50% of People with Type 1 Diabetes Funded by HSE for Glucose Sensor Technologies
Last January, I published some of my thoughts on the situation in Ireland with regards to access to the Flash Glucose Monitor (Freestyle Libre) and some questions I had about it. Some people thought that I was advocating in favour of one product but I am actually advocating for choice because as most of us know, there’s no one size fits all in diabetes. Here’s the link to this post.
As a result of my post I was contacted by a member of a political party who submitted some parliamentary questions to find out just how many people with diabetes were being funded by the HSE for glucose sensor technologies. I was surprised but not surprised to find out that between two of the three sensor devices available that 50% (9,856) of our total population of people with type 1 diabetes are being funded for these devices.
Table 1 below reveals:
65% of people funded for CGM sensors are over the age of 21 years
Enormous annual increase in uptake of CGM - There is a 230% to 270% increase annually on CGM approvals, in the over 21 year age group this annual increase was 274% in 2019 and 301% in 2020.
85% of rejections for a Flash funded sensor are people aged over 21 years.
A 600% increase in CGM uptake in three years!!
There are two piece of data missing before we can make a solid conclusion:
How many Flash applications are approved for people over age 21 years?
How many people over age 21 years who were rejected for Flash were subsequently approved for CGM?
But it does appear that my suspicions that lack of choice in sensor technology is costing the HSE a lot more.
The enormous annual increase in CGM uptake is absolutely continuing in 2021!
Table 1: CGM DATA from PQ reply
Table 2: Libre Data from PQ reply
Similar Eligibility and Clinical need criteria for both Flash & CGM
There really isn’t very much difference between the clinical need criteria for both devices.
A person is eligible if they use either injections or insulin pump, check glucose levels 8-10 times per day or more or frequent episodes of DKA or hypoglycaemia.
The differences in criteria is one device has a HSE imposed age restriction and one device is currently designed with alarms to address hypo unawareness. If someone meets any of these criteria but is over age 21 years they only have the option of applying for the more expensive device.
Table 3: Eligibility and Clinical need criteria for both Flash & CGM
But Flash is not the Same as CGM
When Flash was introduced, we were repeatedly reminded of the differences between Flash and CGM and there were some important differences at that time. But now, not so much. So, our next PQ asked:
Why does the HSE LTI scheme not include the Freestyle Libre Glucose Monitoring system for persons with diabetes aged over 21 years BUT DOES include 2 other Glucose sensor monitors which cost €1,200 more per person per year? [8923/21]
The HSE reply outlined several points of difference between the two devices, however most are actually redundant today since both technologies have advanced so much since this process began in 2018. Turns out three years is a long time in diabetes technology.
Difference 1 - CGMs have alarms and Flash does not (for Hypo Unawareness)
The new Libre2 with an alarms feature has been available in selected countries in Europe and the U.K. since late last year. So now both devices have alarm capability.
Difference 2 - Replacement for SMBG finger stick testing
The Dexcom G6, available here since October 2019, does not require finger-stick calibration. So two of the three products can be a replacement for test strips.
Difference 3 - Connectability to Insulin Pumps
Only one of the two CGM devices currently connects to an insulin pump available in Ireland. We sincerely hope this changes soon but Flash monitoring is also partnering with insulin pump companies for the future.
I also suspect that many people approved for CGM do not use insulin pumps especially as recent data shows that insulin pump uptake in the over 21’s age group is less than 7%
Table 4: CGM and Flash features compared
What’s that about Funding?!?!
The funding is already there!!!
I’m not a math genius or a health economist or even a super intelligent person but even I can see that if the age restriction on Flash was removed and we had a choice, the HSE would save money.
How many people who were rejected for Flash went on to be approved for CGM?
From 2018 to 2020, 815 people over the age of 21 were refused funding for Flash. This may not seem like a very big number but even if only one quarter (203) of these people went on to be approved for CGM this resulted in the HSE paying €238,423 per year more than if they had approved the Libre application.
Libre cost for 203 people = €317,898 PA
CGM cost for 203 people (€2740pp) = €556,321 PA
Costing HSE €238,423 Per Year more than by offering Flash to people over age 21 years
But what if that number is much higher??? What if that number is as high as 50% making the extra cost to the HSE €476,847, which is very close to half a million euros.
How many people asked for Flash but were directed to CGM because of the age restriction?
I know from the many emails and messages that I receive that many people ask for Flash but are directed towards a CGM because of the age restriction.
Well guess what! If you offer people with diabetes a choice between the three sensors you will save on every person who chooses the Flash. Or come up with a reasonable criteria that would create an incremental approach to sensors: try a flash first, if it’s not suitable try the next most expensive sensor, and so on.
How can we get the age restriction removed?
Unfortunately, at the moment, there is very little we can do to change this. The Dail is on summer break and the HSE has been cyber attacked and so if not processing any parliamentary questions to challenge this situation. However, once the HSE gets their IT systems up and running again that we can all start asking our TD’s to ask why the age restriction hasn’t been removed from access to the flash glucose meter already??
Documents referenced in this post
Deputy Sean Sherlock asked the Minister for Health the number of funding applications that were received for the long term illness scheme and the primary care reimbursement service for the FreeStyle Libre glucose monitoring system; the number of applications that were denied; and the number of denied applications that were for persons over 21 years of age. [15204/21]
Deputy Sean Sherlock asked the Minister for Health the reason the HSE long-term illness scheme does not include the FreeStyle Libre glucose monitoring system for persons with diabetes over 21 years of age but does include two other glucose sensor monitors which cost more than €1,200 per person per year. [8923/21]
Deputy Sean Sherlock asked the Minister for Health the number of persons with diabetes who were funded for the dexcom continuous glucose monitoring sensors by the HSE long-term Illness scheme and the primary care reimbursement service; and the number of such persons over 21 years of age by county in each of the years 2018 to 2020, in tabular form. [8924/21]
Reply to PQ: 7148/20
Mattie McGrath: To ask the Minister for Health if he will make the FreeStyle Libre device available to all type 1 diabetics under the long term illness scheme; and if he will make a statement on the matter
Eligibility for Flash glucose monitor (FreeStyle Libre®) Source: FreeStyle Libre website
Eligibility for Continuous Glucose Monitoring (CGM) Source: NCG for Adults with type 1 diabetes 2018