Part 2: The Times They Are A-Changin’

Posted on August 26, 2013 by Laddie

The first part of this series focused on change coming as a result of the Affordable Care Act. This post will discuss one change that has already occurred in my healthcare universe and how I expect it to impact my care.

Late in 2012 I received a notice from my internal medicine clinic that they were switching to a cash-only model starting on April 15, 2013. The primary reason for the change was stated: “The present insurance environment reimburses independent clinics less than large, corporate practices. To continue to provide the high quality care that you have come to expect at our office, we need to change our business model.”

Initially I panicked because I thought I was going to be forced to leave a doctor whom I like and respect. Doing my homework I learned that my insurance will cover visits to this clinic, but it will be as an out-of-network benefit and I will have to file the claims myself. The out-of-network provision means that any difference between the billed amount and the charges allowed by my insurance company will be my responsibility.

There are actually 3 options for continuing my relationship with this practice. The first is a straight fee-for-service plan where office visits are billed based on time and lab/procedure fees are reasonable because they lack the high mark-ups traditionally billed to insurance companies.

The second option is a fee-for-service plan with a $300 annual fee for “Enhanced Primary Care.” This plan provides access to my doctor through phone, email, texts and online care.

The third option is a Comprehensive Care plan where everything including office/hospital visits, labs, EKGs, phone consults and emails is covered for a fee of $2500. This option is basically concierge medicine as shown on the TV show Royal Pains (USA Network) minus the mansions, sports cars, helicopters, and obnoxious brother.

After some thought, I decided that my initial panic was unfounded and that I should not make any changes for the foreseeable future. One reason is that my current insurance through the high-risk pool in Minnesota will disappear in 2014 when insurance companies can no longer refuse me coverage because of Type 1 diabetes. It seemed silly to find a new internist in 2013 and risk having to change again in 2014.

A second reason is that in recent years I have only seen my internist once a year for a physical. Despite being the queen of autoimmune chronic conditions for which I see specialists, I’m pretty healthy otherwise. I figure that if I have no significant changes in my health status, there is no major financial risk to staying with this practice. As I choose insurance in the coming years, I will need to be sure that I have coverage for out-of-network physicians even if it is with a higher co-pay than in-network doctors.

A third reason is that I will be on Medicare in less than four years. Although this clinic will be cash-only for regular insurance, it will continue to accept Medicare. There is a caveat with this acceptance. In order to stay in the practice with Medicare, you are required to pay the annual Enhanced Primary Care fee of $300. I am okay with this fee and understand the necessity for it. Medicare reimbursement is often ridiculously low or nonexistent for many services. I realize that my doctors and their staff need to make a living wage in order for the practice to thrive. Also the telephone consults and online benefits included in that fee will be beneficial.

I have an appointment for my annual physical in three weeks and this will be my first visit under the new cash-only model. I have selected the fee-for-service option because currently I don’t need the benefits of the Enhanced Primary Care or Comprehensive Care models.

Although I was initially frightened by these changes, I am starting to be more comfortable with the idea of a different financial relationship with my internist. In many ways I think that this change may end up ensuring that I have better medical care in the coming years.

Each of the five physicians in the practice has a personal statement on their website explaining his view of the transition to a fee-for-service model and his future in medicine. My doctor ended his statement with the following words:

“The decision to no longer accept insurance is the change we needed to make. It was a very difficult one…. I hope that our sensible pricing system reflecting the service and follow-up provided will be understood as necessary to keep our practice viable. I believe that the new care opportunities for visits and consults, telephone and email, will result in better services and allow us to continue to provide the type of care our patients expect and deserve for many years to come.

I always knew I wanted to be a doctor. I still do. With the patient as my primary focus. Practicing medicine the way it was meant to be practiced.”

Those of the words of a physician that I am pleased to call “my doctor” and I hope that his decision to take the insurance company out of the equation will be a good decision for both of us.

Part 1: The Times They Are A-Changin’

Posted on August 22, 2013 by Laddie

When Bob Dylan wrote this song, I think that he was writing about civil rights, history, and the idea that change is coming whether you want it or not. Sounds a lot like the Affordable Care Act. Some of the provisions in this bill have already been enacted and we’ve seen increased coverage for preventative care and the ability for young adults to stay covered under their parents’ insurance until age 26. But there are still big changes to come in 2014.

I have always had good insurance and know that I am very lucky. In general I have been isolated from changes affecting “other” people. My current insurance is through the high-risk pool in Minnesota. It is expensive but the coverage is very good.

I am 61 years old and a synonym for my insurance in the coming years is going to be “change.” Starting in 2014, I will purchase insurance through the MNsure Marketplace which is the health exchange set up in Minnesota as a result of the Affordable Care Act. Right now I see nothing that indicates that I will get either cost savings or better coverage. Using the calculator on the MNsure website, it looks as though my premiums will go up about $150 per month. However that is not an apples and oranges comparison. I currently have a high deductible plan along with a Health Savings Account and the calculated amount from MNsure is for a “silver” plan with little information on the details. So it is a waste of energy to spend much time thinking about this until the exact details are available in October.

I think that the hardest part about selecting a plan in the fall will be knowing exactly what my coverage will be. Things like office visits and doctor fees will be easy to decipher. As someone with Type 1 diabetes in Minnesota, it is unlikely that I will have to worry about coverage for my insulin pump.

But coverage for my Dexcom Continuous Glucose Monitor (CGM) will be problematic at best. I have used a CGM for 5 years, so how do I prove that I need it? I haven’t had a severe low requiring paramedics in ages. I haven’t been having severe overnight lows. I can hardly remember the last time I even needed my husband to get me some juice. And why is that?

Because I use a CGM.

I suppose I can keep track of how many times the Dex alerts me to lows. I can count the times it wakes me up at night to tell me my BG is 70 or dropping fast. Although I always want to ignore these alerts and go back to sleep, I am very good at eating some glucose tabs from my bedside table and programming a temporary basal of zero on my pump for an hour. I never correct a high without testing and most of the time confirm a low with a test before eating glucose tabs. But I never do nothing. Like many Type 1’s who use a CGM, I rarely have a night that it is not alerting me to something. It’s a nagging parent and I don’t ignore it.

Another question will be test strip coverage. My insurance has always provided me with the number of strips prescribed by my endocrinologist. How will I be able to tell if my new insurance will do so? And then we get to the issue of what brands of strips will be provided. Will I know what the drug and supply formulary is before I select an insurance plan?

Speaking of the drug formulary, will I know what brands of insulin are covered? Will my current insulin type be covered at a higher tier or maybe not covered at all? Frequently I read blogs and message board posts by people being forced to change insulin types because of a formulary change by their insurance company. To many decision makers at insurance companies, all fast-acting insulins are the same. Those of us who use them know that the different chemical compositions and additives can make a big difference in our control and potential allergic reactions.

This fall I will be making a big decision about insurance. I have started a list of questions to address as I compare plans. I hope that I will have enough information to answer those questions. Even if I don’t, I will have to make a choice and keep my fingers crossed that it is a good decision.

Change is coming and there is no exit off this freeway.

My Insurance Appeal for Dexcom Coverage

Posted on August 2, 2013 by Sue from New York

In January 2010 I started using the Dexcom Seven Plus Continuous Glucose Monitor (CGM). I had wanted to go on the FreeStyle Navigator CGM System because of its reputation for accuracy, but I went to the Syracuse Joslin Center to meet with the certified diabetes educator, she advised me to go on the Dexcom Seven Plus instead. I reluctantly agreed. Of course it turned out to be the right decision because not long after that Abbott stopped selling the Navigator in the U.S.

Anyone who uses the Dexcom knows what a life changer it is with controlling blood sugars. I used to have at least two severe overnight hypoglycemic episodes every month. I’ve only had one since going on the Dexcom. Yes, there are nights when my husband and I are woken repeatedly by Dexcom alerts for high or low blood sugar. However, that is a small price to pay to avoid waking up wet with sweat and seeing my husband sitting next to me with a concerned look on his face. What he went through to bring me to back to consciousness was much worse. I know that experience because our son also has Type 1 diabetes and I have been on the caregiver side of severe hypoglycemia.

A year after going on the Seven Plus, my personal diabetes manager (PDM) that controls the sensor went out of warranty. In February 2011 Dexcom sent me a new one. I had changed from one Blue Cross insurance plan to another during the year, and although my new company had been paying for the sensors, they sent me a letter of denial stating the following:

“According to Corporate Medical Policy and peer-reviewed literature, continuous glucose monitoring systems are medically appropriate for patients who are currently using an external insulin pump and, for patients over 18 years of age, diabetes is poorly controlled as evidenced by unexplained severe hypoglycemic episodes defined as an episode of low blood sugar resulting in a profound degree of cognitive dysfunction (e.g., stupor, seizure or unconsciousness) which requires external assistance for recovery. The medical records submitted by Dexcom do not indicate any of the above conditions. Therefore, these services are not medically necessary and are ineligible for coverage for DOS 2/15/11.”

I immediately called the insurance company and was told that I could appeal the decision. I composed a letter of appeal stating that both Dexcom and I had called to get authorization before the replacement PDM was shipped. Dexcom had sent them records of my blood sugars and my endocrinologist’s letter of medical necessity. When I had called, I was told that no pre-authorization was needed, just the letter of medical necessity. So we both thought we were good to go. In the letter, I detailed numerous episodes of severe hypoglycemia, one resulting in cuts after falling into a glass table (luckily it was safety glass), and sometimes needing assistance from medics or transport to the emergency room. I provided them with a copy of the bill from the hospital, as well as printed reports showing numerous blood sugar readings below 50 from my Dexcom and OmniPod pump. In my final paragraph, I stated:

“In consideration of the fact that I am using an external insulin pump, over 18 years of age, and I have poorly controlled diabetes as evidenced by unexplained severe hypoglycemic episodes resulting in a profound degree of cognitive dysfunction, I believe that the CGM provided by Dexcom is in fact medically necessary for the effective management of my blood sugars. In the event that I were to discontinue use of the Dexcom, I believe that I would resume having severe hypoglycemia episodes that would require outside assistance, i.e. a 911 call for assistance and/or emergency room hospitalization, and have higher A1C’s and increased variability in my blood sugar ranges.”

In June they reversed their decision and paid Dexcom.

I have since transitioned to the Dexcom G4 Platinum CGM and now enjoy increased accuracy and ease of use.

In two years I will be of Medicare age and I know that all the rules regarding continuous glucose monitors will be different. I am thankful for people like Sue from Pennsylvania who is assisting her Type 1 husband in appealing Medicare’s denial of payment with an administrative law judge. I pray that they and others will pave the way for Medicare to change their policy of nonpayment for CGM systems so that Type 1’s can continue to stay safe in their retirement years.