The 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″ bit.ly/2b4fmjx @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.
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.
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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.
Test Guess and Go 
I don’t have the G4 tSlim, because I didn’t want to get locked into old tech. I’m not sure if I will upgrade to the new pump for a fee, so that I would be able to view the CGM on my pump or not. The fee to upgrade my daughter’s is $800, so that won’t be happening for just a 2 year upgrade and I know that she would not benefit from it. I chose the regular tSlim because I have the larger sized iPhone and would hate to have to carry that around all day in my pocket. Sugar surfing would be a pita using the pump rather than the receiver or phone I think. You could actually eliminate the receiver if you got the integrated pump though correct? That would cut costs for you. I would chose tSlim again in a heartbeat over any other pump. Customer service is still fantastic and I sure hope it stays that way as the company grows.
I am definitely considering t:slim but only if the new X2 is available. I have lots of insurance changes in the next 8 months and timing is everything. Blogpost or two to follow in the fall.😀
Looks like it will be close, based on the email that I got. Hopefully they will be able to launch it sooner. Otherwise I believe it would cost 399 to upgrade unless they make a change in how that is determined, since this info is likely going to cause people to wait if they can.
Upgrade programs are one reason that the timing of everything is so important. Once you get on Medicare, you are not eligible for upgrade programs. It is not the manufacturers choosing not to let seniors participate, it is federal law I think. I have been looking for the applicable regulation/law but don’t know exactly where it is. It is part of anti-fraud rules, I think. It doesn’t make sense to me that the government should prevent me from using my own money to upgrade my pump, but that’s the way it is. So I will not purchase the current t:slim model and take the risk that I don’t get the upgrade before Medicare. I hope that Medicare X2 users will be able to get the free software updates, but I don’t know.
I have been in touch with the local Tandem Rep and hope to set up a meeting with him. But as these things go, you can’t always trust that the reps give the correct info. Many people who purchased the Ping and then got to Medicare and weren’t able to participate in the Animas $99 upgrade program can attest to that.
I am just a step ahead of you in this Medicare journey. I qualified July 1st. It is tangled web for sure. I upgraded to a Medtronic 530G in December just as you are looking into now with your pump and CGM. My first submission of my prescriptions put me in the donut hole!!!! The main driver being my Humalog. REMINDER if you wear a continuous insulin infusion pump your insulin gets billed to part B NOT part D. That helped the donut hole problem.
I also just stopped a couple of topical creams that were $$$. Crestor now comes in generic so I think I am in a better place. I am now in the process of trying to figure out my total monthly drug costs, to see if s higher premium part D plan could be worth my while. These are things i discovered on my journey to Medicare. I plan on 2-3 hours of computer research every day!! I don’t plan on the actual headache but it comes anyway:( Working with my supplier, I found out I can no longer get my strips from them, so another search began. Also Medicare has a quantity rule before you can re-order pump supplies. They do not allow processing the order for my infusion sets and reservoirs until I am down to my last FIVE sets!! Not to mention the 100 test strips per month rule, another process to contend with. Also PLEASE NOTE anyone reading this, this is information from my dealings with the process. Please research for yourself, as your Plan and supplier may differ the way things are filled.
I understand your feelings of dread. Be informed, if something doesn’t seem quite right ask again or call on another day. I think us Type 1er’s over 65 deserve so much more. But the reasons we have “made it” so far are the same reasons that will keep us pumping and fighting for our health and that of our unique community.
Kathleen-thanks for sharing your experiences and I think that you are right that we Type 1’s are using to fighting for our health. We don’t really have much choice.
Laddie: I do believe we will get there with medicare. But it will take at least one more and likely five years. Still, I have faith. I am convinced that I will go back to a G4 in December. I have no pump restriction but I do not care for the White screen of the G5 and I never use the iPhone app. So it makes little difference for me to have a G5. As a matter of fact, I nearly went back in June at mid-year.
Laddie, I do hope that the Medicare system sees change in the near future. The only way to access CGM in Australia is to self fund, or if you can get on a trial through a hospital clinic. I’ve always been reluctant to try it because I worry about becoming accustomed to something I cannot afford.
Also I just wanted to say that I gave my new infusion set a try. I’m only on my first one, but everything you’ve said is starting to make sense. I think that the angled insertion might be the way to go in the long run, especially as I’m fairly skinny and its easy to hit nerves and blood vessels. I was a bit hesitant to try something new, so thanks for the encouragement.
OMG – auto sensor shut off?! DexCom, come on!
CGM and Medicare is a work in progress. FDA doesn’t approve CGM for treatment decisions/bolusing- meaning Medicare would have to pay for the old fashioned meter AND the CGM and that doesn’t make sense from a cost standpoint. Which is silly- we all use the CGM for treatment. It’s wonderful. I believe in July 2016 the FDA changed their position, I would research it. Hopefully means Medicare will follow. Also, x2 from tandem should be available at the end of THIS month. Speaking personally Tandem is a great company and makes a great product. Very best of luck to you!