Public comment

[mohe0001]

I think someone is asking for public comment from the community on the topic of A1c.

One of the doctors posted it. I had to look up the acronyms to understand what I am reading.

NCQA = National Committee for Quality Assurance (NCQA) https://www.ncqa.org/

HEDIS = Healthcare Effectiveness Data and Information Set.

I think those private groups provide some sort of accreditation to health plans. They are not governmental.

What do you guys think? Is this something or nothing?

Epic says they will incorporate CGM data into the Electronic Medical Record (EMR) soon, so this might relate to that.

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“ ATTENTION DIABETES ADVOCATES & HEALTHCARE INNOVATORS
For decades, HbA1c has been the “gold standard” for measuring diabetes management. But anyone living with or treating diabetes knows that an A1C is just an average—it doesn’t tell the full story of the daily highs, lows, and the “rollercoaster” in between.

We have a massive opportunity to change the narrative.

The NCQA is currently seeking public comment on new HEDIS measures, and there is a pivotal shift on the table: the integration of Continuous Glucose Monitor (CGM) reporting.

This is our chance to move beyond solely looking at A1C and start prioritizing Time in Range (TIR).

Why this matters:
Real-Time Data: TIR reflects the daily lived experience of person with diabetes.
Better Outcomes: Reducing glycemic variability is key to preventing long-term complications.
Modern Medicine: It’s time our reporting standards catch up to the technology patients are actually using.

We need the voices of clinicians, advocates, and patients to ensure these measures reflect the future of care, not the past.

Read the proposed measures here:https://wpcdn.ncqa.org/www-prod/wp-content/uploads/01.-CGD-E.pdf

I’m curious to hear from my network—is this the breakthrough in quality measurement we’ve been waiting for? What are your thoughts on transitioning the focus from A1C to CGM metrics?“

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The post came from Dr Robert Gabby.

[Eric]

@mohe0001

What are your thoughts on transitioning the focus from A1C to CGM metrics?“

The problem is that they will say 80-180 is “in range”.

So you can hover around 170 for weeks and they will say “100% in range!”

It just depends on how they classify range and if they use any intelligent metrics to analyze it.

[mohe0001]

There are also requests for feedback from CMS (from https://www.patientrightsadvocate.org/)

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“CMS has proposed updates to the Transparency in Coverage rule. Now is the time to weigh in.

CMS acknowledges what patients, employers, and researchers have experienced since 2022: posting massive pricing files alone has not delivered real transparency.

The proposed rule makes important improvements, including standardization and better data structure, and those changes deserve support.

But the proposal does not yet go far enough.

The current timeline delays implementation until 2028. There is no requirement for insurers to attest to the accuracy of their data. Key payment mechanics that determine what is actually paid remain undisclosed. Utilization files lack claim counts needed for meaningful comparison. And prescription drug pricing transparency still has no finalized path forward.

Transparency only works if the data is usable, accountable, and complete.
CMS is accepting public comments now. PatientRightsAdvocate encourages employers, purchasers, patients, and industry stakeholders to submit comments and help strengthen this rule so it delivers real accountability and real price transparency.

Comment deadline: February 23, 2026

Link Here: Regulations.gov “

[ClaudnDaye]

I do agree that A1C really doesn’t mean much…i say that for this reason…the A1C tests only capture data for the past 90-days. Since many of us only visit our Endo one time a year, they are only getting data for the past quarter from that A1C. Dexcom / Clarity app also only track 90-days.

So you could have been living in the 300s for the first 9 month but as long as you show up at that A1C test and the last 90 days have been managed, no way too know about the other 9 months until patient begins experiencing the “opathys” that result from prolonged hyperglycemia.

[Rphil2]

I’ve got two big problems with TIR. First, there’s no clear standard. Someone who’s just been diagnosed might hit 100% TIR without even trying, just because they’re still making some of their own insulin. That phase could last a week, a month, or years—no one really knows. It feels unfair to set people up for failure later on, when that leftover insulin production fades away—if it ever does.

The second thing that bothers me is how TIR can make people with unpredictable blood sugars feel like they’re failing. I’ve lived with diabetes for 52 years. At this point, my body can over react to even tiny doses of insulin or carbs. Most mornings, I wake up with my blood sugar hovering around 160. I’ll hit it with insulin, but before I can bring it down, it’ll spike to 200 or 220. Then, around noon, things finally settle down and I can coast for the rest of the day. On average, I still manage to keep my blood sugar in range about 90% of the time.

But what if things were flipped? What if I could only keep it in range 10% of the time, and the rest was chaos? Would it really be that different? The circumstances would be nearly the same—just biology doing its thing. In one case, people would probably congratulate me, and in the other, I’d get scolded for not having things “under control.” But both outcomes are just natural, and neither one tells the whole story.

[Beacher]

@ClaudnDaye

Dexcom / Clarity app also only track 90-days.

Most doctors/clinics/CDEs, etc., would access your data through the website, not your app, though, and here in Canada, the Clarity dot-eu website tracks data from when you signed up. Is the dot-com site for US users different?

[ClaudnDaye]

Clarity, the website, at least in the US, only tracks 90 days.

There are two different logins possible; however…patient and clinic…perhaps clinic login somehow takes them to “more” data? Perhaps archived / stored? Not sure. But our endo looks at only 90-days worth of data in Clarity (I can see it on their monitor when we’re talking) and/or I show NS reporting.

[Terry]

I agree with the general sentiment here that the A1c can hide poor BG management. TIR is better but glucose variability can obscure the quality of that management. The way to make TIR a better concise indicator for both the patient and the clinician is to squeeze the range from 70-180 mg/dL (3.9-10.0) to 70-140 mg/dL (3.9-7.8). Doing this places an emphasis on keeping glucose variability tame.

I believe that the clinician’s refer to this tighter range as “time in tight range” or TITR. If the person with diabetes can consistently master a high % TITR, they can experience a higher quality of life that this metabolic sanity allows. Keeping glucose variability reasonably low is an under-appreciated metric often missed when the talk is over-focussed on A1c and TIR 70-180.

@ClaudnDaye

Clarity, the website, at least in the US, only tracks 90 days

Up until the last year or so, I drew the same conclusion. Just select Overview>90 days>Compare and you can view 180 days of Dexcom CGM data. It lets you view longer term trends. The most useful Dexcom report, for me, is the 14-day AGP.

[ClaudnDaye]

@Terry

Up until the last year or so, I drew the same conclusion. Just select Overview>90 days>Compare and you can view 180 days of Dexcom CGM data. It lets you view longer term trends. The most useful Dexcom report, for me, is the 14-day AGP.

That’s what I see when I try to exceed 90 days.

[Terry]

90 days is the maximum you may select, but then you can compare the earlier 90-day period to the current 90-day period for a total view of 180 days.

[ClaudnDaye]

Very cool! Learned 2 things today! ty!

[Beacher]

@ClaudnDaye

Clarity, the website, at least in the US, only tracks 90 days.

I wonder why they’d have that cutoff on the US site. Doesn’t seem helpful to the patient. I’ve often gone back in time to look at data or pump settings, as in “My numbers are crazy after dinner the past few weeks, what am I doing different from a year ago or two years ago?” In fact just yesterday I was looking at numbers from 2018, to try to figure out why I’m not doing as well lately. I’d hate it if that wasn’t possible.

[Terry]

@Beacher

In fact just yesterday I was looking at numbers from 2018, to try to figure out why I’m not doing as well lately. I’d hate it if that wasn’t possible.

Your comments caused me to wonder as well. It appears that Clarity works the same in the US as it does where you are located, @Beacher. I just completed a Clarity search that compares a recent 90-day period to 90-days in late 2016.

It revealed to me just how dramatic an effect that DIY Loop has had on my BG management! I started Loop mid-November 2016. Here’s the side by side comparison.

Edited to add: It wasn’t just Loop that accounts for BG management improvements in the last 9.5 years. During that time I experienced a stroke and lived through the social isolation of the pandemic. My overall control in 2017-2019 improved a lot but not to levels that I enjoy today. My 2022 stroke neither degraded nor improved my glucose management. The pandemic had a definite positive and lasting effect starting in early 2020.

I’d give DIY Loop most of the credit for the glycemic improvement during that period but realize that the dietary changes imposed by the pandemic (no restaurant eating) had a substantial effect.

[Rphil2]

One issue with a tighter range is where and what a person is doing. I know, for instance, that if I am biking, I cannot start at 140 and expect to stay above 80. Not even running in exercise mode helps, since my Blood sugar is so volatile. Honestly, the volatility is just scary at my age. (68) That is why increasingly the ADA is suggesting that T1’s over 70 allow A1C’s to float up to 6.5-7.0; it’s a safety thing.

There is just no decent universal measure.

[jbowler]

@mohe0001

Epic says they will incorporate CGM data into the Electronic Medical Record (EMR) soon, so this might relate to that.

The issue with CGM data is that the ongoing FDA investigations into QA with both Dexcom and Abbott have demonstrated beyond a shadow of doubt that the data is flawed.

In this specific context the date is systematically flawed; the G7-10 lot I was using was consistently showing off-by-40mg/dL readings (a very, dangerously, bad non-systematic error) and consistently running high by about 20mg/dL (a systematic error corresponding to about +0.7% HbA1c). My G7-15 has, so far, been a whole lot better but maybe they are doing more quality control.

Over several years comparing eAG values and HbA1c from both lab tests and Walmart’s “Relion” fingerstick HbA1c meter the CGM “HbA1c” (i.e. eAG) runs about 0.4% higher than the HbA1c blood tests. Walmart and the Lab agree pretty closely (maybe the Lab uses the same meter…)

The medical evidence that excursions are health-harmful is not clear, at least that’s what I get from my own examination of recent review papers. The “TIR is better” argument relies on one or both of two assumptions:

1. Low and high BG excursions are debilitating, uncomfortable and depressing. This is true, particular for low but also for high.
2. Low and high BG excursions are damaging for long term health. This is unproved, therefore false. (I like to think of myself as William of Occam with a Broadsword.)

TIR is valuable for us and for informed and non-judgemental docs, but HbA1c really is the platinum standard. I see my endo every three months; if I didn’t I would buy more of the Walmart test kits.

You posted the ncqa.org proposal. That is something completely different from the relative merits of HbA1c and TIR. It has been demonstrated beyond any reasonable doubt that CGM use helps long term control; IRC most of that is in the better HbA1c control. There’s no competition here; CGM is the single best addition to conventional diabetes treatment. That’s not saying it is good for everyone but, across the board (so, on average) it works. The Medicare rules are inappropriate and should be dropped.

What I am saying here is simpler and more general than the proposal; CGM use is appropriate for anyone with a diagnosis of diabetes while the individual continues to be diagnosed with that condition. Use of CGM should only be conditional on the willingness of the patient and the doctor and where doctors feel unable to handle CGM data referral should be recommended.

Use of CGM data cannot replace existing blood test mechanisms; BG fingersticks or HbA1c tests, though it may lessen the desired frequency of BG fingersticks.

[drbbennett]

I’ve been advocating for TIR over A1C for a while. Back when I was seen at Joslin they used to yell at us for anything under 6.5 or so because it meant you were having too many lows. But that was before widespread CGM use, which can be checked to make sure you’re not getting there by crashing into the basement all the time. But that raises another issue. TIR I is totally dependent on CGM technology, which is not everyone. The Google says CGM use among T1s has gone way up just over the last few years, something like 85%. But it is more prevalent in some demographics than others, highest among non-hispanic whites, less among other groups, higher for people with private insurance, etc etc. And not all CGMs are created equal. And as others have pointed out, TIR doesn’t say what that range actually is. You can be 100% in range with an absolute crap A1C in the 10s if you set your range wide enough. I think there’s still a case for keeping it around. Having multiple measures for assessing control seems like a good thing.

[TomH]

@drbbennett is correct about the importance of knowing what TIR range means. Most devices/apps I’m aware of come set with a default TIR of 70-180, but most, if not all, of can be changed by the user. So, unless the range is stipulated in any conversations held (user with Endo, PCP, or just a friend) there may be misunderstanding of what TIR means, it could lead to incorrect/bad doctors note or understanding of person’s actual result. TITR (Time in Tight Range) also has become a popular term of reference, but is subject to the same issue. TITR in most devices I’m familiar defaults to 70-140, but it may also be user modified so it also needs to be specified in conversations or the term will mis-understood by whoever hears or reads the data. I don’t question that people should have the ability to modify the ranges, TIR or TITR, but we/they also need to understand the importance of ensuring what they mean in conversations held or written about.

[Terry]

I agree with you that a tighter range, across the board, can’t be applied everyone. A personal glucose target is an individual thing since we all are subject to many physical, social, and psychological factors. We all walk a daunting tightrope.

I’ve found that the single factor that has enable me to live safely in a tighter and lower BG range has been the lowering of my glycemic variability.

In my comparison of my 2016 data versus 2026 data, the Coefficient of Variation (variability) drastically fell to a normal level. Absent lowering variability, the safe lowering of average glucose is unlikely. I still must remain vigilant and I’m grateful for technical advances, especially CGM and automated insulin dosing systems.

With all that being said, I believe there is always still room for individual glycemic improvement if the person decides to move in that direction. Safely, of course.

[CarlosLuis]

@Terry

With all that being said, I believe there is always still room for individual glycemic improvement if the person decides to move in that direction. Safely, of course.

I am lucky that my Endo (2nd generation endo) pays attention to much more than HbA1c and fBG. He looks at all the metrics on AGP. He alson is paying attention to my kidney health, lipids and thyroid.