Diabetes Pregnancy: Now and Then, Part Two

As I mentioned in yesterday’s post, I recently approached Kerri Sparling of Six Until Me about sharing my pregnancy and childbirth stories from the late 1970’s and early 1980’s. Those were the diabetes days of no home BG monitoring and one or two injections of insulin a day. Yesterday the first part of my story was highlighted at Six Until Me. Today is the second part of my tale. Check it out!

Diabetes Pregnancy: Now and Then, Part Two

 

Diabetes Pregnancy: Now and Then

A while back I approached Kerri Sparling of Six Until Me about sharing my pregnancy and childbirth stories from the late 1970’s and early 1980’s. Those were the diabetes days of no home BG monitoring and one or two injections of insulin a day. Today the first part of my story (with a few choice comments from Kerri) is highlighted at Six Until Me. Check it out!

Diabetes Pregnancy: Now and Then

Learning to Like Tidepool

In previous blogposts I have mentioned my frustration with finding a platform where I can download and view data from all of my diabetes devices. Diasend used to be my go-to site and would still work for me if I used my Dexcom G5 receiver. But I am a hipster-oldster who uses her iPhone and Apple Watch for CGM numbers. An email to Diasend followed by a phone call to Dexcom last week indicated that there are no plans to allow G5 Mobile integration into Diasend for US users. Dexcom Clarity is great for analyzing my CGM data but it doesn’t include pump or BG meter information. Tandem t:connect allows me to download my pump and Freestyle Lite meters but does not show CGM information. Maybe when the Dexcom G5 is integrated into the t:slim X2 later this year, the Tandem site will include all of my information. Although I love mySugr and the cute monsters, I don’t need a day-to-day logging app. Pretty quickly I get down to Tidepool as the only platform that is compatible with all of my devices.

My first experience with Tidepool was last fall when I participated in a research study through Glu. I downloaded my pump and meters weekly while my CGM synced to Tidepool through Apple Health. I was required to enter my food and carb counts through the Blip Notes app. The use of hashtags for notes initially bugged me but with practice it became quite easy. The Basics screen in the Blip dashboard was novel and my data was displayed in charts and domino dot patterns. I don’t recall spending much time reviewing the Daily View screen. In general I couldn’t envision how my endocrinologist would work with Tidepool because she requires printed reports. After the Glu study ended, I drifted away from Tidepool.

Fast forward 7-8 months and I am becoming a Tidepool fan. A couple of things happened to bring the website back to my attention. One, Chris Snider was hired as Community Manager and I assume that he is instrumental in the new informative emails showing up in my inbox. Two, it was announced that Tidepool users are now able to share their data with Type 1 diabetes researchers. You can learn more about the Tidepool Big Data Donation Project and how to participate at this link. Three, a recent email shared a clinician’s video featuring Diabetologist Dr. Anne Peters demonstrating how she uses and interprets Tidepool reports. I am always interested in what endocrinologists are seeing and thinking and her presentation helped me understand how I could gain insights into my diabetes using Tidepool.

I encourage you to take the opportunity to watch this video.

 

***** Interruption *****

Why do I download data?

I download data: 1) to take to every endocrinology appointment,  2) to review my numbers for a pat-on-the-head or a kick-in-the-butt, 3) to provide printed reports for Medicare which requires a 30-day log for pump supplies and a 60-day log for CGM supplies, 4) for various clinical studies and/or beta-testing apps, and 5) for curiosity to test new data platforms.

***** End of Interruption *****

Tidepool is a non-profit company and was founded in 2013 by Howard Look, a self-described nerd who has a daughter with Type 1 diabetes. Like many small diabetes tech companies it grew out of the #WeAreNotWaiting movement and is powered by geeks, D-parents, and PWD’s. As Look mentions at the end of the video, employees at Tidepool “have pancreas in the game.”

To get started with Tidepool, go to www.tidepool.org. Although you can check out the website in any browser, the Uploader is a Google App and you must use Chrome on either a Windows or Mac computer for downloading and viewing data. I have contacted Tidepool support several times by email and have always received prompt and courteous help.

Where do I go with Tidepool from here? I am pleased to be participating in the Big Data Donation Project and have recurring calendar reminders to download my pump and meters. My Dexcom G5 syncs to Tidepool continuously through Apple health. I also plan to periodically review my own D-numbers and graphs through the Blip dashboard. After 40+ years of Type 1, I am not good about day-to-day logging and probably won’t use the phone app very often, but you never know. I am currently a beta-tester for a new version of the app and maybe I’ll get hooked. Rather than reviewing my graphs and numbers on a computer, my endocrinologist uses print-outs that are eventually scanned into my medical record. In the Tidepool video above, Dr. Peters provides a glimpse of the future where diabetes data is viewed online and interactively with patients. It will be a long time before that future shows up at my doctor’s office.

In addition to exploring Tidepool.org and signing up for the Big Data Donation Project, you can learn more about the company through these links:

Diatribe (2014):  How the Tidepool Data Integration Platform Can Ease Diabetes Management: Our Interview with Tidepool CEO Howard Look

Six Until Me (2015):  #WeAreNotWaiting: The (Not So?) Brief Story of Tidepool

Diabetes Mine (2016):  Tidepool Goes Big After White House Visit

Diabetes Numbers Podcast Episode 23 (2017):  Tidepool’s Big Data Donation Project

In conclusion here are screenshots provided by Tidepool of the Blip Basics Home screen and a Daily data view. Note that the Daily view shows insulin, carbs, BG’s, and notes in the same timeline as CGM data.

Wildflowers, Wildlife, and Diabetes in the Wild

My spring has been filled with wildflowers on the hiking trail and wildlife in the neighborhood. I’ve seen hillsides of yellow poppies along with purple desert lupines, orange globe mallow, red Indian paintbrushes, and white soaptree yucca blooms. I’ve seen snakes, lizards, javelina, coyotes, and recently a bobcat while on an after-dinner bunny hunt** with my grandchildren. My spring has also had an interesting mix of “diabetes in the wild.”

**Whenever my grandchildren visit Arizona, we go out in the golf cart after dinner and look for bunnies. The children maintain a bunny book where nightly bunny totals are recorded. There is a column for “Ciyotes” which was edited this year to include bobcats. 

Neighbor

My first “diabetes in the wild” encounter happened when my next door neighbor came to talk to me about a tree issue affecting both of our yards. She and her husband are part-time Arizona visitors because he still works full time. We’ve always been friendly but have never talked about much except the weather and grandchildren. Sylvia indicated that Jim wasn’t there yet because he was traveling for work. I knew that he was affiliated with a major university in their home state but had never asked for more details. I asked Sylvia about Jim’s profession and she said that he was a teaching professor and practicing physician in the speciality of…. Wait for it! ….Endocrinology!

So for 8-9 years my Type 1 diabetes of 40 years and I have spent the winter months next door to a renowned specialist in diabetes. Similarly he has unknowingly lived next door to a not-so-renown diabetes blogger!

It rained the next couple of days and before I knew it, Jim and Sylvia had left and I didn’t see them again before I returned to Minnesota. Thus I never got to have a celebrity-crush visit with the neighborhood diabetes doctor. I Googled him and learned that he is quite renown on a national basis. I didn’t get a chance to give him one of my blog business cards and I have no idea whether he ever reads patient blogs. My own endocrinologist avoids diabetes social media and does not read the blogs of her patients. On one hand I think doctors benefit from hearing patient voices; on the other hand I know my endo works long hours with insufficient pay and I don’t expect diabetes to be her hobby. If Dr. Jim chooses to read any of my blog, he will learn that I am an educated and involved patient who does her homework and improvises with “her own thing.” It will be up to interpretation whether he sees me as an empowered consumer or a nightmare patient….

Gym Meet-Up #1

I went to my Arizona community gym a few days before returning to Minnesota. A man about my age was the only other person there. We said “Hi” and continued with our workouts. After about 15 minutes, he introduced himself as “Tony” and asked about the Dexcom transmitter on my arm: “Hey, is that thing on your arm for diabetes?” I said yes and indicated that it was a continuous glucose monitor and described what it did. He told me that a year ago he had started working out and changing his diet to try to avoid diabetes which runs rampant in his family. He had lost 43 pounds, gained muscle, and felt energized by his new level of fitness. His doctor was thrilled with the effect on his lab work. I don’t think that Tony had been diagnosed with pre-diabetes but hopefully his hard work will prevent or at least delay diabetes coming into his life.

Gym Meet-Up #2

While Tony and I were speaking, an elderly man (I’m old, but he is older!) came into the gym and started his workout. After Tony returned to his weights, this gentleman came over and pointed to my JDRF tee shirt and said that his wife had been very involved with them. (Thanks to Sara of “Moments of Wonderful” for the shirt.)

A bit teary-eyed he told me that she had died six months ago after 60 years of marriage. He was an engineer by trade and had always helped her take care of her diabetes. She wasn’t good with numbers he explained. She used a pump and CGM which I assume were Medtronic because he said that her “thing” didn’t look like mine. It turns out that Morrie lives next door to one of my friends so I plan on looking him up next year when I’m back in Arizona. I would enjoy hearing more of his story as a caregiver and more about his wife’s journey with diabetes. Morrie indicated that he hadn’t been getting out much since his wife died and how much he enjoyed talking with me. The enjoyment was mutual, but tinged with sadness.

Poppies, bobcats, and diabetes. Wild things.

Fighting the Diabetes Chocolate Demons

This post is dedicated to my friend Carol. I met Carol through my blog and we periodically email each other talking about Type 1 diabetes, Medicare, and stuff like that. She doesn’t live near me and I don’t know if we will ever meet in person. But we share the journey, the joy, and the struggle of women aging with Type 1 diabetes. Thank-you for being part of my life, Carol.

Dear Carol-

The anguish you described in your latest email about chocolate, post-dinner eating, and making “bad” decisions probably rings true for almost everyone with diabetes. In fact it might ring true for every human being who has access to potato chips, chocolate, cigarettes, and/or alcohol. Unfortunately for those of us with diabetes, we have BG meters that provide a visual reminder of how often we have failed to live up to our expectations.

I am good at finding temporary solutions to the problem of evening snacking. I long ago gave up hope of ever totally eliminating it. Sometimes I play games that work for a while. For example I package something like Hershey’s Kisses in plastic bags of 15g carbs. I put them in the freezer and allow myself 1 bag each evening. That works for a few weeks before I realize that nothing is stopping me from grabbing a second or third bag of chocolate. Then I play around with my digital calendar and add a daily resolution event of “No cr*p eating after dinner.” When I am successful, I change the color of the event from a boring gray to a pretty color. It’s stupid, but once again it works for a couple of weeks. Sometimes I put a big “No!” sign on the refrigerator or snack cupboard, but this only works for a day to two. I have a couple more games that frankly are reminiscent of Stupid Pet Tricks…. Another thing I do is have a cup of caffeine-free tea after dinner. That burns up some of the time when I might have the urge to start snacking. Going for a walk after dinner helps but I am usually so active during the day that I don’t want or need more Fitbit steps. Some people learn to knit or crochet and others play computer solitaire to avoid snacking.

I understand some of my triggers for chocolate orgies. Snacking in the late afternoon sometimes leads to skipping dinner and that’s a recipe for disaster. Too much wine before and during dinner definitely ruins my willpower and I don’t keep it in the house anymore. I think my biggest frustration is that I can convince myself that the “correct” insulin bolus will take care of the snack food and I’ll just have a couple of cookies. But it doesn’t work. Never, never, never. It doesn’t work.

Recently I’ve had a string of successful evenings with a Nature Valley Protein Bar (Peanut Butter Dark Chocolate—14g carbs) along with a mug of warm FairLife milk (6g carbs). You can buy the bars in boxes of 5 at the grocery store or in the big boxes of 30 at Costco. I’ve been known to eat two bars, but usually one is enough and the addition of the warm milk extends the enjoyment time of the snack. A friend recently told me about FairLife milk which is ultra-filtered and has half the carbs and sugar of regular milk. I like it much better than almond milk and the impact on BG is minimal.

I know that periodically I am going to relapse from whatever temporary solution I have found and I try to forgive myself for those times. At the same time my slip-ups drive me crazy because my overnights are so much better when I don’t lose the evening munchie battle. My Dexcom CGM doesn’t alarm to lows in the early night hours followed by 2:00AM highs as the junk food digests. My fasting BG in the morning doesn’t randomly pingpong between low and high. A  reasonably-sized evening snack leads to a higher percentage of “good” overnight BG numbers with only minor low and high excursions. My fasting numbers tend to be more stable. I sleep better. I feel better.

Why can’t I do what I know is good for me and what makes me feel better???!!! That’s the million dollar question.

Carol, you described the anguish over our lack of perfection so well. After recently pouring your heart out to your endocrinologist for help, you wrote:

From eating the stupid chocolate I had to have. It is totally the opposite of who I am all day – so disciplined. I’ve asked the Endo for help with the chocolate — counseling for why I need comfort food when I know it’s bad for me? I asked her why I would be 90 after dinner and yet have to have chocolate that I know will spike me to 190?

You call it “Diabetes Distress” and that’s as good a name as any. I have no great advice for you, but I have a lot of understanding. I hope that the next time you beat yourself up over chocolate that you remember that you are not alone. There is no one with diabetes who has ever done it “right” all of the time. Food is a complicated issue as we have to eat to live. Food is our medicine for fighting lows and balancing blood sugars. Foods like chocolate are enjoyable and taste good. Food, especially food with sugar, is addictive. For me there is no doubt than none is easier than one. One cookie and one piece of chocolate don’t live in my world and moderation is often an elusive goal.

Diabetes can easily become a disease of disordered eating, but I think that our distress is not just the chocolate. It’s the relentless pressure of diabetes which is easier to picture as a pile of candy bars than the inner demon of inadequacy as we try to mimic a healthy pancreas.

Carol, it is easy for me to pat you on the head and say what a good job you are doing with your diabetes. Because you are. But it’s harder than that and we can’t pretend that it isn’t. I hope that you may find some answers through counseling. Meanwhile don’t forget to be kind to yourself and remember that you are not alone in your struggles or your successes. If you learn some inner mantras or even Stupid Pet Tricks to tackle the problem, please share. Until then, keep up the good fight.

Laddie

Countdown to Medicare with Type 1 Diabetes:  1 Month / Growing Old with T1D

Laddie_Head SquareI don’t have much to write about this month when it comes to Medicare. I am signed up for Medicare Part A and Part B. I have enrolled in a Supplemental Plan offered by BCBS of MN. I have selected an AARP Walgreen’s Part D drug plan. For better or worse I am ready to tackle Medicare on April 1.

Turning 65 years old and going on Medicare is a milestone in the progression of growing old. It is impossible for me to make this transition without thinking about growing old with Type 1 diabetes. Below you’ll find some of my thoughts.

The idea of “phases of aging” makes sense to me and I am moving into the “young-old” subgroup described in a Lumen Learning sociology course:

The United States’ older adult population can be divided into three life-stage subgroups: the young-old (approximately 65–74), the middle-old (ages 75–84), and the old-old (over age 85). Today’s young-old age group is generally happier, healthier, and financially better off than the young-old of previous generations.

As a young-old person who has lived with Type 1 diabetes for over 40 years, I am the most confident and empowered in relation to my diabetes than I have ever been. That is not going to change on April 1.

When I was diagnosed in 1976, I knew nothing about diabetes and had access to only a few books and magazines. Today the Internet has opened doors to scientific knowledge, professional recommendations, advocacy issues, and the cumulative knowledge of thecountdown-to-medicare-1-month Diabetes Online Community (DOC). Although I don’t blindly follow online diabetes advice and have never consumed okra water, I strongly believe that my fellow people with diabetes (PWD) have taught me almost everything I know about Type 1 and have motivated and empowered me to succeed. Continued learning about diabetes won’t go away just because I get a Medicare card.

I have lived a privileged diabetes life and have never worried about access to care. I understand that I will have a huge learning curve when it comes to getting supplies and medications under Medicare. I am not yet losing sleep over potential roadblocks although I know that it is naive to think that there won’t be any.

There is no doubt that improvements in both insulin formulations and technology have allowed me to reach age 65 in reasonably good health. I can’t envision what my health status would be (or if I would even still be alive) had I continued on my 1976 insulin regimen of one injection a day and no home BG monitoring. Insulin pumps and CGMs have exponentially increased the quality of my life. I can’t even begin to hypothesize on how and if Medicare will cover future diabetes tech such as artificial pancreas systems.

In some ways I am living with a different diabetes than at other stages of my life. Although hormones never completely disappear, they don’t rage as much for me anymore and are usually more predictable than when I was younger. In Figure 5-2 of Think Like a Pancreas, Gary Scheiner shows graphs of “typical basal insulin levels by age group.”

fullsizeoutput_19f0

The thick line is for ages 60 and older and shows a decrease in total basal insulin along with a sharper rise in insulin needs in the early morning hours. I am experiencing both of those changes and they didn’t make sense to me until I saw Gary’s chart. Most of my bolus ratios have remained the same so far.

Hypoglycemia unawareness is a mixed gift bag as I move into my senior years. On one hand, I feel better because I don’t get the sweats, shakiness, blurry vision, and insatiable hunger of my younger years. I also don’t tend to over-treat lows and multiple bowls of Frosted Flakes at 3:00am are a distant memory. At the same time I know that hypoglycemia is a huge problem for seniors with diabetes and my risks for falls, hospitalization, and permanent disability resulting from severe lows will increase. Knowing that Medicare will soon be covering CGMs for seniors is a huge relief, but I won’t consider it a done deal until I am approved under the not-yet-established CMS guidelines.

When I look at my diabetes, I am comfortable believing that I will be in control of my diabetes throughout my “young-old” years and hopefully well into my “middle-old” years. It is likely that I may require help with care at some point in my “old-old” years…. That terrifies me because I don’t trust anyone else to take care of my diabetes and my biggest fear of aging is losing independence.

Aging is a process. My life isn’t going to be much different on April 1 than it was on March 31. I’ll still have type 1 diabetes and will continue to test my blood and take insulin. I’ll still have arthritis and sometimes I worry more about that than diabetes. But one change that will happen is that I will finally start using the red, white, and blue Medicare card stashed in my wallet. Wish me luck.

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.