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.