A Review of the Tandem t:slim X2

Laddie_Head SquareI started using the Tandem t:slim X2 insulin pump on December 13 and this review is long overdue. After 2 months, I am mostly happy with the pump. I am comfortable navigating through the menus and have learned a few shortcuts. I like the touchscreen and the “modern” look of the pump. I like knowing that I will be able to add new features to my pump with software updates. At the same time I am annoyed with almost daily alerts about one thing or another. Most significantly, I am frustrated with occlusion alarms which I never experienced with previous pumps.

The Good Things

I like the touchscreen and being able to enter numbers for carbs and BG levels rather than scrolling up and down.

I like the looks and size of the X2.

I like the ability to turn off the screen to preserve battery life. I like the ability to go backwards through menus and tap the “T” to return to the home screen.

I like being able to fine tune settings. For example with Active Insulin Time, my early Medtronic pumps restricted changes to hours. 3 hours seemed too short; 4 hours seemed too long. Then with Animas, I could select 3-1/2 hours or 4 hours and neither seemed perfect. Now with Tandem, I am using 3-3/4 hours and could even select 3 hours and 39 minutes.

I like the ease of setting Site Reminders on my X2. This wasn’t a feature that I particularly missed on previous pumps, but now that I have it, I use it often.

I like that the reservoir icon remains red after I clear the customizable low reservoir alert.

I like that I can read the pump screen in bright sunlight when hiking. Sometimes I have to take off my sunglasses to read it, but it is much better than my Animas pump screens which were totally unreadable.

I like that Tandem has attempted to create a pump that is contemporary and has worked to creatively meet the needs of insulin users.

I like that I will be able to download software updates to add new features such as CGM integration to my X2 as they are released by Tandem. My fingers are crossed that these updates will be allowed under Medicare rules.

I really like this pump.

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The Annoying Things

I find filling the reservoir to be an overly complex and time-consuming process. It is like a “black hole” because I can’t see the insulin in the reservoir or troubleshoot air bubbles. I dislike that the icon on the home screen does not give me a more exact estimate for the number of remaining units of insulin. I can start with a syringe of 250 units and the pump registers 180+ units. After delivering 10 units of insulin (that’s half a day for me), it displays units of insulin rounding to the nearest 5 units. Below 40 units it begins to show specific units. I seem to “lose” more than the 45 (!) units that Tandem indicates as normal.

There are alerts which interrupt me on almost a daily basis. I use temp basals of “0” often for 30-60 minutes when I am moderately low and don’t want to eat. Unfortunately the X2 alerts 2 minutes later to indicate that my basal rate is less than half of my normal basal rate. Well, duh! That’s what I programmed. I suspect the alert is actually a result of a sensor, but IMO software should dismiss the alert if the basal change had been programmed.

I dislike the pigtail connection between the cartridge and the tubing. It tends to stick out and cause tubing to hang out of my clothes.

The t:clip vertical case that accompanies the X2 is bulky and poorly balanced. My guess is that it was designed by men who wear it on a belt. When I clip it to my waistband, the pump is top-heavy and leans forward resulting in an odd bulge in my clothing. If I bend over, it frequently falls off. Rumor is that a new case will be released soon.

Things to Which I am Indifferent

I have never wanted a rechargeable pump but it doesn’t bother me. The X2 charges quickly and does not require a proprietary charger. I can even charge it in my car. So it’s fine.

A lot of people like the way that basal and bolus settings are programmed together in blocks of time on the t:slim. So far I don’t find much benefit doing it that way but I don’t care.

The X2 holds 300 units of insulin. I was fine with 180-200 unit reservoirs, but it’s easy to fill the cartridge partway.

User Error Problems

Some of my issues with the X2 have been due to “user error” and are resolving as I become used to the differences between the X2 and my previous pumps.

The most common error that I make is not resuming insulin after filling the cannula on new infusion sets. I can’t quite remember how it was handled with Animas, but I never had the problem of not resuming insulin. With the X2 I have to wade through a couple of screens like “Stopping Fill” and “Test BG in 1-2 hours” before I get to the option of “Resume Insulin.” Many times I have returned the pump to my pocket before those extra screens. Thankfully I always get an alarm that the pump is not delivering insulin and can fix the problem. I am getting better at slowing down and not forgetting to resume insulin, but occasionally I still mess up.

Another annoyance is if I accidentally touch Bolus on the home screen (and this is easy to do) and don’t clear it, I will get an alert for an incomplete bolus although I haven’t entered any data. The alert will not clear until I go back into the pump, clear the alert, and back out of the bolus feature. Once again this is happening less often as I become more focused when handling the pump with an active screen and being sure to push the top button to turn off the display.

I used Animas pumps for the last 4 years and bolus insulin is infused quickly and immediately. Tandem pumps use a patented “Micro-Delivery” process and can take a couple of minutes to infuse a bolus. More than once I have pulled the same trick that used to mess me up with Medtronic pumps. I bolus for my breakfast while getting dressed. Forgetting that I programmed a bolus a minute ago, I unhook my pump to thread the tubing through the hole in my pocket or even to take a shower. Meanwhile insulin is dripping out and I have no way of knowing how much of my bolus I missed. Once again I am working hard to break this habit.

Occlusion Alarms – The Elephant in the Room

I have used an insulin pump since 2005, first Medtronic and then Animas. In all of that time I had at most 2 or 3 occlusion alarms. If you want to add “loss of prime” alerts on my Animas Ping, maybe you could add 5 more alarms. In 12 years I estimate that I had a problem with insulin delivery 7-8 times. Less than once a year. I cracked pump cases more times than I can count, but I never had a pump replaced because it did not deliver insulin.

I have used the Tandem t:slim X2 for almost 10 weeks. In that time I have had 9 occlusion alarms resulting in an immediate stoppage of insulin delivery. The first couple of times I panicked at the shrieking pump alarm fearing that something was actually wrong. Nope. Not once has there been a problem that did not disappear by working my way through the menu screens and pressing “Resume Insulin.” The vast majority of these alarms have been while delivering meal boluses, but not all.fullsizeoutput_1c6b

Before I go any farther, I must admit that I do not change my cartridges every 3 days as recommended. (I do change infusion sets every 2-3 days.) My first occlusions happened when my cartridges had been in use for 8, 9, and 7 days. So I shortened my cartridge use and had occlusion alarms at cartridge ages of 2, 5, 7, and 1 day. I have only used one cartridge without an occlusion alarm. FYI my total daily insulin dose ranges from 13 units to 26 units and averages 18-20 units. I regularly used reservoirs for 8 days with both Medtronic and Animas and never had a problem.

I have been in contact with both people at Tandem and “experts” in the diabetes online community and have considered every suggestion. I have changed cartridges more frequently. I have used a Spibelt and a Flipbelt. I have used the awkward Tandem case because Tandem techs think it is a temperature issue. (I did learn that the case traps in heat and your insulin goes bad in about 5 days.) I have carried the pump in my pocket and worn it on my waistband. I am 100% convinced that my manually inserted Comfort Shorts (Silhouettes) are not the problem. The occlusion alarms have not correlated with site age and have randomly occurred at site ages of 1, 2, and 3 days. I have had no failed or kinked sites and have used these sets for 12 years with no issues. A Tandem tech assured me that the pigtail design of the cartridge/tubing is not at fault because an internal coil protects it from kinking.

Replacing the pump has not yet been requested by me or suggested by anyone at Tandem. I am currently wearing the pump on my waistband using a Nite Ize hip clip attached directly to the pump and I will see if I can make it 2 weeks without an occlusion alarm. (Thanks Sarah Sugabetic and Kerri Sparling.) My record is 13 days; so far I’m on Day 6.

One thing I must give kudos to Tandem on is that when I get an occlusion alarm during a bolus, it does let me know how much of the bolus was delivered so that I can reprogram the rest after clearing the alarm.

Everyone at Tandem has been respectful and concerned. I sit here in the middle of this experience wondering “What separates the many people who never have occlusion alarms from those of us who are plagued with them?” For me these alarms are #FakeNews and #AlternativeFacts and not once have I seen a kink in my tubing or needed to change out an infusion set or cartridge to resolve the issue.

Conclusion

I like my X2 and do not regret the purchase. I wrote extensively about why I chose this pump and I would not make a different decision today.

At the same time I am conflicted about wholeheartedly recommending this pump to others. How can I recommend a pump that averages a once-a-week stoppage of insulin for seemingly no reason? I admit that I don’t follow all of the rules, but in general I am a conscientious PWD and am doing nothing differently than I did with Medtronic and Animas. Because I have always heard the occlusion alarms, I have been able to restart insulin delivery immediately and have suffered no ill effects from these events.

I delayed writing this pump review because of the occlusion alarms. My hope has been that every “fix” would resolve the issue and I could write a glowingly positive review of the X2. I want to love this pump and I want Tandem to grow and be a successful pump company. As I said before, I really like this pump.

Maybe the hip clip will be the solution.

If not, I will probably argue for a replacement pump as the next step. At this point I am confident that I will not be abandoned by Tandem.

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Please note that this review only reflects my personal experiences. Many users do not experience occlusion alarms with the t:slim X2. Others had these problems with other brands of pumps and don’t with Tandem. Be sure to talk with your medical team, contact a Tandem representative, and read as many reviews as possible if you are in the market for a new insulin pump.

Countdown to Medicare with Type 1 Diabetes: 2 Months / A Decision

Laddie_Head SquareI’ve made a decision, but will it matter in the long run?

A month ago I planned to sign up for a Platinum Blue Cost plan offered by Blue Cross Blue Shield of Minnesota. It seemed to promise a relatively easy transition into Medicare with the option of switching to the Senior Gold Supplemental plan within 12 months with no health questions. I believe that longterm Senior Gold is a safer plan for me because it covers all Medicare providers, guarantees no reduction in benefits, and provides better coverage when I am out of state. Unfortunately it is more expensive, mandates the use of Competitive Bidding suppliers, and requires the purchase of a separate drug plan. It should be okay for me to start on Platinum Blue and then switch to Senior Gold for 2018, but the BCBS rep has not been able to give me a link within the policy guaranteeing the ability to switch. I don’t trust anyone in today’s healthcare environment and I’ve decided to dive headfirst into Senior Gold and traditional Medicare.

Like most people living with a chronic medical condition, I am stressed to the max considering the present and future of healthcare in the United States. I am working to stay informed and involved in advocacy while protecting myself from going batshit crazy. I am rationing Facebook time, newspaper reading, and TV news. I am not worried that I willcountdown-to-medicare-2-months ever be in the position of having no access to some level of diabetes care. It may not be a state-of-the-art insulin pump and CGM, but I have to believe that I will always have access to insulin. I worry for other seniors who do not have the resources than I have. I worry for younger people as the protections of the Affordable Care Act (ACA) are repealed without a plan for the future. I worry that some of our elected representatives are more interested in reducing healthcare costs by limiting access to care rather than reining in costs, particularly drug costs.

The future of Medicare is a big unknown and I have read articles that suggest that the repeal of the ACA and changes to Medicaid will precede any major changes to Medicare. At the same time Tom Price, Trump’s cabinet nominee for the Department of Health and Human Services, is in favor of privatizing Medicare and House Speaker Paul Ryan has pledged to reform Medicare in 2017. A recent article in Forbes suggested that Trump might surprise everyone and come out in support of MFA (Medicare for All). So who knows? All I know is that we are in for a wild ride and probably not a ride that will be fun for people with pre-existing health conditions. I will enter Medicare trying to make the best choices I can while knowing that my choices might not matter at all as we move into a crapshoot future.

I haven’t selected a Part D drug plan yet. I currently take three drugs, four if you include insulin. Two have good coverage with any plan. The third is well-covered as a Tier 2 generic drug in the BCBS Platinum Blue formulary. Unfortunately this same drug is non-formulary and/or covered poorly in Part D plans. It’s been a good drug for me but not so great that I won’t be willing to switch to something more affordable.

I have received notification from SSA that I have been accepted into Parts A and B of Medicare. I have not yet received my Medicare card and that is required before I can apply for a supplemental or drug plan.

I am not dreading Medicare as much as when I started this series almost a year ago. I know some people with Type 1 diabetes who are thriving on Medicare and have learned to navigate the system to get the care and supplies they need. I know others who live on a 90-day cycle of frustration and fear as they repeatedly run into roadblocks getting test strips, insulin, and pump supplies. I know that I will go crazy when things don’t happen the way I expect and I will scream at automated phone menus. But I choose to be optimistic that I will get everything figured out. That might be blind, stupid optimism and I reserve the right to change my tune at any point in the future and start cursing and howling at the moon.

Medicare and CGM Coverage: Love Your Receiver!

Laddie_Head SquareI was surprised, thrilled, elated, stunned, relieved, and every other adjective that you can think of when I received Friday’s mass email from Derek App, JDRF President, with the breaking news:

CMS Labels Continuous Glucose Monitors as Durable Medical Equipment

JDRF is pleased to share that the Centers for Medicare & Medicaid Services (CMS) decided today to recognize continuous glucose monitoring (CGM) devices approved for use in making diabetes treatment decisions as durable medical equipment, a significant step toward making them eligible for coverage under Medicare. Today’s decision lays a pathway toward extension of Medicare coverage for the devices that will bring the nation’s largest insurer in line with the vast majority of the country’s private payers. Although the significant benefits of CGM use have been known since 2008, CMS had previously refused to consider covering the devices under Medicare, saying they did not meet the statutory definitions of durable medical equipment or any other category the agency could cover. Today’s decision removes that impediment.

In recent years I have wavered between optimism and pessimism as I advocated, hoped, and prayed for Medicare coverage of continuous glucose monitors. Now it looks as though the day is coming! I don’t know how long it will be before procedures are in place for receiving reimbursement, but it will be soon. Soon may mean later in 2017. Soon may mean 2018. But there is finally a path in sight for Medicare reimbursement of CGM’s.

Today I read through the 15-page CMS Ruling with a yellow highlighter. You will find some of the specifics of the report well-described in Mike Hoskins’ Diabetes Mine article:  NEWSFLASH: Medicare Will Cover Some CGMs Now! Below I will expound on a couple of Mike’s points and then talk more about the specifics of durable medical equipment.

Dexcom Only: This ruling only applies to the Dexcom G5 because it is the only CGM approved by the FDA for insulin dosing. Therefore the G5 is the only system that fits the definition of a “therapeutic CGM.” Currently CGM systems by Medtronic have not been approved for insulin dosing and are considered “non-therapeutic.” They do not fit the definition of Durable Medical Equipment (DME).

No Guarantee of Coverage: This ruling only states that therapeutic CGM systems fall within the scope of Medicare Part B DME. There has not yet been a national coverage determination to guarantee approval if one satisfies still-to-be-determined coverage criteria. Right now MAC’s (Medicare Administrative Contractors) have the option of issuing local CGM coverage determinations or coverage may be obtained on a claim-by-claim basis. What does this mean? We will learn as Medicare beneficiaries begin filing claims for CGM coverage. You can bet that I will apply for coverage as soon as possible after starting Medicare in April.

All Types of Diabetes: Just as people with all types of diabetes are able to receive coverage for home BG monitoring, all PWD will be eligible for CGMs according to this ruling. Don’t get too excited because IMO the coverage criteria will most likely restrict reimbursement to some people with Type 1 diabetes and some insulin-using Type 2’s. Just as it is more difficult for Type 2’s to obtain coverage for insulin pumps, it may be more difficult for them to obtain CGM coverage. But this is still an improvement over the 2015 congressional bills (S.804 and H.R.1427) that specified Type 1 diabetes.

One thing not addressed in Mike’s article is how the Dexcom G5 fits into the Medicare definition of Durable Medical Equipment (DME).

According to the CMS ruling, there are 5 criteria which must be established in order for a device to considered as DME:

  • Can withstand repeated use;
  • Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years;
  • Is primarily and customarily used to serve a medical purpose;
  • Generally is not useful to a person in the absence of an illness or injury; and
  • Is appropriate for use in the home.

Home blood glucose meters and supplies have been in this category for a long time. Technically the meters are “durable” and have an expected life of at least 3 years. For “multicomponent” systems, the other components are covered as long as one component (the meter) is “durable.” Therefore test strips are covered because they are an integral part of the system.

Looking at the Dexcom G5 system, CMS quickly specifies that sensors with an expected life of 1 week are not durable. Neither are transmitters with an expected life of 3 months. So we are left with the receiver. According to CMS, “reliability analysis data from an engineering firm that evaluated the receiver component of the recently approved therapeutic CGM predicts a lifetime of greater than 3 years for the receiver.” CMS goes on to say that the receiver “is the only component of the therapeutic CGM that can be considered durable and satisfy the 3-year MLR criterion of the definition.”

What does this mean? It means Love Your Receiver!!! Without the receiver, the Dexcom G5 system does not satisfy the criteria for DME.

dexcom-love-your-receiver

The FDA approval of the G5 system required the purchase of a receiver and many people complain about that requirement since they use their phones as the receiver. Just know that CMS is never going to classify your phone as a reimbursable medical device, so cherish your receiver even if you never take it out of the box. If you’re not on Medicare, still cherish your receiver so that seniors can receive CGM coverage! Also Medicare coverage of CGM’s is important for everyone because it is a vital component to coverage of artificial pancreas systems.

In the coming weeks and months, we will learn more about the implementation and impact of this CMS ruling. If you’d like to learn more, here are a few links.

Text of CMS Ruling

Diabetes Mine Analysis  

Diatribe’s Preliminary Analysis

Expanded Statement from JDRF

And no matter what, don’t forget to Love Your Receiver!

 

Countdown to Medicare with Type 1 Diabetes: 3 Months / It’s Happening

Laddie_Head SquareOn April 1, 2016 I started writing about my journey to Medicare with the sentence  “A year from today I will be on Medicare.”  With 3 months to go I’m not yet at the finish line. However, on January 1st I entered my “Initial Enrollment Period.” That means that I can finally start doing something about Medicare rather than just talking about it.

Tuesday morning I applied for Medicare benefits online. (I did not apply for monthly retirement cash benefits because as someone born in 1952, my NRA (Normal Retirement Age) to receive full benefits is age 66.) Enrollment in Medicare Part A (Hospital insurance) and Part B (Medical insurance) or Part B only is required before I can apply for a supplemental or cost/advantage plan in my state. Therefore I will need to wait for proof of enrollment and I assume that will be my red, white, and blue Medicare card.

The online enrollment was easy and I immediately received an email confirming my application. About 24 hours later, I received an email from SSA.gov indicating that my application was being processed and I could expect to receive a letter within 30 days.

Thank you for filing your Social Security application online. Our Social Security Office in CHICAGO, IL received your claim and will be working with you to process it. Our goal is to process all applications efficiently.

A representative may call you for more information at the phone number you provided on your application. Please be aware that our representative may call you outside normal business hours, such as on a weekend or during the evening. If we are unable to reach you by phone, we may also contact you by e-mail or U.S. mail.

You should receive a letter in the mail within 30 days with a decision or to request additional information. If you have a future month of entitlement, you should receive a letter in the mail approximately thirty days before your benefits should start. Also, you can check the status of your application at Status of your application or you may call us at (800) 842-0588 with questions. Please wait five days from the time that you filed before checking the status online.

Now my job is to reply to any requests for further information from a SSA representative and then to wait.

countdown-to-medicare-3-monthsUnless something happens in the next month to change my mind, I have decided to enroll in a Platinum Blue Cost plan offered by BlueCross BlueShield for 2017. I will write more about the decision in a future blogpost, but this plan essentially “cushions” my entrance into Medicare. It allows me to use BCBS DME suppliers and not deal with Competitive Bidding. It exempts me from several other Medicare regulations such as seeing my pump-prescribing physician every 3 months and extensive record keeping to justify more than 3 test strips per day. It includes prescription coverage and for the most part functions like the commercial insurance I currently use.

With any Cost plan in Minnesota I would have 6 months to switch to a Supplemental/Medigap plan with no questions about pre-existing health conditions. However, by going with the BCBS Cost plan, I am allowed 12 months to switch to Senior Gold, the supplemental plan offered by BCBS. I am still not sure about the best Medicare plan longterm, but this strategy buys me time to consider that choice again for 2018.

So now I wait.

Countdown to Medicare with Type 1 Diabetes:  4 Months / No Decision

Laddie_Head SquareI thought that I would have made a decision about Medicare by now and I haven’t. I don’t feel that I am much closer to a “right” decision than I was a few months ago. I have narrowed my choices to 3 plans: 2 Cost plans and 1 Supplemental plan. Each plan has definite pluses and minuses.

About 6 weeks ago I was close to making the decision to go with one of the Cost plans offered by BCBS of MN. The advantages of this plan are reasonable cost, excellent coverage for pump supplies, formulary inclusion for all of my drugs, and a preferred test strip brand that I am satisfied with. It allows me to use BCBS DME suppliers without dealing with the Competitive Bidding suppliers of Basic Medicare. With this plan I will have 12 months to change my mind and switch to the BCBS Supplemental plan with no consideration of pre-existing medical conditions. Therefore I can stay on this plan for all of 2017 and have all Medicare options available in 2018. The major disadvantages of this plan are no CGM coverage and that starting in 2017, Walgreen’s is not a preferred pharmacy. I have always had great service with Walgreen’s and my first choice is to stay with them.

A couple of weeks ago it was announced that Fairview, one of the major health systems in Minnesota, has not come to a network agreement with BCBS for 2017. Therefore many of my health providers will be out-of-network if I choose a BCBS Cost plan. I believe that an agreement will eventually be reached, but….

The second Cost plan that I am considering is offered by HealthPartners. The main advantage of this plan is that it provides CGM coverage. It should be a no-brainer to go with this plan, but co-pays for pump supplies and test strips cost substantially more than on the BCBS plan and the total cost of the two plans is about the same. Plus the preferred brand of test strips for HealthPartners is one that I have not had good success with. I will only have 6 months to revert to Basic Medicare and a Supplemental plan and I will need tocountdown-to-medicare-4-months re-evaluate my options partway through 2017.

The Supplemental plan that I am considering is BCBS Senior Gold. The advantages of Senior Gold are that benefits will never be reduced in the future and I can take the plan with me if I move out of Minnesota. With this plan I will experience few or no out-of-pocket costs. There are no network restrictions and I can see any provider who accepts Medicare. I can always choose to switch to a Cost or Advantage plan in the future. The downside is that Supplemental plans follow Medicare guidelines and there is no CGM coverage. Also I will be forced to use Competitive Bidding suppliers for mail order test strips and pump supplies. I will be required to see my endocrinologist every 90 days in order to receive pump supplies. Although this plan allows the most flexibility for future coverage, it is substantially more expensive than the two Cost plans I am considering.

I don’t know what I am going to choose. I have a list of questions that I will present to an insurance broker I have been in contact with and to a representative from my local SHIP agency. Because I do not need to make my decision until February, I have avoided recent contact with these consultants until the Medicare Open Enrollment period ends today.

Last month I wrote about the anxiety I was experiencing as I thought about Medicare. Today I am not worrying about it. Frankly there are so many unknowns that I am beginning to think that it may not matter what I decide. I have written that Medicare Cost plans are unique to Minnesota, Wisconsin, and a few other states. I was told by a representative from BCBS of MN that these plans will probably be disappearing in the next year or two due to pressure from Medicare. They will be replaced by Advantage plans with different guidelines and network restrictions but more similar to plans offered in other states. The plan I select now may possibly not exist in two years. I know people with diabetes who are using Supplemental plans. I know people with diabetes who are using Cost or Advantage plans. Whatever I select, I will be part of a population of people with diabetes who are in the same boat as I am.

Meanwhile a Trump presidency along with a Republican-controlled legislature is an indication that we may see substantial changes to Medicare in the coming years. Will current Medicare beneficiaries be exempt from future changes or will we all move into a new unproven system? What will happen to people with pre-existing conditions and serious illnesses?

I don’t know the answers to these questions. The only thing I know is that there may not be a “correct” decision for me to right now. There are different decisions. There is Plan A, Plan B, and Plan C. Maybe my choice will make a difference. Maybe it won’t.

I just don’t know.

Insulin Pump Decision 2016

Laddie_Head SquareAnd the choice is…

Next week I will be ordering a new pump or at least I hope I will. My decision could have been difficult, but because of the narrow time window for ordering my pump and looking at my future under Medicare, it was easy.

Timing:

As someone who uses a lot of technology to manage my diabetes, I satisfy my insurance deductible long before the end of the year. With my 2016 deductible satisfied, my pump will be covered at no cost to me—as long as it is shipped before the end of the year. I think I dawdled last time I purchased a pump and ended up with a warranty expiration date in December. Not great timing as I would feel more comfortable if I already had the pump in hand.

My timing is also affected by my move to Medicare in April 2017. I will have individual insurance for January-March, but it will have such a high deductible that a pump purchase would essentially be out-of-pocket. If for some reason I don’t get the new pump in December, I will wait until after April 1. It is not ideal to start Medicare needing a high-ticket item and I don’t know whether I would be forced to abide by the Medicare policy of a 5-year warranty on pumps. I don’t think so because Medicare did not purchase my current pump, but you never know.

Timing also affects what pump I will select. I would like the opportunity to try out the Medtronic 630G, but only if I would be eligible to upgrade to the 670G. Unfortunately I will be on Medicare by the time the 670G is released and Medicare beneficiaries are not allowed to participate in manufacturer upgrade programs. I have been told that this rule is part of anti-fraud regulations, but it truly makes no sense to me. It is not as though there is any cost to Medicare to allow me to upgrade if I pay the out-of-pocket cost (if any) and I don’t see how anything about it is fraudulent. But this is not a battle I can win and therefore I will not buy a Medtronic pump at this time. I don’t find the 630G sufficiently appealing to live with for 4 or 5 years especially since it uses the current generation of Enlite sensors and not the improved sensors that are part of the 670G system. I could wait until the 670G is released but there is no guarantee of Medicare coverage.

Pump Options:

Accu-Chek: I have never considered an Accu-Chek pump. I think some people are very happy with the Accu-Chek Combo, but there is little about it that excites me. I don’t want a meter-remote and given my recent experience with the Accu-Chek Connect meter, I don’t want to be tied to using Accu-Chek test strips. Just not a good fit for me.

Animas: I currently use an Animas Vibe and it is an okay pump although I do not use it as a Dexcom G4 receiver. I have a very difficult time reading the screen in bright sunlight and that has been a real problem when hiking. It has started to lose the date/time info when I change the battery and I would not trust it for very long as an out-of-warranty device. A new Animas pump with Dexcom G5 integration is on the horizon, but there is no timetable for its release. Four years ago I purchased an Animas Ping because the market release of the Vibe was expected to be any day. It was over two years later.

Insulet: I have never been interested in the Omnipod and do not mind pump tubing. Although some Medicare Advantage and Cost plans cover the Pod, basic Medicare does not. As someone moving on to Medicare in four months, there is no reason to fall in love with the Omnipod.

Medtronic: It is mostly a timing problem as described above. I won’t purchase the Minimed 630G because it is a Windows Millennium pump. If you don’t know what that means, you are lucky. We owned several Windows ME computers and they ended up being a very short-lived and poorly-supported generation of computers. If the 670G were available today, I would seriously consider it.

So what’s left???

Tandem: I have decided to go with the Tandem t:slim X2. I am excited to move to a touchscreen device and am especially excited about the integrated Bluetooth and Tandem Updater. Do you notice that I used the word “excited” twice? When I selected the Animas Ping four years ago, I considered the t:slim and passed on it because of the lack of an upgrade program and I didn’t want a rechargeable pump. I never liked my Ping and was jealous of those who “loved” and were “excited” about their t:slims.

A huge selling-point of the X2 is that it will allow users to update the software in the future to accommodate new features, the first being integration with the Dexcom G5 CGM. Automated insulin delivery algorithms are also on the horizon. I personally hope that the Bluetooth connectivity will allow Bluetooth BG meters to automatically populate BG numbers into the pump. Although Medicare does not allow participation in hardwaretslim_x2_insulin_pump_front_view_rgb upgrade programs, my fingers are crossed that software updates will be allowed. I discussed the Medicare problem with my local Tandem Rep and he indicated that Tandem is aware of the issue and hopes to make Medicare recipients eligible for software updates. I know that nothing is guaranteed.

To tell the truth, I still do not want a rechargeable pump. I have always liked the confidence generated by a spare battery in my meter case. But I will adjust.

One Worry:

My individual insurance policy is being cancelled at the end of the year because BCBS of MN is leaving the individual insurance market except for one hugely expensive policy. When I ordered sensors 10 days ago, the supplier indicated that I needed an insurance pre-authorization which I had not needed in several years. I panicked thinking that the insurance company was implementing a year-end money-saving policy of denying DME. I had visions of a new pump being denied. Fortunately Tandem has reviewed my policy and indicated that they are confident the pump will be approved. But until it is safely in my hands, I will worry. (And I did receive the sensors.)

Final Thoughts:

In our family we keep cars a long time. Although my primary car is a 2012 model, I still drive a 1999 SUV several times a week. As I age, it is easy to wonder if my current or next car will be my “last car.” That makes me a little sad because I love the excitement of buying and driving a new car.

I am not yet at the point where I think that the pump I select today will be my “last pump.” But with Medicare’s pump 5-year warranty policy, I am certainly not looking at an unending stream of new insulin devices. At age 64 I hope to have many years of continued good health and many more pumps, but the future is unknown. Will I get the opportunity to use an artificial pancreas-enabled pump? Maybe. Will I quit pumping entirely? Maybe. Will I some day live with implanted beta cells? Doubtful. Will I be cured of diabetes? No. I am not worrying about any of this. It is all in the “I wonder” category.

Today I look forward to using a Tandem X2 pump. Unlike previous pump decisions where I had doubts about the “right” choice, I am confident about this decision. I don’t expect absolute perfection with the X2, but I hope for excitement and the opportunity to have pump hardware that can move into the future with software changes. Fingers crossed.

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Pump comparison charts quickly become out-of-date as new pumps and manufacturers enter and leave the market. If you’re considering an insulin pump purchase, a good place to begin is here and here along with technology articles at Diatribe and Diabetes Mine. Ultimately manufacturer websites and sales reps are an excellent (but biased?) source for current information. And don’t forget to ask your DOC friends for their experiences and opinions.

Not FDA Approved

Laddie_Head SquareAfter my husband and I finished putting up the Christmas tree this morning, I discovered that my Dexcom G4 Share receiver was missing. We searched tree branches, boxes of decorations, upstairs, and downstairs and couldn’t find it. I knew that the receiver was somewhere in the house because I was getting numbers on my phone through the Share app.

My BG at this point was in the 140’s several hours after breakfast and normally I would take a correction bolus. Instead I ate a couple of glucose tabs and hoped that I would hear vibrating alerts as my BG passed over 160. No luck. My BG went up but we heard nothing. (All of my alerts are set to Vibrate.)

Once my BG hit the stratosphere, I gave up on high alerts. My only recourse was to drop below 55 and get the mandatory audio alert. I injected a mega-dose of insulin and got ready for the gluco-coaster ride. Don’t try this at home, Kids.

It took a while but eventually I was below 100 with double down arrows. About this time my husband asked if an ambulance ride would cost more than replacing the receiver. I explained that I had reached my deductible for the year so emergency care would be free…. Then I assured him that I would be okay and ate a couple of Smarties to control the BG drop.

We didn’t hear vibrations as the BG dropped below 70. So it was 55 or Bust!

Finally we heard muffled audio beeps, but we couldn’t figure out where they were coming from. Certainly not near the Christmas tree or the couch or the many boxes where I expected to find it. I’m not sure how many minutes separate each series of alerts—maybe about ten. Finally on the 3rd or 4th round of beeps, we found the receiver upstairs in the pocket of my pajamas.

This should be the end of the story, but it is not. The reason that I had not checked upstairs is that I had been on a 40-minute walk long after getting dressed. I had seen reasonable BG numbers on my Apple Watch while walking and given no thought to the idea that the receiver was not with me.

It turns out that obviously my receiver was upstairs all morning and the number I was seeing on my Apple Watch was from the Watch Sugar app. When the Dex Share app on the phone and watch loses contact with the Dexcom receiver, it displays blank dashes instead of numbers. Had I been using this app during the walk, I would have noticed a problem. But I was checking my watch face with the Watch Sugar complication. Well, I learned today that the Watch Sugar app will keep displaying the last number received whether it is 30 seconds ago or 5 hours ago.

Once my BG returned to normal according to my meter, I turned off the Dex receiver for 20 minutes. As expected, the number 46 for Watch Sugar never changed while the Dexcom Share app (not shown on watch face) quickly showed no data. Hypothesis confirmed.watch-face

Everything is now fine in Diabetes Land.

I found my Dexcom receiver.

My post-Thanksgiving low carb diet got blown to bits with glucose tabs, Smarties, an apple, a pear, yogurt, and an English muffin.

I learned that it is better to keep the Dexcom app open on my watch rather than rely on Watch Sugar.

My BG’s are stable and back in range. Dexcom 91. Freestyle 93.

Just another day with Type 1 diabetes.

Postscript:  Sometimes I think I have little control over my diabetes. Today I felt totally in charge of what I wanted my blood glucose to do. I never felt that I was doing anything dangerous. I was not alone and I had lots of orange juice and glucose tabs available. That being said— please remember that nothing you read on this blog should be considered medical advice or even good advice.

Healthy Lunch Day

Laddie_Head SquareI have been a quiet blogger this November and done little to advertise or celebrate diabetes month. I was an active participant in the Big Blue Test but that was all behind the scenes. I have read the wonderful blogposts by other diabetes advocates and  chosen not to feel guilty for my lack of participation.

This morning I received an email from Chelsea at the American Diabetes Association asking me to participate in the second annual Healthy Lunch Day which is celebrated today. Easy enough because I eat lunch almost every day and it is usually a “healthy” meal!

A salad is my most common lunch and today was no exception. The base was a Mann’s Power Blend containing Brussels sprouts, Napa cabbage, kohlrabi, broccoli, carrots, and kale. I topped it with raspberries, leftover cooked broccoli, a hard-boiled egg, and a yogurt-based dressing. I guessed the carb count to be 18 grams and bolused accordingly.

fullsizeoutput_1a22I tend to spend two or three hours each afternoon at my kitchen table “desk” and like to avoid BG spikes with a lowish carb lunch. I go heavy on vegetables and berries to make up for my oatmeal breakfast that has nothing green or colorful.

So here’s to #HealthyLunchDay and the ADA’s November theme of #ThisIsDiabetes. My lunch was healthy and I have diabetes, so it’s a perfect fit!

Countdown to Medicare with Type 1 Diabetes:  5 Months / Anxiety

Laddie_Head SquareThere are frequent online discussions about addressing mental health issues along with physical concerns when living with diabetes. I am lucky to be mostly immune from things like diabetes burnout and depression. I don’t like diabetes but it doesn’t haunt or slow me down much. I come from a family with a history of depression but its dark clouds have never settled over me for very long. Still…

I have a tendency towards anxiety. The kind of worry that radiates in my chest and aches in my belly. It has never been so crippling that I have felt the need for professional help and I have been helped by progressive relaxation tools I learned from a book many years ago. Deep breathing and exercise also help.

I am very in tune with my anxiety. It surfaces when I need to make a decision or address a problem and I don’t feel in control. Sometimes the issues are trivial or at least very fixable, but my rational brain can’t convince my gut that I shouldn’t be stressed. I won’t call them silly, but my anxiety worries are not life-or-death. Maybe it is a leaky roof. Maybe it is a grandchild getting her feelings hurt. Maybe it is Christmas. Maybe it is thinking about what needs to be done to sell our house and we don’t even plan on selling the house.

Maybe it is Medicare.

I have been trying to get a handle on Medicare options for several months. I haven’t decided whether I know too much or not enough. I wake up many nights at 2:00AM and start thinking about Supplemental versus Cost* plans. I walk the dog and my stomach cramps thinking of Competitive Bidding. Part B insulin and test strip brands are a constant concern. This stuff is important, but not so important that I should be losing sleep.

But anxiety does not always make sense.

I finally have premium costs and plan information for 2017 and I am making worksheets to compare my options. I have only one decision that could have an impact beyond my first year on Medicare and that is the Supplemental versus Cost plan decision. Supplemental (Medigap) policies are only required to accept me (a person with pre-existing conditions)countdown-to-medicare-5-months during the first 6 months that I am on Medicare. After that I can be denied coverage or charged higher rates. At the same time there are guidelines about having guaranteed Medigap rights and some of those scenarios will grant me needed flexibility in the future.

The things that stress me are discrepancies like one plan agreeing that insulin for a pump will be covered under Part B and a similar plan saying it won’t. (That can be a big deal because Part B insulin does not go into donut hole calculations.) I think the plan saying no is wrong, but what do I do about it and do I dare risk signing up with that company? I need to consider that company because it happens to offer CGM coverage. Yes, I am lucky to have the option of CGM coverage with one plan! But I need to consider the whole package, not just one thing. More homework to do.

Another thing that is stressful is trying to figure out what pump and testing supplies cost. For the most part I have been using the negotiated prices from my current BCBS policy. But one friend shared his test strip cost info with me and it looks as though he is paying 20% of what I consider a high retail price compared to what a negotiated price should be. Am I right? Right or wrong it certainly makes me wonder what prices I should be using to figure out my anticipated costs.

Another thing that kicks me in the gut is competitive bidding. This is only relevant if I choose a Supplemental plan because Cost plans use their own suppliers. DPAC has published a couple of blogposts recently that scare the bejesus out of me. One post was written by a person with diabetes on Medicare and the other was written by someone who owns a durable medical equipment company. These are great articles to spur advocacy, but frightening for those of us anticipating Medicare.

One benefit of participating in the DOC is that I have support from other people affected by diabetes. A downside is that I read stories of people having nightmare experiences with Medicare. As a blogger, I get emails from readers sharing their stories and problems. At the same time I know many people with Type 1 who are doing fine on Medicare but those people don’t write much about their experiences. I mostly hear the bad stuff.

anxiety

I have anxiety. Some of it is unreasonable. I live in Minnesota and have several good (not perfect) options for Medicare. My husband still works and his income will provide a buffer from the shortcomings of Medicare. At the same time some anxiety might be reasonable because healthcare reimbursement at all levels in the United States is under siege and people with diabetes are getting hit particularly hard.

I expect that my next Countdown to Medicare post in December will outline some specifics of my choices. Obviously cost is a major concern, but so are things like drug formularies, test strip brands, and requirements for getting pump supplies. I have already eliminated choices that do not network my current doctors and I am looking at the plans of two different companies. It is likely that I will choose a plan that allows me to avoid competitive bidding because anyone with a tendency towards anxiety might not survive that disaster.

More to come. 😀

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**Minnesota is one of very few states that offers Cost plans. These plans are hybrids that combine features of traditional Medicare and Advantage plans. Most people reading this post will not encounter Cost plans in their Medicare journey.

A Diabetes Data Machine

Laddie_Head SquareI am currently involved in a couple of projects that require tracking my diabetes data. The good part is that some of the data is automatically logged with little or no input from me. The bad part is that I am using 3 different apps on my phone and must enter food information twice. The good part is that I have learned new things about my diabetes. The bad part is that I am uber-involved in the input of data and not paying much attention to the output.

Big Blue Test

Most of you are familiar with the Big Blue Test sponsored by the Diabetes Hands Foundation. Every test logged between October 14 and November 14 will result inBig Blue Test Logo a $3 donation to support people with diabetes. Three charities will receive $5000:  Diabetes Sisters, We Are Diabetes, and the Riverside Community Diabetes Collaborative.

The Big Blue Test is by far the easiest of my current data projects. I use the app on my phone and it’s a quick 30 seconds to record my exercise. Although participation is easy, I am no Big Blue Test slouch. Yesterday I managed to input 5 (!) tests. Dog walk. Gym session. Rake. Rake again. Dog walk. That translates into a $15 donation for diabetes.

If you are participating in the Big Blue Test, keep up the good work. If you are not involved, check out this link to learn more. It’s not just walking and running. You can include housework, yard work, weight work, and dancing. You can help a couple of diabetes groups while receiving the physical and mental benefits of moving your body. Sounds like a win for all.

mySugr Consulting

I continue to be a beta-tester for the mySugr consulting module. As outlined in my September post, mySugr is launching a feature to allow virtual coaching from Gary Scheiner and the team at Integrated Diabetes Services. You can learn more about themysugr-copy program here and here.

Today I am not addressing the coaching experience except to say that Gary Scheiner does a better job of understanding my D-data than I do. Instead I am writing to share that amazingly I am still logging after 3 months!

I am still learning shortcuts for entering my data and have reduced the number of data points I am tracking. I continue to enter food and carb counts, but don’t classify the food anymore as vegetable, meat, etc. Similarly I am not distinguishing between food and correction bolus amounts, just total insulin. What I like about mySugr is the ability to customize my logbook to show only the data points that are important to me and to list them in an order that makes sense to me.

My newest “cool” discovery about mySugr is that if I use the workout app on my Apple Watch, it automatically transfers the activity to mySugr. Another diabetes/life datapoint automatically logged!

Glu and T1D Exchange

Glu is the patient community of the T1D Exchange and provides an easy way to participate in research relating to type 1 diabetes. I am currently part of a study about blood sugar results and treatment satisfaction for T1 adults using pumps or multiple daily injections.blip_logo

The logging requirements of this study are not difficult because most of my data goes into Tidepool’s Blip. If you don’t know about Tidepool and their innovative diabetes apps, check it out here. I download my Animas pump and Freestyle meters once a week. My Dexcom CGM automatically links with the Blip Notes app on my iPhone. My only daily responsibility is to create a Blip note whenever I eat. I click on #food and record the meal with the carb count. To make it easy, I copy and paste the meal info just entered into mySugr. Takes 30 seconds or less.

Where to from here?

The Big Blue Test ends November 14.

The mySugr logging has no end date and I’ll keep at it a while longer. But not forever.

The T1D Exchange study lasts 4 weeks.

I have learned a lot from this intensive logging. I tend to eat a little bit all of the time and now have visual proof that my BG is better when I eat more at meals and reduce snacking. I have done some basal testing and am seeing better CGM tracings. Better basals allow for less snacking.

But I am tired of logging. My head is exploding with numbers and my brain is drowning in data. I am thinking about diabetes too much and will be happy to quit recording my life in a couple of weeks. Being a diabetes data machine is fine for a while, but for me the benefit gets lost when I do it too long. For sure I will quit before Thanksgiving because there is no way I want to start the holiday season being accountable for my food decisions….