Please explain the logic, Oh Bureaucrats

Eric's healthcare is paid for by MaineCare's S-CHIP program, which (perhaps counterintuitively) is generally pretty high quality. They cover most of what I need covered, and the few things they don't cover, aside from CGM — which is another rant for another day — are inexpensive enough that I can foot the bill. Zofran, ketone strips, stuff like that. The company they contracted with to supply Eric's insulin pump supplies, Bedard Medical, is very conscientious, and I have absolutely no complaints with their service.

BUT (and you knew there was a BUT coming), recently the company informed me that where, in the past, they had been sending Eric's pump sites and other supplies every 3 months, now they would be sending them monthly. And I'm like, wha...?

Bedard was at pains to let me know that this was a mandate from DHHS for MaineCare patients. It wasn't something the company itself had decided to do. I understand why they felt the need to explain because frankly... it makes NO SENSE. Particularly for a state whose governor has harped ceaselessly on the "excessive" costs of covering low-income citizens via Medicaid (which, I should note, he refuses to expand out of opposition to the ACA, thus depriving my state of the federal funds that would be obtained by doing so).

Leaving aside my thoughts on the validity of the governor's position, let's look at the facts here:

• Eric's prescribed rate of site changes is 1 site per every 2 days. This means that his prescribed use of supplies is 15 infusion sets per month, plus 30 pieces of IV Hand 3000 tape and 15 individual IV Prep wipes. Reservoirs are a bit less predictable, as of course the number of reservoirs used depends on how much insulin is drawn in per reservoir and how much is used per day. On average, though, we've been changing reservoirs about once a week, so a box of 10 will last 2 months. As any pump user knows, though, the frequency of site changes is not set in stone. I've had times when I can make a site last 3-4 days. I've also had times when I've had to change sites 5 times in 4 days. There have even been times when the tape has failed but the site has not, so that I end up using 3 or 4 pieces of tape per site instead of the usual 2. On average, though, the assumption that I'll use 1 site + 1 wipe + 2 pieces of tape per every 2 days seems to work reasonably well. It follows, then, that I'd need 1.5 boxes of reservoirs, 4.5 boxes of insertion sets, 1 box of IV Prep wipes, and 2 boxes of IV Hand tape every 3 months.

It costs more money to ship less product more often than it does to ship more product less often. There is absolutely no way anyone can argue with this observation. The cost of the product itself does not change — Bedard sends me the same number of boxes over the course of a year regardless of whether it ships to me 4 times or 18 times [I'll get to why it's 18 rather than 12 in a minute] — so it's not the product cost itself that is the issue, but the frequency of shipment. Each time you fill an order for a smaller amount of product, a human employee must initiate the transaction (or if the system is automated, confirm it) on the company database and fill the order. Someone at the warehouse has to identify the product(s) to be shipped and package them for shipment. Someone has to pass the package along to the appropriate shipping partner, and the shipper has to deliver the package. And then, the cost of shipping the supplies must be invoiced so that payment can be received. ALL of these individual transactions are paid transactions, whether per-item or per-man-hour. And the more often you initiate these transactions, the greater your total cost.

Durable medical equipment cannot be misused. You can only use insulin pump sites or insulin reservoirs if you have an insulin pump and need insulin. Well, OK, perhaps there are some strange people out there who think it's enjoyable to poke themselves with pins for fun, but they would not need to obtain a $169 box of 10 insulin pump sites for this purpose. They can go buy 100 craft pins for $5 instead. Is there a thriving black market in insulin pump sites I'm not aware of? Maybe, but I tend to doubt it. IV Hand tape and IV Prep wipes are a bit more multi-purpose, but they also cost a hell of a lot less, and I don't think you need a prescription to get them. So if the thinking behind it was based on trying to limit fraud, well... WHAT fraud?

I calculated out the cost difference of the old way they used to ship Eric's supplies (1 large UPS box containing 4 to 5 10-ct boxes of insertion sets, plus 1 100-ct box of IV Hand tape and 1 100-ct box of IV Prep wipes sent every 90 days) versus their new strategy of sending 1 10-ct box of insertion sets every 20 days, plus wipes or tape if I reported needing any. Let's look:

Per UPS, an 11 x 9 x 6 box weighing ~ 5 lb shipped from Auburn ME to my home costs $16.06. Four such shipments/year adds up to $64.24/year, plus the costs associated with paying Bedard's and UPS's customer service and shipping personnel for 4 individual sets of transactions.

Now consider the costs of shipping the new way: to meet the needs of Eric's prescription for a site change every 2 days, 1 10-ct box of sites must ship every 20 days [this is why the 18x rather than 12x transaction rate] via USPS priority mail flat rate service. The 11 x 8.5 x 5.5 box in which my last shipment, consisting of 1 10-ct box of sites and 1 100-ct box of IV Hand tape, was sent costs $5.32 to ship at commercial rates. Multiply $5.32 x 18 shipments/year and you get a grand total of $95.76 — a more than $30 per year increase in cost over the prior method, without taking into consideration the fact that you have also increased the per-transaction costs associated with documenting, packaging, shipping, and invoicing the shipment by more than 4-fold.

I really have no idea how many MaineCare clients receive these services, but if even 100 of them exist, with similar requirements for DME as Eric's, then MaineCare is paying $3000 more per year just for shipping, and a 450% increase in the per-transaction costs of fulfillment and billing.


Seems to me that if they'd simply switched from UPS to USPS, that would've been a savings, and saving money is good. Spending more is not. There is no good reason whatsoever to have initiated such a change.

Now consider another factor. As I mentioned, there are indeed times that I have to use more sites than the prescription calls for. Sites fail for myriad reasons: Eric is a young, active child, and cannulas crimp, sites fall out, we all know how it is. But, similarly, there are often stretches where I get more than 3 days of use out of a site. When I have 3 months' worth of supplies on hand, the averages even out. If I rip through 20 sites one month, but 10 sites the next, and 15 sites the next, I'm still averaging the 15 sites I was prescribed. But when I have just 10 sites on hand, and I have one of those weeks where it seems like insertion sets are categorically opposed to adhering to my child's flesh, that may mean I have to request a shipment sooner than expected — which adds an additional shipment, and an additional set of transaction costs, to the total.

Please explain the logic, Oh DHHS Bureaucrats. Because I don't think you really thought this through.

Sorry you're having to deal with this. Your comments sparked my curiosity and I came across this proposed rule change for MainCare. You might already be aware of it, but it looks like they're considering covering CGMs!

I wouldn't be surprised if you might be one of the moving forces behind the CGM coverage change -- is that the case?


Did not know that. Irony is, we stopped using CGM as much because Eric kept getting staph infections as because of cost. But, given the opportunity, I'd put him on a Dexcom in a heartbeat.

No, I'm not a moving force behind it, but I'm sure as heck willing to get out & push.

As far as the policy change is concerned — it's more of a nuisance than anything, but when you stop to think about the incremental costs involved, it really does make you wonder why they did it. If they can genuinely show me why it makes financial sense to make this switch, I'd dearly love to know... because from where I sit, it looks like it increases costs to the taxpayer as well as inconvenience to the patient, and I would expect it would need a pretty darn good offset to balance that pair of factors.

Elizabeth there is no rhyme or reason to something this ridiculous. Any more than there is a reason Medicare to which 2.9% of my lifetime earnings has been deposited does not cover an Omnipod Insulin delivery system and yet will cover virtually any other tubed pump. There is no logic in it. Never mind getting coverage for a CGM for the most vulnerable of the D populations those people who are hypoglycemia unaware including children and seniors.

Re the change to 30 day supplies, perhaps they concluded it benefits them when they terminate someone's coverage. God forbid they ship someone a 90-day supply, but then terminate their coverage in 30 days. I was going to say some bean counter somewhere must have decided it made sense, but then I remembered, this is a government agency we're talking about so common sense is optional.

to me this whole thing sounds very scary
so stupid
it's not like we can go to the store next door & buy what we need whenever we need

I keep thinking someone, somewhere, must have had a reason for why this makes sense and if only I could find out what it was, it would make sense to me. You may be right about the reasoning. But it's so short-sighted and small scale, it's breathtaking. Because even in situations where the DO send a 3-month supply and then terminate benefits a month later, the cost to the system is smaller than the expense of sending supplies more often.

But look at me, expecting government agencies to behave rationally.