day and said “well, my insurance won't cover this brand. They cover the other brand”. So I just flipped him over. So that was a key factor in that patient. But also knowing like dexterity, is it easier to put in one device versus putting two things together? Do you need followers? I had a patient that was in a skill nursing facility, but the family were followers, so they would go and put the censors on the patient themselves, because the patient couldn't do it, And then they monitor their father from afar. And so then they needed a compatible censor that would have followers. So there's all sorts of different things. So think about what your patient’s going through and then what censor might match better, but then present all of them. So I'm not in favor one brand over another, and I always say there's a reason why they're all on the market because they have customers that love their product. And so it's just a matter of them finding which one they want.
dana moreau:
That's terrific and again I like the story about the followers. I was so happy to see that the Libre 3 added that functionality this round.
celia_levesque:
Yes.
dana moreau:
Is there anything else that we haven't talked about today that you think would be of particular importance to those listening to this podcast?
celia_levesque:
Yeah, I think overall is that it's not for everybody, but I think you should at least offer it to everybody and tell them the advantages and disadvantages and then if they don't choose to be on a CGM all the time, then they may want to wear one censor before their visits, that’s another option. And then you can bill for interpreting reports. You can also bill for training the patient, putting them on it, and then whether it's an office owned device or patient owned device, there's different bills that you can do. All the companies have billing instructions on how you can bill for it and what you have to include in your note in order to bill, and who can submit which bill, because one of them might be a technical component for training, and the other one is the professional component for interpreting the results and changing therapy.
dana moreau:
This was incredibly helpful, thank you so much for joining us today, Celia. I actually learned a little bit more. Hoping everybody who listened to this did as well. Thanks for being here!
celia_levesque:
Thank you.
dana moreau:
As we mentioned at the start of this podcast, there is so much more to cover on this topic. So, if you have any questions on what you heard today or need more information, we really encourage you to head to danatech.org. Specifically, you can view and compare all CGMs you heard Celia mention today. We have practical point of care tools to help with assessment adjustments in education, and we have live and prerecorded training webinars on most of the CGMs available right now. We add new content weekly, so if you don't see something that you need, please check back.
Thank you again for listening to this episode of The Huddle. Make sure to download the resources discussed on today's episode. You can find them linked in the show notes at diabeteseducator.org/podcast. And remember, being an ADCES member gets you access to many many resources, education, networking opportunities, and so on. Learn about the many benefits of ADCES membership at diabeteseducator.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult with your healthcare professional for any medical questions. Thanks again for listening, and we hope you'll join us again soon.