Thoughts on Patient Empowerment

Laddie_Head SquareI recently read two articles by Dr. Niran S. Al-Agba, a pediatrician in Washington State and blogger at MommyDoc. I discovered her posts through and have added her blog to my Feedly list. As a grandmother with 40 years of Type 1 diabetes, you might wonder why I plan to follow the writings of this young pediatrician. I think it is because her thoughtful views on the roles of patients and physicians in our healthcare system (or lack thereof?) give voice to some of my opinions and experiences.

The first article I read was titled “Building Better Metrics: Focus on Patient Empowerment.” Mid-article Dr. Al-Agba writes something that many of us who use insulin believe is essential: “Patient-centered care is often talked about as a virtue worthwhile to attain because it puts them at the heart of their healthcare team. Empowerment goes one step further by actually giving power and authority to the patient.”

She goes on to share the characteristics of an “empowered activated patient” as listed by ENOPE (European Network on Patient Empowerment):

  • Understands their health condition and its effect on their body.
  • Feels able to participate in decision-making with their healthcare professionals.
  • Feels able to make informed choices about treatment.
  • Understands the need to make necessary changes to their lifestyle for managing their condition.
  • Is able to challenge and ask questions of the healthcare professionals providing their care.
  • Takes responsibility for their health and actively seeks care only when necessary.
  • Actively seeks out, evaluates and makes use of information.

I don’t know about you, but I believe this list describes me and many of us living with diabetes. At least most of the time.

The second article by Dr. Al-Agba is titled “Building Better Metrics: Patient Satisfaction Can Be Done Right!” Building on the first article, she writes that physicians are often more comfortable with “standards of care” and need to become more comfortable in the role of giving information, sharing options, and empowering patients to take more control. She goes on to discuss that sometimes that means disagreeing with a patient’s decision while respecting the right of the patient to make that decision.

That idea really hit home for me based on a recent experience with a new physician. My longtime internist retired this summer and suggested that I follow one of his younger partners to a nearby clinic that is part of a large provider system. Until now all of my doctors have been part of independent clinics. Such practices are starting to be an anomaly in big cities and I was not opposed to moving into a “system.” I knew that it wasdoctor-patient-respect probably a good idea to narrow my network of doctors as I look to future health insurance and Medicare restrictions.

In August I had my annual physical with the new internist. He asked several questions and for the most part seemed to accept my answers. Many queries seemed to be coming from a computer-generated checklist which I suspect was labeled “Old Lady with Diabetes.” I had to fight the urge to say “Hey, that’s not me!”–because of course that is me. Our only area of conflict was over statins which I have resisted up until now. In May I wrote about my previous doctor’s support for my decision to avoid that class of drugs. I felt a bit bullied by the new doctor but given that it was his first week in the new system, our first meeting, and already an overly long appointment, I decided to let it go. And I agreed to give statins a try.

Two months later I am experiencing clear side effects from the statin drug and have chosen to stop taking it. One thing that I love about my new medical system is a complete online health record along with the ability to send secure messages to my health team. I was able to share my statin decision without talking to anyone or feeling that I was hiding something from the new medical team. I wrote several drafts of the email and believe that I ended up with a respectful but confident and empowered message.

I did not get a reply to the message nor did I expect one. I am sure that it will be a item of discussion next time I see this doctor. I am very comfortable with the idea that he can strongly disagree with my decision. However, I need to feel that he respects my right to make that decision. If not, I will look for a new internist. However, based on most of the August appointment, I am optimistic that as we get to know each other, we will do just fine. Fingers crossed.

Back to the Future:  Dexcom G4 Share and Apple Watch

Laddie_Head SquareIn the last 10 days, my diabetes technology world has changed. On one hand I have reverted to an older tech platform. On the other hand I have zoomed into the future with a modern and cool-for-a-64-year-old-woman device.

Stepping Back:  After getting my free(!) upgrade to the Dexcom G5 last fall, I was lucky to be left with an unused G4 transmitter. I didn’t start using the G5 until March when my previous G4 transmitter passed its 1-year anniversary. It was still working fine, but I abandoned it to transition to the G5 platform. A bit wasteful, but gee whiz, that transmitter was never going to die! I used two G5 transmitters and for the most part was happy with G5.

That unused G4 transmitter did not disappear and kept sending “Use Me! Use Me!” messages to my brain inbox. If I were not moving to Medicare and no CGM coverage in 6 months, I probably would have used my “privileged diabetes patient” status to stay with G5 and give the unused G4 transmitter to a  needy DOC friend.

Last weekend my second G5 transmitter timed out and I bit the bullet to go back to G4. My CGM warranty expired in early September and I was able to order a new G4 Share receiver. Although it had only been 6+ months since I had last used Share, I panicked as it seemed totally foreign to me. Also because I am using the mySugr logbook, I needed to be sure that my CGM information would continue to sync to the app. Miraculously I figured everything out and it is working correctly.

Onward to the Future:  Earlier this fall I decided that I would use my #firstworldprivilege to order an Apple Watch so that I could see my current blood sugar just by raising my wrist. Please remember that I started my diabetes career in the days of urine testing and things like this are magical to me.d-tech-privilege-circle

My Apple Watch 2 arrived last week. I have not worn a wristwatch in 12+ years since I got my first insulin pump, aka pocket watch. It wasn’t terribly difficult to add the Share app to the watch and it works okay. Unfortunately it cannot be used as a watch face “complication” like the G5 app. There is another app called “Watch Sugar” that allows me to add the Dexcom number to my watch face, but it is so time-delayed that I don’t find it helpful.

Basically I leave the Dexcom Share app open on the watch all of the time and it is usually what I see first when I raise my wrist. When Share is not the wake-up screen, it is easy to find the app in the dashboard and restore it. My difficulty with this whole set-up is that occasionally it just doesn’t work. If I am using other Bluetooth devices such as headphones or a speaker, I think the phone gets confused and occasionally loses the signal from the Dexcom receiver. There are also user-error problems such as leaving the receiver upstairs or closing out the Share app on my phone.

Clash of the Past and Future:  The bad part about these D-tech changes is that now I have two more devices to carry, coordinate, and charge than I did two weeks ago. The G4 requires a receiver and of course the watch is added. The blood glucose number that I see on my wrist starts with the transmitter beaming info to the receiver which communicates with the phone that sends it to the watch. There is definitely some mental fatigue and data overload with this set-up. At the same time I love not having to reach into my pocket to retrieve Dexcom data.

Life is good. It might would be nice if I didn’t diabetes but that horse left the barn a long time ago. So today I give thanks for access to technology that make my life with diabetes a little bit easier and a lot more interesting. 😀

Countdown to Medicare with Type 1 Diabetes: 6 Months / The Journey

Laddie_Head SquareI occasionally have readers who contact me by email rather than leave comments on my blogposts. Kathy K from New York is one of those readers. She and I have an amazingly number of things in common. She was diagnosed with Type 1 diabetes in 1974 at age 23 after recently graduating from school and getting married. I was diagnosed in 1976 at age 24 after recently graduating from school and getting married. She has 2 children and 5 grandchildren. I have 2 children and 5 grandchildren. Do you see a pattern here?

Kathy is a few steps ahead of me in the Medicare process. Today she has written about some of her experiences as a newcomer to Medicare. There is no doubt that she knows “diabetes.” In addition to living with Type 1, she is a retired RN and BSN Certified Diabetes Educator.

Welcome, Kathy K from New York, and I hope that this is the first of many guest posts!


The Journey that is Medicare

kathy-krieg-headshotThank goodness that I found Laddie. I was fuming with frustration trying to get my first prescriptions, pump supplies and strips through Medicare. Even though Laddie is not quite there yet, her blog regarding her journey toward Medicare eligibility sounded exactly like mine.

The  psychological profile of most persons with Type 1 diabetes who use an insulin pump probably include such traits as independence, controlling, problem solving and motivated. (well maybe that’s just me!) I have lived with Type 1 diabetes for 42 years and thankfully had excellent health insurance and a wonderful physician willing to let me “run the show”

What a shock to realize that Medicare regulations takes all that away. You all know how we make sure we have enough pump supplies on hand, strips to cover frequent testing and insulin. I am here to tell you to be sure to have enough on hand to withstand ins and outs of new insurance rules.

Some of the biggies are Medicare does not cover CGM. Only 100 test strips are allowed if you take insulin and calculating your individual costs for medications is an accounting nightmare! But wait, there’s more to share. Do not take any of those restrictions at face value. My motto “Never take NO for an answer.” As many people that you call looking for help, that’s as many different answers you can get for the very same question.

Here is what I found out along my journey.  I am now knee deep in the muddy waters of Medicare coverage. Medicare has been approving some CGMs. A very specific appeal process needs to be followed but even courts have directed Medicare to approve of these devices. With that said, contact your supplier for help. They will probably offer you a decreased price for persons who have to pay out of pocket. My experience with Medtroniccountdown-to-medicare-6-months is that before you order supplies, you have to sign a disclaimer that states:  1) bill Medicare the full price and you will proceed with the appeals process to get the bill for $473.00 for a box of 5 sensors. If the appeal fails, you are responsible for the entire amount. Or 2) I want the sensors but will pay a decreased price up front now and cannot then bill Medicare and go through the appeals process. This price is about 45% off or approximately $260.

Another fact to keep in mind for those on an insulin pump, the insulin used in the infusion device is covered under Part B of your Medicare health insurance. Do not back down on this one. Find a pharmacy that has experience billing this way and use them. For me that was Walgreens. My Walmart pharmacist looked at me like I had two heads when when I was trying to explain this. I have a Medicare supplement policy that picks up all costs that are not paid by Medicare. So my cost $0!! Yep, that’s right—$0 for my Humalog insulin. My infusion sets and reservoirs are also covered under this same policy. That is one of my biggest successes in this journey. A new order for pump supplies, for me reservoirs and infusion sets, cannot be started until you only have 5 sets left!!! or 81 days from the previous order.

Another change I encountered is that I can no longer get my test strips from the pump company. There is a bidding process for providers in some areas and whomever Medicare chooses as the winner of the bid is the type of strips and the place where you need get them. Additionally, you will only be allowed 100 strips per month. Not nearly enough for me and probably you too! Once again Medicare also known as CMS, has a process for appeal. You need to supply a log of your tests and a physician note documenting the need. I have yet to submit for strips. I am not due to reorder yet.

Lastly, at least for now, is drug coverage. This is the biggest stumbling block for me. I tried the mail order supplier the insurance company suggested. I am quite dissatisfied with this company and that is another long story. I am finding it difficult to follow how much each of my medications cost and how far down the line to the donut hole I am. Hopefully, that’s a learning curve I will master soon.

DISCLAIMER:  Please do your own research into your specific state and insurance companies regulations. This is just my experience in the journey that is Medicare.

ONE MORE THING:  I have an additional psychological trait. I am so stubborn with a 2 year-old’s “ME DO IT!” attitude. Hummmm… A 2 year-old battles Medicare! Stay tuned.

Congrats to Medtronic!

Laddie_Head SquareUnless you are living in an underground bunker, you know that Medtronic Diabetes announced yesterday that the MiniMed 670G hybrid closed loop system has been approved by the FDA with anticipated shipping in the spring of 2017. Here’s a link to the press release if you haven’t read it yet.

Am I excited about this? Absolutely yes!!! Will I purchase it? Absolutely not!!!

You may think that I won’t purchase this because I am currently a Dexcom and Animas user. You may think that I won’t purchase this because I’m mad about the United Healthcare/Medtronic agreement. You may think that I won’t purchase this because “The Cure” will be here in five years. No, those are not the reasons. What is preventing me from pursuing this device is my next pump and CGM is ⚡️⚡️⚡️⚡️

Those lightening bolts are supposed to grab your attention and make you sit on the edge of your seat as I explain my predicament.

My issue is that I am going on Medicare in April 2017 after having my current pump go out of warranty in December 2016. I long ago satisfied my deductible for 2016 and if I purchase a pump before the end of the year, it will be at no cost. The individual health insurance market in Minnesota is in chaos and I plan to purchase the cheapest insurance plan possible for January through March 2017. It will be expensive despite a high deductible. No way can I purchase a new pump in that time frame.

So my choice is to purchase a pump in early December or enter 2017 with an out-of-110089warranty pump and wait until Medicare. A naive advisor might suggest that I buy the Medtronic 630G in December knowing that those buyers will be the first in line for the 670G pump when it is released in the spring. But guess what! Once you get on Medicare, it is against Medicare law for beneficiaries to participate in upgrade programs. So if I purchase a 630G, that will be my pump for the next 4-5 years because I will not be allowed to upgrade to the 670G.

A Medtronic representative told me on Saturday that the 630G is now being reimbursed by Medicare. The sensors are not Medicare-eligible, but at least the pump is covered. If I wait hoping to purchase a 670G after April 1, the most likely possibility is that it will not be covered by Medicare for quite a while. Hopefully I am wrong on that.

I am excited that the FDA has approved the MiniMed 670G. Medtronic is not calling it an  artificial pancreas, but it is an important step on the journey to complete insulin automation. That is good for all of us excited about the future of diabetes technology.

But for me, it is not in the game. My reimbursement scenarios just don’t fit the timing of this release. Anyone who reads my blog regularly knows that I currently use Dexcom after several unhappy years with Medtronic SofSensors. The Guardian Sensor 3 that is part of the 670G is many generations removed from that nightmare and I would be open to trying them. But it would be too big a leap of faith to move back to Medtronic without a trial run. Maybe that will be possible in the future when hopefully, hopefully, hopefully CGM/pump systems will be reimbursable under Medicare.

Today my options are too tangled and uncertain to make the MiniMed 670G part of my plans. But I will still camp out in the grandstands with other diabetes advocates yelling “Congrats!” to Medtronic. We live in a golden age of diabetes tech. Unfortunately we also live in a stone age of diabetes reimbursement for those of us who are approaching age 65 and older.

Moosh and Monsters:  A Journal about mySugr

Laddie_Head SquareI am currently one of the beta-testers for the coaching module which has just been added to the mySugr Diabetes Logbook app. You may have seen a recent announcement about this feature which will allow users to receive virtual coaching from Gary Scheiner and other CDE’s of Integrated Diabetes Services. To learn about the program, check out “mySugr Coaching – your shortcut to great diabetes management” by Scott Johnson, the USA Communications Lead for mySugr. Another good source of information is this Diabetes Mine article by Mike Hoskins titled “A New Age of Mobile Diabetes Education and Coaching.”

I have been using the mySugr Diabetes Logbook full-time for two months. To best describe the experience, I am sharing my journal of insights, problems, and opinions. Please note that I am in the early stages of the coaching experience and will share that story in another blogpost.


Thursday 7/21/16:  I saw Scott Johnson at an ADA seminar today. He asked if I would like some personal consulting sessions with Gary Scheiner of Integrated Diabetes Services. I have several times been a phone call away from calling IDS for help, but have never done it. So of course I said yes. According to Scott, the details of the project are still a little sketchy but will involve using the mySugr Logbook app to communicate virtually.

I like mySugr and have always thought that it is by far the best of the diabetes logging apps. But I have never been a faithful user. Too much data entry has always sidelined me after a week or two.

Friday, 7/22/16:  I began using mySugr again. I have to admit that it has been a year since I last used it and it is much more functional than before. My Dexcom CGM data ismy-monster automatically synced to the app through Apple Health. Most of the data entry is easy with icons and the ability to customize, rearrange, and delete line items. My personal monster whom I named Glukomutant is cute.

Friday 7/29:  I am a week into logging and a day into using the Accu-Chek Connect meter provided to me by mySugr. The meter automatically sends BG numbers to my phone and the mySugr app.

The Connect meter makes mySugr infinitely easier to use because it is one more piece of data that I don’t have to type in. The hardest part of having my phone be a medical device is that I am using my sometimes-bad memory to coordinate data from the Dexcom app, the mySugr app, my pump, my meters, and my life. Scott showed me a couple of shortcuts and let me know what info he enters and what he ignores. He indicated that the app will “moosh” all data entered within 10 minutes into one entry. “Moosh” is Scott-lingo for “fetch and combine.” For example, I test my BG and enter a correction bolus. A few minutes later I decide I to eat and enter my food, carb count, and a couple of tags. It will “moosh” it all together into one log to prevent an unwieldy number of entries in the logbook.

Right now I keep forgetting bolus details the second the pump delivers the insulin and I have to go to the pump history menu to get the info. I’m sure that I will get better at remembering numbers and not get so tangled up creating an entry. Long term mySugr hopes to automate all data sources so that there is very little manual data entry.

Tuesday, August 2:  Today I started a new Dexcom sensor. For the 2 start-up calibrations, I got the following numbers from the Accu-Chek Connect meter: 85 / 108. I did a 3rd test to get a better sense and got 78. This is why I use Freestyle meters. I will try to stick with the Accu-Chek meter for my trial and I did order a bunch of test strips. Out of curiosity I tested on my Freestyle Lite meter. I got 84 / 87. For consistency I used the Accu-chek to calibrate my CGM which interpreted the two tests as 96. Since Freestyle is often considered to test on the low side, the numbers aren’t too horribly different.

Saturday, August 6:  The mySugr app allows basal changes by the hour or half-hour. When using half-hour, I would prefer that the basal rate still show the hourly rate because I have never thought of basal rates in half-hour segments although I often change rates on the half-hour. Does that make sense?

logbook-en-homescreenSaturday, August 6:  I am used to reviewing my CGM tracings and feel as though I get a good overview of the “forest.” With mySugr I feel as though I am down in the trees with a lot of emphasis on average and deviation, both of which are highly affected by a single number. I think that once I have more weeks of data, the summary reports will be more helpful.

Saturday, August 6:  Once again not thrilled with meter. CGM 145, Accu-Chek 118, Freestyle 138. Most of the time the meter is fine and aligns very well with my Freestyle. It syncs amazingly fast to my phone.

Sunday, Aug 7:  Would like an icon for combo/extended bolus and maybe a way to log it besides using notes.

Although the ability to take photos of food is nice, I rarely do it. One of the most useful features is Search. Since I live in a rut and often eat the same foods every day, I can search by things such as “Lunch” and “Salad” and compare how I have bolused for similar meals in the past.

Thursday August 11:  Love how the app learns words I use. For example: CGM, Oatmeal, Walking.

Wish pump bolus info was synced. I do everything on my pump and then enter it again on app. I have accessed my pump history more times in the last month than the previous four years. Wish I remembered it better.

Would like an icon for CGM calibration.

Sunday, August 14:  I learn something new every day. When scrolling down BG numbers, I see that the ones from the Accu-Chek meter are marked with a “Verified” symbol while manual entry ones aren’t.

Saturday, August 20:  I am definitely in the habit of logging, but am hitting the wall of data fatigue. It is quite horrible to see how many “interactions” I have with diabetes every day.

Wednesday Aug 24:  Noticed that my step count from Apple Health is now included in the mySugr daily summary. I love data that I don’t have to enter!

Sunday, Aug 28:  I need to learn more about the reports and graph. Would like to see the graph in landscape view.

Wednesday, Sept 7:  When I activated the consulting module, I filled out everything. Then when I went to settings to activate the camera for a selfie, everything was lost. The perils of being a beta-tester. 🙁

Monday, Sept 12:  Learned that I can swipe an entry to the right to see a menu of Share-Edit-Delete (I had been selecting the entry and pressing the Edit button). This is so much faster. Scott probably showed me this and I forgot. #OldAge. 😀

Saturday, September 17:  My consulting request has been submitted and I am waiting to hear back from Gary. I usually think that my numbers are erratic and unexplainable. However mySugr reports show that my 7-day, 14-day, and 30-day summaries are eerily consistent. I am nervous about having someone review my data.

To be continued…. 


Fitbit Fun

Laddie_Head SquareIn the spring of 2015 I wrote a couple of blogposts (here and here) about how much I enjoy using a Fitbit and how I find it to be a motivating addition to my diabetes toolbox. A year and a half later I am still using my Fitbit and participating in a regular challenge with members of the diabetes community. (Thanks to Sue R who invites me every week!)

Although I am a self-motivated Fitbit user and would tackle my daily step goal without DOC competition, I still enjoy the motivation resulting my daily interactions with other D-people. Recent thoughts include:

I have a good chance of beating Kerri of Six Until Me in a challenge for the first time ever because she had a baby by C-section two weeks ago. I wouldn’t be so stupid as to place a bet on my results once that “little tomato” “biscuit” “fourth chair” is a month old….

My trick of attaching my Fitbit One to my pump tubing is gaining traction as I recently witnessed Scott Johnson borrow an old-style Fitbit (Zip and One, unlike the more recent bracelet models) so that he could clip it to his pump tubing to track his steps on the basketball court.

David E has moved from being an “also-ran” to an unbeatable champion almost every week. I’m not sure that he is more active these days. I think that he is just becoming better at syncing his Fitbit so that his steps count.

Just so your know!  On Monday Fitbit added a new do-it-yourself challenge called “Adventures.” If you click on “Challenges” from your phone/tablet Fitbit home screen, you’ll see a section called Adventures. This allows you to select a daily or multi-day hike to challenge yourself and receive the rewards of 180º photos at landmarks along the trail. Today I selected the Vernal Falls hike which requires 15,000 steps. (The options that show up in your adventures are based on your average steps.) Although my daily goal is 10,000 steps, my average is closer to 15,000 and that is why all of my adventure options require a lot of steps. As I type this blogpost, I am 331 steps short of my goal and I will walk around the house this evening to make sure I reach my destination.


Because I am a hiker, I enjoy the idea of “Adventures” and it is something different from my normal goals. If you need motivation to pull your Fitbit out of the junk drawer, check out Adventures on the Fitbit website and see if it interests you. If nothing else, you can download some new wallpapers from the Yosemite Adventure as seen below:


See you out on the Fitbit trail!

Countdown to Medicare with Type 1 Diabetes: 7 Months / Ducks in a Row

Laddie_Head SquareI went to court last month. Was I nabbed by the diabetes police? Nope. How about the regular police? Not them either. Was I dragged into the legal system for breaking the rules by dosing insulin off my CGM? Nothing like that. So what was I doing?

I was getting my ducks in a row.

What does that have to do with Social Security and Medicare? The answer to that is a lot.

As you approach your initial sign-up date for retirement benefits under Social Security, you need to be sure that you have the required documentation for your claim. According to the Social Security Administration (SSA) website, in most circumstances you will need the following documents:

•your Social Security card (or a record of your number);

•your original birth certificate or other proof of birth (You may also submit a copy of your birth certificate certified by the issuing agency);

•proof of U.S. citizenship or lawful alien status if you were not born in the U.S. [More Info];

•a copy of your U.S. military service paper(s) (e.g., DD-214 – Certificate of Release or Discharge from Active Duty) if you had military service before 1968; and

•a copy of your W-2 form(s) and/or self-employment tax return for last year.

My advice is to consider this list at least 3 months before signing up for Social Security so Countdown to Medicare 7 Monthsthat you will have time to obtain any missing documents. Although I had a copy of my birth certificate, I chose to get a certified copy just to be safe. It took about 3 weeks to get the official document from the vital records department of my birth state.

Fortunately if you have any gaps in documentation, you can and should sign up for Social Security on time. From the Social Security Administration (SSA) website:

“Even if you don’t have all the documents you need, don’t delay signing up for Social Security. You can submit any documents you do have. You can provide the missing documents later or we may be able to help you get them.

In many cases, your local Social Security office can contact your state Bureau of Vital Statistics and verify your information online at no cost to you. If we can’t verify your information online, we can still help you get the information you need.

If you delay signing up, you could lose some benefits you may be due.”

So why did I have to go to court?

I had to get a court order for an official name change. Since 1976 I have had a discrepancy between the middle name on my driver’s license and the middle name on my Social Security card. When I got married I chose to keep my maiden name as my middle name and abandoned my previous middle name. Or so I thought. I went to Social Security and had a card issued in my new name. When we moved to Minnesota, the DMV required me to use the old middle name on my driver’s license. I don’t remember how my passport was handled, but it has always matched my driver’s license. So my two main forms of ID for the last forty years have not matched my tax information, bank accounts, and everything else that we own.

I should have fixed this discrepancy years ago, but it amazingly has never been a problem. Thinking of approaching Social Security and handling our assets in our senior years, I finally determined that it was time to resolve the issue.

Changing your name is not difficult. I didn’t need to use an attorney, but did so because a good friend was willing to help me. I filled out a lot of paperwork, seemingly the same thing over and over again. I signed a form allowing for a criminal background check by the FBI. I completed another form for a background check by the MN BCA (Bureau of Criminal Apprehension). More than once I signed that I was not changing my name for fraudulent reasons or to hide assets. On my scheduled court date, I went before a judge with two witnesses and received an official court order for a name change.

With the certified copy of my court order, I have applied for a new driver’s license and will apply for a new passport once the DL arrives.

It is possible that my name discrepancy might not have been noticed with my Social Security application. However in our increasingly ID-conscious society, it seemed to be an unnecessary risk to be a citizen with two aliases. Two aliases sounds so criminal compared to two middle names….

I don’t know everything about Social Security and Medicare yet, but at least I have my ducks in a row. Most of you won’t have to go to court to get ready for Medicare. However, you may have other things that should be taken care of as you enter this new stage of your life.

Now is as good a time as any to get your ducks in a row.

Ducks in a Row

The Last D-Tech

Laddie_Head SquareThe last CGM.

The last pump.

The last D-tech before going on Medicare.

In early September I will purchase my last CGM system before going on Medicare in the spring. That will be followed by my final pump selection in early December. Rather than view these decisions with my usual excitement, I sit here with a stomachache of dread, frustration, and uncertainty. I tend to be naive and think that there is a “correct” decision when it comes to things like this, but there is enough going on in both the reimbursement and technology landscapes that I am faced with a lot of doubt.

First the CGM. It will be Dexcom for sure, but I am torn between staying with the G5 or going back to G4 platform. Although Dexcom is primarily marketing the G5, I use an Animas Vibe and have the option of staying with the G4 for the foreseeable future. (Please ignore the fact that I rarely use my pump as the CGM receiver. Click here for an explanation.) Currently Medicare does not cover continuous glucose monitoring for seniors with Type 1 diabetes. Many individuals and organizations are working hard for a policy change, but I am discouraged and convinced that I will have to self-fund my CGM starting at age 65.

Dexcom has made and continues to make decisions that make self-funding a CGM increasingly expensive. Looking at transmitters, G4 transmitters had a 6-month warranty but many of us experienced a much longer life than that. My most recent G4 transmitter lasted a year. G5 transmitters place a higher demand on batteries, but also have a software-mandated drop-dead date of about 100 days. Thus for someone who self-pays, transmitter costs have almost doubled from G4 to G5.

As yet no changes have been made that impact the cost of sensors. Unfortunately as reported at Diabetes Mine last week, the Dexcom CEO brought up the idea of Sensor Auto Shut-off during the latest quarterly earnings call. This was presented as a safety consideration and my initial snarky response was tweeted by Diabetes Hands Foundation: “So we can kill ourselves on Day 1 of a sensor when Dex is at its most inaccurate, but not on Day 11″ @MNAZLaddie.” In Dexcom’s defense, no one can ignore the financial repercussions to Dexcom of customers using sensors for 2-3 times as long as warrantied.spiral with words_2016

I currently use most of my sensors for about 2-1/2 weeks. I have full insurance coverage for sensors, but experience better accuracy the second week than the first. I often finally change out a sensor for scheduling reasons or because it falls off despite SkinTac and additional tape. Very rarely is it because of performance problems. I doubt that there will be sensor auto shut-off until the G6, but it is another change that will greatly impact those who self-pay.

I think it makes sense for me to return to G4 for now, especially since I can use the Share feature to see data on my phone. Going back to carrying a receiver won’t bother me much, especially because I like the alarm profiles of the receiver much better than my phone. I am also tired of keeping my phone with me all of the time.

The CGM decision is tangled in my thoughts about a new pump. I am not in love with the Vibe and it doesn’t make sense to buy another one. Tandem is close to retiring the t:slim G4 and I know that if I go with Tandem, I would prefer to buy the t:slim X2 to be released in the fall. The last time I selected a pump for CGM reasons was the Ping in 2012 and it wasn’t a good choice for me. I’ll be writing more about pump musings in the fall, but as with previous pump decisions, it will be complicated by insurance considerations and the uncertain release date of new technology. Medicare rules will also come into play.

One undiscussed topic in today’s post is: If the cost of using a Dexcom continues to spiral upwards and there is no Medicare coverage, at what point will I choose to live without a CGM? Going back to the second paragraph of this blogpost, that is the sort of decision that fills me with “dread, frustration, and uncertainty.”

And fear.


I sometimes conclude technology posts with the admission that my concerns are a #firstworldproblem. I am a privileged patient when it comes to diabetes and I am grateful.

Countdown to Medicare with Type 1 Diabetes: 8 Months / Drugs and Donuts

Laddie_Head SquareWhen you start investigating Medicare plans, it is easy to get overwhelmed with letters and options. Parts A, B, C, and D are well-known, but depending on where you live, you may find Parts F, G, K, L, M, and N.

In this blogpost I plan to be simple and just talk about Part D Medicare prescription drug coverage. That’s a joke because there is nothing simple about Part D.

Let’s start with a few straightforward facts:

  • Part D is regulated by Medicare but all drug plans are administered by private companies.
  • Part D plans provide coverage for generic and name-brand drugs. All plans must Countdown to Medicare 8 Monthsprovide at least a Medicare-approved level of coverage, but can vary by specific drugs covered, rates, and pharmacy networks.
  • In order to purchase a Part D plan, you must be eligible for Medicare Part A and/or enrolled in Part B. You must also live in the plan’s service area.
  • You may purchase Part D as part of a Cost/Advantage plan or as a stand-alone Part D plan.
  • Part D coverage is not required. However, if you do not purchase it when you are first eligible, you may be subject to penalties and higher premiums when you do. Those penalties will continue for as long as you participate in Part D. Like for the rest of your life.

The most complicated part of standard Medicare drug coverage is understanding the four cost stages, particularly the coverage gap or donut hole.

The first stage is the Deductible Stage where you pay 100% of your prescription drug costs. The maximum deductible allowed by Medicare in 2016 is $360. Some plans have lower deductibles.

Once you satisfy your deductible (doesn’t take long if you have diabetes!), you enter the Initial Coverage Stage. In this “cost sharing” phase you pay either a copay or a percentage copayment depending on your drug plan. In 2016 this stage continues until the payments by you and your plan combined total $3310. For example, you buy 4 vials of Lantus with a total contracted price of $1000. You have a coinsurance plan where you pay 25% or $250 and the plan pays 75% or $750. The entire $1000, not just your out-of-pocket cost, counts towards the $3310 amount to put you into the Coverage Gap or Donut Hole.

If you use insulin, you can see how quickly you will enter the donut hole where the out-of-pocket drug costs increase significantly. In 2016 under a standard Medicare Part D plan, you can expect to pay 45% of the cost of covered name-brand drugs and 58% of the cost of generics once you reach the coverage gap. I could write a book trying to explain the donut hole, but here are a few things to put it in context.

The donut hole terminology came from the Medicare Modernization Act of 2003 (MMA) in which prescription drug coverage became available to all Medicare beneficiaries. If you are interested in the history of this law, check out this publication by Jonathan Blum who was a professional staff member to the Senate Finance Committee at that time.

As recently as 2010, most Medicare beneficiaries paid 100% of drug costs once they reached the coverage gap. One of the few changes made to Medicare by the Affordable Care Act was the implementation of a blueprint to gradually eliminate the donut hole by 2020. A good explanation of these changes can be found in this Medicare publication “Closing the Coverage Gap—Medicare Prescriptions are Becoming More Affordable.”

Part D Rectangle

One unanswered question I have about the coverage gap is how the $4850 to enter the catastrophic stage is computed. I have attended two Medicare information meetings and both insurance companies indicated that the $4850 is totally paid by me. However, the Medicare publication mentioned above states: “Although, you’ll only pay a certain percentage of the price for the brand-name drug, the entire price (including the discount the drug company pays) will count toward the amount you need to qualify for catastrophic coverage.” If you know the answer, please leave a comment. Once I get to Medicare, I suspect I’ll figure it out.

The last stage of Part D prescription drug coverage is the Catastrophic Coverage Stage. In 2016 you pay either $2.95 for generics and $7.40 for brand-name drugs or 5% of drug costs, whichever is greater.

Just when things look complicated enough, there is another consideration for those of us who use insulin pumps. Although insulin is usually purchased through a Part D plan, it is covered under Part B for pump users. Fine and dandy, but it can be extremely difficult to find a supplier for Part B insulin. To get a clue how difficult, read Sue from Pennsylvania’s post “Hey, He Needs his Insulin!” One reason is that many pharmacies rarely deal with this and plead ignorance. Another reason is that the reimbursement rate for Part B insulin is so low that pharmacies/suppliers lose money when selling Part B insulin. A 2013 Lincoln Journal Star article states:

A Medicare spokeswoman said the price is set in federal law — at 95 percent of the average, wholesale price in effect on Oct. 1, 2003. So it requires Congress to change it, she said in an email to the newspaper.“

The cost savings for buying insulin under Part B are substantial. Medicare pays 80% of the cost and a supplemental/advantage/cost plan should pay the remaining 20%. Insulin is therefore usually provided at no cost to someone using a pump. In addition, insulin under Part B is excluded from Part D donut hole calculations.

That’s it for today. I hope that this blogpost has provided some information without totally putting you to sleep. I have done my best to research Medicare drug coverage and if any of what I have written is incorrect, please send me a message along with a dozen donuts.

Most of us think that when we grow old, we will play golf, watch TV, do crossword puzzles, and relax on the patio. I am beginning to think that I’ll be sitting at my desk trying to figure out Medicare….


Most of the information in this blogpost comes from current publications of Blue Cross Blue Shield of Minnesota and HealthPartners. I attended community meetings offered by those companies in July. The official Medicare website is also an excellent resource.

Friday Notes

Laddie_Head SquareYesterday was a busy diabetes day. In addition to just having diabetes (and believe me, that’s enough!), I attended an advocacy training program sponsored by the American Diabetes Association (ADA) and there was a vote by an FDA Advisory Committee regarding the Dexcom G5.

Number #1: My DiabetesNothing momentous to say about my diabetes except that yep, I’ve still got it. I had a big unexpected BG spike after a restaurant salad lunch. Maybe there was hidden sugar in the salad dressing. Maybe my glass of wine decided to be a problem. Maybe it was the mid-morning peanut snack dosed with an extended bolus. Maybe it was because it was 90+ degrees outside with off-the-chart humidity even though I was comfortable inside with air conditioning. Maybe it was because it was Thursday. This is the sort of stuff that makes it a miracle that those of us dealing with Type 1 even have a modicum of sanity left in our lives.

Number #2: ADA Advocacy Training:  I attended a late afternoon Advocacy Training seminar sponsored by the American Diabetes Association. I found it to be very empowering and in a moment of bravado, I signed up to be available for in-person office visits to my congressional representatives. I am a confident advocate when writing, but speaking and putting myself “out there” border on terrifying.

The ADA has a good app for advocacy and I suggest that you check it out. It provides information on national and state advocacy priorities and links to easily become involved in ADA advocacy. Search for “Diabetes Advocacy” in the app store.IMG_0298

Because Scott Johnson was the reason that I knew about this seminar, I can’t say that it was a surprise to run into him by the Diet Coke cooler. But it’s always a pleasure to see Scott.IMG_0295

Number #3: FDA and Dexcom G5:  I was pleased to receive an email from Bennet Dunlap of DPAC sharing news from yesterday’s FDA Advisory Committee meeting on Dexcom G5 labeling. The panel voted 8-2 to recommend approval of a G5 labeling change to allow insulin dosing without a confirmatory BG meter test. The FDA will have to make the final approval, but it is likely that the advisory committee’s recommendation will be accepted. This change should help justify Medicare coverage for CGM’s as well as expand the use of CGM to more patient populations.IMG_0932

That’s it for today. Have a good weekend!