CMS misses mark for CGMs, insulin pumps

YARMOUTH, Maine – Including continuous glucose monitors (CGMs) and insulin pumps in the next round of Medicare’s competitive bidding program overlooks how they are used and will not result in savings to the Medicare program, providers say.

Bundled CGM payments shift upfront costs and risk to suppliers

Currently, Medicare typically pays a one-time amount for CGM receivers, along with a monthly allowance for sensors, transmitters and other disposable supplies. Under the next round of CBP, the agency will pay one monthly amount for everything.

The change means providers will carry a higher financial burden for a product category that will likely see reduced reimbursement under the CBP, says Adam Nadler, CEO and co-founder of Quest Health Solutions.

“When the (CGM) reader becomes a rental rather than a purchase, the entire cash flow profile of the business changes,” he said. “So, DME suppliers are now carrying the asset on their books and absorbing the upfront device cost. And instead of collecting reimbursement right away, they're collecting it in monthly increments, and that ends up becoming a working capital problem at scale.”

Remote-item delivery framework raises new access concerns

In addition to the bundled amount for CGMs, providers are concerned about the CBP’s new remote-item delivery (RID) framework, which they say will have a negative impact on access to technology. RID requires providers to service beneficiaries nationwide, putting smaller providers at a disadvantage.

This contradicts with Medicare’s previous decision to expand coverage for CGMs to Type 2 diabetes in 2023, they say.

“There's going to be a lot of patients drop off because of this transition that is going to be felt across the industry,” Nadler said. “The non-bid winners are not going to want to pass the documentation to the bid winners, and the patient's physicians aren't going to know which CGM supplier has won the bid.”

Insulin pumps add complexity to long-term rental structure

The proposed competitive bidding framework would also bring insulin pumps and related supplies under a long-term rental model alongside CGMs, another major departure from current policy. Providers say the move raises complex questions around pricing, rental timelines and the capital required to support long-term rentals.

There are additional operational risks specific to insulin pumps, which are typically single-use devices today, said Matt Edwards, CEO of GEMCORE. If a pump is returned during a rental period, the supplier could face a total loss on the device.

“In addition, suppliers must carefully assess the clinical support and patient care requirements that accompany insulin pump therapy,” he said. “Taken together, these factors require extensive analysis before a supplier – particularly one not currently active in the insulin pump market – can make an informed decision about whether and how to participate in competitive bidding under the proposed framework.”

Related: Senators introduce bill to delay bidding for CGMs, insulin pumps