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Reducing ‘unnecessary’ blood glucose test strip use


Blood glucose test strips are the third most expensive cost for the Ontario Public Drug Program.

A study released in 2009 suggests that the Ontario government is unnecessarily spending between $19 and $42 million per year on glucose test strips.

However, no changes have yet been made to reduce the use of blood glucose test strips.

Researchers have suggested that the Ontario Ministry of Health and Long-Term Care (MOHLTC) is unnecessarily spending tens of millions of dollars per year on blood glucose test strips that don’t benefit patients. The studies were published in 2009, yet the government continues to pay for the strips. What’s the story?

What are blood glucose testing strips, and why do we measure blood sugar levels in persons with diabetes?

People with diabetes have high blood sugar (also known as blood glucose) levels. Lowering the blood glucose close to normal can decrease the chances of developing serious long-term complications of diabetes such as blindness and requiring dialysis, and is an important part of good diabetes care.

Many people with diabetes can control their blood glucose levels with diet and exercise, some need to take pills, and others require insulin.

Insulin can lower the blood sugar rapidly and dramatically. Therefore, people on insulin –everyone with type 1 diabetes and a small proportion of those with type 2 diabetes are on insulin – must check their blood glucose levels many times a day to ensure that their levels are neither too high nor too low. The blood glucose level is measured by pricking a fingertip with a tiny stylet, putting a drop of blood on a small plastic blood glucose strip, and inserting the strip into a machine the size of a cell phone called a glucometer. The glucometer automatically produces a reading that indicates what the blood glucose level is. Glucometers are often provided free of charge to persons with diabetes. However, the strips cost between $0.44 and $0.77 per strip in 2008, and they are not re-usable.

People with diabetes who are not on insulin need to monitor their blood sugars so glucose-lowering medications can be started or adjusted when needed. However, most do not need to measure their blood glucose levels on a daily basis, because oral medications are adjusted every few weeks or months (not every day as can be the case with insulin), and pills rarely cause the blood glucose levels to drop to dangerous levels.

What the Ontario government spends on glucose test strips

The MOHLTC pays for glucose test strips in the same manner that it pays for many prescription drugs – in other words, Ontarians 65 years of age and older and younger people who are on disability support or welfare pay very close to nothing for the test strips. Because diabetes is extremely common (there are about 1.2 million Ontarians with diabetes), the government expenditure on test strips is extremely high – around $85 Million in 2008. This makes it the 3rd highest “drug” expenditure in the Ontario Drug Benefit Plan.

However, a significant chunk of the expenditure on test strips in Ontario is for people who are either on no glucose-lowering drugs at all (who use about 13 million test strips per year), or on pills that do not cause a dangerously low blood glucose level (who use about 25 million test strips per year).

Why do physicians order, and patients use, glucose test strips if they are highly unlikely to provide benefit?

A recent study found that the MOHLTC could save between $19 million and $42 million per year by not paying for test strips used by persons with diabetes who are highly unlikely to derive any benefit by regular self-monitoring of blood glucose.

Some persons with diabetes probably like the security of constantly knowing that their blood glucose is under control, and immediately knowing if it gets too high. If their physicians recommend regular testing, many patients are unlikely to question the value for money of regular testing, especially because they do not have to pay for the glucose strips themselves.

Physicians who order blood glucose monitoring in patients highly unlikely to benefit likely do so for a combination of reasons that include patient request and a feeling that it is good for patients to monitor their diabetes as closely as possible. They, like their patients, may not think much about the costs because the costs are covered by the government and many may not know that the total cost is so high.

Why does the Ontario government continue to pay for glucose test strips in people unlikely to benefit?

With the Ontario government dealing with a significant deficit, saving millions of dollars annually by reducing spending on unnecessary blood glucose test strips may seem like a “no brainer”. Why does the government continue to pay for the strips?

Withdrawing a service that it is already providing can be politically risky for governments.  In this case, some persons with diabetes and their physicians may accuse the government of abandoning them. The manufacturers of glucose strips will certainly be unhappy and will almost certainly vigorously criticize any attempt to decrease expenditures on glucose test strips.

On the other hand, restricting public funding may seem sensible to many Ontarians: the millions saved by not paying for these test strips can be used elsewhere in the health care system to greater effect, and the government will continue to pay for test strips in persons with diabetes who benefit from them (those on insulin and taking pills that can dangerously decrease blood glucose levels). Also, if the government doesn’t pay for the strips, many persons with diabetes can afford to pay for the strips themselves if they want to test their own blood sugars.

Should the Ontario government stop paying for blood glucose test strips for persons with diabetes who do not need frequent blood sugar monitoring?

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5 comments

  1. Anandita Gokhale

    Interesting article! I feel that the responsibility lies with the physicians for properly prescribing glucose monitoring for only those patients that will need it and benefit from it. That being said, if the majority of physicians are for some reason failing to recognize this (as per the arguments stated in the article), then it makes sense to discontinue this service.

    This will stimulate prescribing glucose monitoring only for those on insulin, thus curbing costs. And it will better educate physicians and patients who may erroneously believe that their sugars must be monitored at all times, even though they’re not on insulin.

  2. Ritika Goel

    The Canadian Diabetes Guidelines recommend glucose monitoring once daily for diabetics on oral hypoglycemics and 3-4x/d for those on insulin. This article suggests stable diabetics on orals need testing less regularly which makes a lot of sense. However, I think:
    1. The guideline should take cost effectiveness into account and change accordingly
    2. The govt should consider funding a limited supply of strips per person unless they’re on insulin (kind of like a LU code, but for quantity allowed per month). This may be a way around the issue. I do know however, that I serve an inner city population often consisting of patients that may have poor compliance with blood sugar checking, and any added barriers to this would be unfair.

  3. faisal_q

    Glucose strips are needed for monitoring and should be funded, especially for those on limited budgets. But let’s examine what that $42M is doing. What is actually being monitored? Glucose meters store information. Unless a patient is adept with computers and knows how to download the results to their PC, those results aren’t examined until their next doctor’s visit. We need better cheaper tools that constantly monitor blood sugar throughout the day so that providers can quickly asses a patient to see if they’ve gone off track.

    Otherwise we’re buying into $42M of a piece of cloth glued onto a plastic stick.

  4. Richard

    I’m a Type 1 diabetic but I was on oral medication (pills) only, with no insulin, for over a year. A year and a half after diagnosis I am now on pills and insulin. While on orals, I had to check my sugars at least twice a day, and that normally means going through all my test strips every 50 days. I’m otherwise healthy (not obese, am young and active), but I’m not high-income, so it would be a burden to have to pay the extra $100 every few months for strips. By my calculations that would cost me an additional $560 per year our of pocket

    Also I don’t agree with the thrust of the argument. it seems counter-intuitive to assume most diabetics don’t record their readings or derive benefit from regular testing of their sugars. Surely if someone is testing it is because of concern over their sugar level, and I presume they use the readings to try to take corrective action, both immediate and planning for future meals. Is his not a good thing worthy of funding under medicare?

  5. Gagan

    Interesting article–it raises a lot of issues about our healthcare system, and the doctor patient relationship. In my opinion, I agree that while non-diabetic patients may get a sense of security from testing their blood glucose, funding is limited, and should be used to help patients in a more dire need of drugs. Further, if we can afford–both from an economic and a patient-safety perspective–to test blood glucose less frequently, then we should do so.

    With that being said, I feel as though these decisions should not be made at the doctor-patient level. That is, a doctor should not tell a patient “you should avoid the glucose strips because you will cost the healthcare system money!” This may cause strain in the physician’s relationship with the patient, and undermine the patient’s trust in our publicly funded healthcare system. Instead, funding decisions should be made at the societal level (government, associations representing various healthcare practitioners, drug industry, etc) and incorporated into clinical guidelines for the physicians.

    However, in the situation that there is no therapeutic benefit from providing glucose testing for patients (patient is very healthy, no indication of abnormal glucose levels, etc. ), then I do not feel that doctors are obligated to even recommend this option to patients.

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