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.

Cracked Again

Laddie_Head SquareI just received a replacement Animas Vibe pump. At my last battery change, I discovered a crack in my pump from the top of the battery compartment down about 5/8 inch. Did I over-tighten the battery cap? I have no idea. Is it a design flaw or weakness in the type of plastic used for the pump case? Maybe. I would label it as an isolated problem but less than a year ago, I had my Animas Ping replaced for the same problem.

Animas Vibe Pumps2

In the seven years that I used Medtronic pumps, I cracked at least 3 pumps (maybe 4?). All of the cracks were in the exact same location: from the reservoir view window to the Esc button.Medtronic Pump Cracks

Maybe I am a kid who is rough with my pumps and break them whenever I wrestle and beat up my older sister. Nope. Maybe I get frustrated with diabetes and throw my pumps against cement walls whenever my BG tops 300. Nope. Maybe I have unlimited money and don’t take care of my diabetes devices. Nope.

So what is the truth? I am a middle-aged woman who will soon be called “old.” I line up my diabetes supplies in LIFO (last in, first out) order and never once in 39 years have I ever run out of supplies. I am not perfect at the diabetes game but I do a pretty good job. If nothing else, I am definitely mega-organized, methodical, and careful.

So what is the story?

After cracking the 3rd (or was it the 4th?) Medtronic pump, I spoke with a phone representative who told me that they would not replace any more pumps for me. Huh???  I called back a few days later and got a rep who asked how I was carrying my pump. I was using the Medtronic clip attached to my waistband as I had been ever since I started pumping. She suggested that after they replaced this pump that I should quit using the clip. She arranged for a free leather case (brown and ultra-masculine) which I hated. But from that day forward, I abandoned the Medtronic clip and began carrying the pump in my pocket. Never again did I crack a Medtronic pump. For whatever reason, the Medtronic clip on my waistband caused pumps to crack. For me. Obviously not for everyone. Medtronic pumps still ship with the same clip that for whatever reason didn’t work for me.

When I first started using the Animas Ping I got a few “No Delivery” (Loss of Prime???) error messages. It turned out that when I inserted the reservoir, I wasn’t pushing it in far enough or tightening the reservoir cap tight enough. With Medtronic I was always advised not to tighten things too tight. Whatever. I quickly learned to push Animas reservoirs in as far as I could and tighten the cap tightly. I have never had a reservoir error since then. So now I am cracking the pumps when I insert batteries. Am I over tightening them? I have no idea. But from now on, I will follow the Animas manual exactly as the photo below shows.Battery Insructions

So here I am. A middle-aged woman who has cracked 5 pumps in ten years of pumping. What happens with kids and teenagers who are rough with pumps? What happens with athletes who play football, hockey, and soccer? What happens with people whose pumps are randomly snatched by ceiling fans (Scott Johnson)? Although I hate to jinx myself, I have never had a pump failure. Just cracked cases. Except for the one rogue Medtronic rep, the pump companies have been fabulous in sending me new pumps as soon as possible.

So what’s the story? Is my experience mirrored by others on insulin pumps or am I just one rough, tough lady?

Beats me. As far as I am concerned, It’s just another day in a life with diabetes.

The Ultimate Pump!

I’ve been working on this post for a few months, but other topics kept pushing themselves to the front of the line.  On  11/7/13 @MHoskins2179, @txtngmypancreas, and @AMNimlos used Twitter to brainstorm the idea of having custom-made pumps.  Argh!  My idea was going mainstream!  I immediately called my lawyer, filed my patents, and got back to work.  A few weeks later I have gotten no indication that the interlopers have backed down and I guess we’re at an impasse.  Consider Microsoft vs. Apple, Dell vs. Gateway, Best Buy vs. Circuit City, Target vs. WalMart and if you’re still interested, I have a bridge in Brooklyn I’d like to sell you.

 

Laddie_Head SquareI’ve decided to buy a custom-made pump.  No pump on the market has all of the features I want and many of them have features that I definitely don’t want.  So I’ve decided to do what we used to do for many of our family’s computers. I’m going to find a small, reliable company to assemble a pump with the hardware and software from various pump companies as specified by me.  Working with the Comparison of Current Insulin Pumps at Diabetes Net, I’ll select components line by line.  I’ll also include some features that are not available on current pumps, but should be.  When I’m finished, I’ll look forward to having my ideal pump.

Size and Shape:  Because I don’t mind tubing and prefer small infusion sets in contrast to the size of even the newest Omnipod, Insulet will end up having no presence on my custom pump.  Although I like the idea of the smaller and lighter Asante Snap, I plan on having an integrated CGMS and will need a larger screen.  So I choose the Tandem t:slim for its sleek modern look and the largest useable screen.

Reservoir Options:  I have used both Medtronic and Animus pumps and have no preference for one reservoir system over the other.  But since I am designing my dream pump, I will go with the pre-filled Asante reservoirs which in my ideal world will be available in multiple sizes with all insulin types and non-proprietary connection types.  For me it will be a 200ml Novolog pre-filled reservoir.  (Of course ideally I would have access to the next generation faster insulins, but let’s be realistic here….)

Touchscreen or Buttons:  This is an easy choice.  I will go with the Tandem touchscreen where I can enter numbers on a keypad rather than scrolling up-down-up-down and continually missing my target number.  My Animas Ping requires even more scrolling than my Medtronic pumps did and has a bad habit of continuing to scroll after I release the button.  Almost anything will be an improvement for me over the Ping.

Screen:  I enjoy the readability of the black background with bright color screens of my Ping and Dexcom G4 and I will continue with color.  The downside of these screens is the difficulty of seeing some of the colors in bright sunlight and Medtronic boring gray does have some merit.  I don’t know how color is used on the t:slim, but I do like how the Ping uses white text with colors for highlighting.  The white text is much easier to read in sunlight than colors such as red.  Whoever chose red for the numbers and graphs depicting lows on the Dexcom did not do their homework.  Check out my blog post from 8/29/13.

Basal and Bolus Increments:  in most areas, I would be happy with the rates of Animas, Medtronic, or Tandem.  I would definitely like the t:slim’s options for temporary basals because I am frustrated by the Ping which only allows 30 minute increments.  Even 15 minute increments per the Asante Snap would be fine.  I also like the Medtronic option of setting temporary basals as either an exact basal rate or a percentage.

Bolus Calculator Options:  There is no pump that has exactly what I want.  I want a straightforward and streamlined menu system where I can calculate and administer bolus insulin logically and quickly.  According to Wil’s 7/22/13 post at LifeAfterDx, the Asante Snap requires only 6 steps versus the 14 steps of the Tandem t:slim to bolus for a meal.  Tandem has fallen for the FDA-endorsed idea that users actually pay attention to the warning and “Are you sure?” screens that pop up on their pumps.  If the FDA knew how little most users paid attention to safety screens and warnings, they probably wouldn’t allow any of us to use a pump.   I was satisfied with Medtronic menu system and totally hate navigating through the Ping system.  So I will check out the Asante menus and either select that or Medtronic.

Power source:  For this line item I am definitely in the battery camp and have no interest in a rechargeable pump.  I can’t count the times that I have been unable to use my Verio meter because I ignored the charging warning.  Same with my battery powered toothbrush.  Compared to the price of most of my diabetes supplies, a battery is a cheap power source.  I have carried an extra pump battery in my meter case for years and I feel more confident in this back-up plan than the idea of finding a cord and power source to recharge my pump.

Motor and Memory:  I don’t know enough about pump motors to have much preference.  As far as memory, it looks as though the Tandem keeps the most info.  So I’ll go that direction and try to convince myself to download my devices more often.

Software Download:  I haven’t seen Tandem’s software, so I’ll be conservative and go with Carelink.  The one requirement for my pump software is that it be compatible with all of my devices regardless of brand.   And it should work like my Fitbit with all devices automatically downloading with Bluetooth.

Waterproof:  I’m not sure that the Animas Ping is really more waterproof than other pumps, but I appreciate the fact that because they guarantee the replacement of my pump if I have water damage. So I’ll stick with Animas.

CGM:  Although I know that Medtronic’s Enlite sensor is a huge improvement over the previous Sof-sensor, I am committed to a Dexcom CGM for my pump.  But I want Medtronic software to integrate the CGM readings into my pump..  As much as I like Dexcom, I miss the information that is readily available on Medtronic pumps.  I like that you can scroll backwards in time and see actual sensor values rather than just graphs.  I like predictive alerts and missed those when I switched to Dexcom.

Blood Glucose Meter:  In an ideal world, all brands of meters would be compatible with all brand of pumps and have universal connectivity.  I find Freestyle to be the most accurate for me and I will stick with that.Pump Puzzle Shifted_No Back

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Summary:  The whole idea of a custom-designed pump is a pipe dream.  We will never see online promises of build to order, unleash the power, get the best, the fastest and the ultimate pump.  Because I have rarely had a computer work properly for four years, I know that I should appreciate the FDA review of our pumps.  At the same time I am frustrated with the sub-optimal and old-fashioned devices that are compromises between safety and good design.  But I can’t complain too much.  I started my diabetes career thirty-seven years ago peeing on strips and taking insulin once a day.  I am a happy camper with my Animas Ping, Dexcom CGM, and Freestyle meter.  But a girl can dream, can’t she?

Pin the Tail on the Donkey: Buying a New Pump

This post is my June entry in the DSMA Blog Carnival. If you’d like to participate too, you can get all of the information at http://diabetessocmed.com/2013/june-dsma-blog-carnival-3/ The topic is: How do you select the diabetes devices you use? To others looking into new or replacement devices, what would be your best advice to someone shopping around?

Laddie_Head SquareWhen I select medical devices, I put on a blindfold, turn around 3 times, and pin the tail on the donkey.  Oops, wrong game.  But that is what it felt like when I bought my last pump in December 2012.

When I began my pump search, I was using an out-of-warranty Medtronic Revel pump and a Dexcom CGM (continuous glucose monitor).  I had previously used the Medtronic CGM and found it to be painful and inaccurate.  But I loved having a sensor augmented pump and only having to carry one device.  So a pump/CGM combo was my #1 criteria for my next pump.  Unfortunately there was no device on the market that had the features I desired given that I was unwilling to use the Medtronic CGM.

Medical device companies are prohibited from giving detailed information about pumps in development and they have no control over how long FDA approval will take.  So ultimately I had to make my purchase decision based on my best guess of which future pump would have the features I wanted along with a guess of how soon it would get to market.  So I put on my blindfold and went to work.

Pin the TailI was very happy with my Medtronic pump and I knew that their improved Enlite sensor system would “soon” be available in the USA.  Animas was on track to release a pump that would be combined with the newest Dexcom G4 Platinum CGM.  The new kid on the block, the Tandem t:slim, was a touchscreen rechargeable pump that would also eventually link up with Dexcom.  I didn’t have any reason to consider the Accu-Chek pump, so I ignored it in my decision.  I don’t mind tubes and was not interested in the Omnipod.

Normally I would love to make a chart and compare features pump by pump.  But I didn’t have sufficient information to do that with my most important decision points. I had no way to evaluate the Medtronic Enlite sensor system, and I wasn’t willing to leave Dexcom to take a chance on it.  I found the Tandem pump intriguing, but they had no upgrade program in place and I wasn’t willing to risk not having an affordable pathway to buy their future sensor integrated pump.  I chose Animas because it will be the first pump released with an integrated Dexcom CGM and I am guaranteed a $99 upgrade fee to get that pump.

Am I happy with my Animas Ping pump?  Not really.  I knew that I would hate the menu system, but I actually underestimated how much I dislike it.  But it’s a good pump and it does the job of delivering my insulin safely.  Do I regret my decision?  No, because I made the decision based on the future which has not arrived yet.  I am still waiting for the Animas Vibe to come to market and I think that it will fix the things I don’t like about the Ping.  It will definitely give me the pump/Dexcom combo that was and is my #1 requirement.

My advice to others who are shopping for their first pump or a new pump?

Do your homework:

  • With yourself.  Decide which features are most important to you.  Do you want tubeless?  Do you require a large reservoir?  Do you want a Pump/CGM combo?  In most cases you won’t get everything on your wish list, so be open to considering several brands of pumps.
  • With the pump companies.  Visit their websites and request their brochures.  If a local rep is available, meet with him/her to see the pump and learn more about it.  Omnipod even has a non-operational sample pod that allows you to try it out on your body.
  • With your medical team.  If this is your first pump, your medical team may require classes about pumping and carb counting before prescribing a pump.  I think it’s valuable to ask for your team’s opinions on pumps, although ultimately you should get what you want not what your doctor likes.  Your doctor’s office might also have demo pumps and infusion set samples.
  • With your insurance company.  Many insurance companies will cover all pump brands.  But if they don’t, it’s good to know that up front.  For example, Medicare will not pay for the Omnipod at this time.  Also, it’s a good idea to determine your financial responsibility for the pump purchase and the ongoing supply expense.
  • With other pumpers and the online community.  Message boards and blogs are a wonderful source of information and opinions on pumps.  Fortunately most people end up happy with the pump that they choose, but it’s still helpful to learn as much as you can about the pros and cons of each brand.

It has been six months since I purchased my pump.  The questions I would have liked answered then are still unanswered.  The Animas/Dexcom pump has been submitted to the FDA, so there has been progress.  I have some regret that I did not go with the t:slim, but for the most part I think I made the right decision.  And if you think about it, it’s only 3-1/2 years until I go shopping for my next pump!