The COVID-19 Pandemic: A “Tech”-tonic Shift Toward Virtual Diabetes Care

As a result of the COVID-19 pandemic, I have learned that transformative, radical change can take place at breakneck pace, even in the historically stubborn world of health care. It’s hard to say what has been more surprising: (1) how quickly many long-standing bureaucratic barriers to telemedicine and other innovative health technologies have disappeared, or (2) how quickly these technologies have been adopted by patients, practices, and health care systems.

While the first confirmed case of COVID-19 in California was announced on January 26, 2020, in Orange County, California, the impact of the pandemic was not felt at the Mary & Dick Allen Diabetes Center until mid-March, when the end of normalcy happened swiftly over the span of seven days. Initially, the rising importance of social distancing led our diabetes education group classes to be briefly capped at five attendees seated six feet apart. However, soon after all group classes were cancelled as public gatherings became discouraged and local schools began announcing closures. The group class cancellations were followed shortly thereafter by the cancellation of all in-person individual education visits for the next six weeks as the governor issued a stay-at-home order on March 19, 2020.

Fortunately, our Center had previously implemented video telehealth visits in a limited capacity for diabetes education with our pregnant mothers, allowing our Diabetes Care and Education Specialists to already be equipped to use the Zoom platform. Thus, we were able to swiftly convert all our pregnancy-related diabetes education to 1:1 video visits. Given the urgency and time sensitivity of pregnancy, we were extremely fortunate to provide diabetes education to this population without any meaningful delays. Over the following weeks, nonpregnancy education services such as Diabetes Self-Management Education and Support and Medical Nutrition Therapy visits would restart also in the form of 1:1 virtual visits.

Unlike our patient education visits, endocrinologist visits at our Center continued in-person as an essential service for an additional week beyond California’s stay-at-home order. Beyond one week, however, over 90% of physician visits were either postponed or converted to telemedicine, depending on clinical urgency and patient preference. In-person physician visits remained available as a last-resort option for patients unable to teleconference or who required hands-on interaction such as Freestyle Libre Pro or Eversense insertions/removals.

Prior to the COVID-19 pandemic, California’s telemedicine parity laws ensured equivalent reimbursement for video visits under commercial insurance, but Medicare reimbursement for telemedicine was restricted to patients in rural, less densely populated areas. However, as states began to announce stay-at-home orders, President Trump and the Centers for Medicare & Medicaid Services promptly expanded telehealth benefits temporarily for Medicare beneficiaries on March 17, 2020.

As a result, the sudden shift to telemedicine was taking place in medical practices across the country, paralleling our own experience. Based on discussion forums such as the American Diabetes Association Interest Groups and endocrinologist-only Facebook Groups, providers ranging from solo private practitioners to employees of large health care systems were quickly adapting on-the-fly to virtual care and its unique challenges and opportunities.

A primary driver for the success (and also distress) with video endocrinology visits is our heavy reliance on patient data such as lab results, glucose measurements, and insulin pump records. In hopes of reducing our patients’ risk of exposure, we instructed a majority of them to defer their laboratory visits until after the stay-at-home orders had passed. The absence of lab data heightened the importance of glucose meter and especially continuous glucose monitor (CGM) data. As all the major CGMs offer smartphone compatibility, CGM data proved to be invaluable thanks to their relative ease with data sharing and ability to serve as a reliable surrogate for hemoglobin A1c. On the contrary, most patients do not routinely download their own glucose meter or pump data to a computer or smartphone, so these crucial sources of data were inconsistently available during visits. In their absence, clinicians often resorted to the more basic form of having patients read aloud their pump settings or glucose history.

In the future, I predict that the evolution of diabetes clinics will be defined by the implications of telemedicine. As patients and providers become more comfortable with the conveniences afforded by virtual visits, they will turn to telemedicine as the norm rather than the exception, especially for established patients. The telemedicine boom will coincide with the continued growth of continuous glucose monitoring as it becomes more cost-effective and convenient. As such, smartphones will play a central role in the management of diabetes as their always-on internet connection is the ideal gateway for diabetes data transfer from CGM, next-generation insulin pumps, and connected insulin pens.

From there, as diabetes data flows freely through smartphone nexuses and as virtual visits become standard, my sincere hope is that the entire paradigm of diabetes care will shift away from arbitrarily-scheduled quarterly visits to need-based visits that more efficiently serve the entire population. Acutely struggling or newly diagnosed patients would be identified and receive frequent monitoring and guidance to overcome clinical inertia and arrive at better glycemic control in a timely fashion, while stably controlled patients would only need to be seen sparingly for health maintenance purposes. Additionally, more nuanced reimbursement models that are now starting to emerge will better incentivize providers to address both brief and complex clinical questions in a timely fashion.

For years, the seemingly impenetrable inertia of health care had blocked any meaningful disruption as far as telemedicine and population health were concerned. However, a silver lining of the COVID-19 pandemic has been the forced system-wide reboot of health care delivery models, simultaneously occurring at every level from the government to institutional health care to providers and to patients. As a result, more progress has been made toward the future of diabetes care in two weeks than had been achieved in the previous two years.