Insurance: Always Thinking Short Term

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Insurance and Diabetes

Updated February 5, 2016

A few months ago, I was thinking of switching to the pump. Since then I have tweaked my daily injection regimen and gotten myself back into very good A1C territory, and will be sticking with it (no pun intended), at least for the time being. However, I have also been looking into the feasibility and practicality of continuous glucose monitoring (CGM), as my sensitivity to lows is not at all what it once was. This, coupled with a few miscalculations for late-night food, has led to a few scary mornings for my wife, who has had to pour juice down my throat to make sure I revive. Very scary, indeed, and more than reason enough to investigate my options.

A quick Google search has shown that CGM has evolved somewhat since it first came on the scene about ten years ago. It’s still not as accurate as a fingerstick, and is intended as something to use in addition to traditional glucose monitoring, not a replacement. And of course, because it is measuring interstitial fluid and not capillary blood, the results tend to lag a bit behind the true glucose levels in the blood by about 5–10 minutes. However, the accuracy has improved, and the technology is more reliable, and so it is becoming a much more valuable potential tool for daily treatment decisions. My current endocrinologist is on board with it and suggested I look into it.

But, as always, insurance lags behind. I wrote an entire blog entry dedicated to the fact that insurance companies almost all classify pump supplies as “durable medical equipment” (DME) instead of “diabetic supplies.” What’s the trouble with that? Well, “diabetic supplies” are covered as prescriptions, meaning they are not susceptible to large deductibles every year, and you, the patient, need only worry about a relatively small co-pay. DME, however, is different. Every year, you have to pay 100% out of pocket until the deductible amount is met (in my case, about $2,000), and after that, most of us are lucky if the insurance company shells out 50% of the rest of cost.

It is no wonder, then, that so few people are on the pump! There are probably countless people out there who would be on pump therapy, but simply cannot afford the extra $4,000 a year it would cost. Now, I’ve always preferred insulin through daily injections, and aside from the hypoglycemic insensitivity (which would be present regardless of how I’m delivering my insulin), I’ve been able to tweak my insulin regimen so that I’m in much better range again. So I don’t count myself 100% in that camp, but I can’t say that the sheer cost didn’t give me an extra nudge in the direction of continuing with daily injections.

And as you might have guessed, CGM technology is treated largely the same way. In fact, Medicare won’t cover CGM at all! The JDRF is currently trying to pass a bill in Congress that would require Medicare to cover GCM treatment. And just as with pump therapy, almost every study on the issue has shown that A1C levels go down, control goes up, and therefore long-term costs go way down with this technology. And yet, insurance continues to do what insurance always seems to do. They choose the short-term savings of denying coverage for new technology.

Now, there must be an actuarial table somewhere that shows this shortsighted approach is, in fact, the best fiscal option for insurance companies. Perhaps the numbers suggest that by the time most people belonging to any particular insurance plan are facing complications brought on by the poorer control achieved without the use of the latest treatment options, they will no longer be on that particular plan. Sure, the cost of caring for those complications will be massive, but it won’t be that insurance company’s problem anymore.

I think this gets right to the heart of the problem with how we handle health-care access (and really, how we handle almost any big issue). We tend to treat it like a hot potato, just trying to get rid of the inconvenience quickly and letting someone else deal with the fallout. Deny coverage for the people currently on the insurance rolls, and let someone else deal with the long-term impacts that approach will undoubtedly have on them.

Ultimately, you can’t even really blame the companies for making these decisions. They’re part of a money-driven system, and they have to stay competitive. There really is no incentive for them to invest the money now in the treatments that will save money later. And that, more than anything, is why I deem our health-care system to be truly broken. When insurance tries to avoid providing people with a serious chronic condition access to the most recent (and clinically-proven best) treatment options, that’s a broken system.

In spite of all of this, I will pursue the CGM. If we have to pay out of pocket, my wife and will find a way. We may have to cut back elsewhere make it happen, but we’ll figure out a way. But that shouldn’t be the choice. It shouldn’t be the choice for any of us. We deserve a system that pushes us toward the best treatment, not the cheapest. We deserve a system that pushes us toward long-term health of the patient, not the short-term financial gain of the insurance companies. We deserve better than this.

Are you dealing with painful calf cramps from peripheral arterial disease? Bookmark and tune in tomorrow to hear about new research that may help.

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