RE: coverage of CGM's

Type 1 and LADA
41

As the seemingly sole contrarian here I want to make clear that I think CGMs should be standard care for T1s, covered by insurance, and would support legislation mandating that much narrower program than availability to all diabetics.

I say this as a T2 with a CGM, covered by insurance. A T2 for which this technology has changed my life.

Yet, it is not essential for me, not by any means. More so than for non-insulin using T2s, but still, I could get by pretty well without it.

A CGM is, in my opinion, essential for a T1.

It's a fantastic tool for the T2 that wants to achieve tight tight tight control, and for those T2s (like me) I think it should also be covered.

However, I'd place far more restrictions on T2s asking for these technologies ensuring that it's actually making a difference, and not just something they want to have.

As offensive as it is to have to read the truth, the fact is there are far too many T2s that are not very engaged in managing their disease, by choice. There's a component too of poor counseling and advice from doctors, but the fact remains that many, if most T2s just don't take their disease seriously.

Until the complications start.

T1s, being threatened constantly with DKA, hypo, possibly death, are far more inclined to take things seriously, although even among T1s there're far too many that make completely irrational choices (like diabulemia, for example).

42

I obviously disagree with such nonsense.

A cgm built in volume and sensors to go could be reduced to a couple of hundreed dollars.

Such sohpistry is revolting, angering amd rediculous.

When Video tape recorders were made by ampex; they were monsters for the tv studios costing millions of dollars.

The funny part is that Sony and JVC figured out how to make the 3/4 cartridge taoe recorders incorporating all the complec helix scan heads and servos and initial units sold for $ 1,000 to $2,000. Eventually they were made and sold for $200 to $ 300 each.

I see the same on cgms technology which is simpler and far less involved. So what if every one wants one. The human body comes with no gauges. Even the auto has more.

This argument is discimminating, specious and undeserved.

In any event my wife has serious disabilities I have been caring for in a long time. I had a stroke and 2007 and thank goodness it was not serious enough to completely disable me and I am her care giver still.

I do not have time for crap arguments like this , self centered and nasty and not any longer as I need to help my wife and work my diabetes.

These statements continue to be nasty, discrimnitory and unnaceptable!

43

Oh my goodness, the kings and queens of type 1 diabetes.

15 % of all diabetics yet the other 85 % of diabetics type 2 can rot in hell and make use of less equipment and tools. What a farce that is!

No thanks Dave, your exclusive view that the 15 per cent get the help while all else can screw off does not sit well on my ship.

The simple fact of the matter is that get the price point on these tools down to something reasonable and the insurance companies, medicare et all would probably be glad to approve and make available!

Test tools are required to resolve difficult problkems requiring data visibility and sufficient frequent data.

Why are type 1's so special!

44

Jim, you've got some sort of major chip on your shoulder about this, and I'm sorry it gets in the way of polite discussion.

Wishing you and your wife well, sincerely.

45
Why are type 1's so special
Because they face a serious damage, suffering, and several days in the hospital 24/7 if they don't closely manage their blood sugar, every minute of every day -- and that's the best-case scenario. Worst case, they face death. Not long-term complications death, death tomorrow.

This simply is not a risk T2s, generally face. Not the vast majority of T2s.

46

I'm a T1, and I have no restrictions on the amount of test strips I get. But I think that part of the reason that many T2s are not very involved in their treatment is that they actually don't know what's happening in their bodies, and have not been given the education or equipment that would teach them that intensive care NOW means less chance of complications later. And I think that is what jims is getting at.

If a T2 is very stable, maybe they don't need a CGM. But that is not to say that all T2s are stable. Pumps would actually help a lot of T2s manage their BGs and give them a freer lifestyle than the regimented on they have to follow to regulate BGs. When I was on MDI, I had to be very regulated, and still had a lot of highs and lows. I don't imagine a T2 who has lost most of their insulin secretion would be very different.

Maybe there do need to be criteria about which patients are suitable candidates for pumps and CGMs, but that should be up to the doctor, not the bureaucrats. And EVERYONE should get just as many strips as they need, no questions asked, unless the number is so excessive that there is suspicion that they are selling them on Craigs List or something. I feel so sorry for the people who are really trying to control their diabetes, and can only get 3 strips a day. that kind of makes diabetes treatment a joke.

47
But I think that part of the reason that many T2s are not very involved in their treatment is that they actually don't know what's happening in their bodies, and have not been given the education or equipment that would teach them that intensive care NOW means less chance of complications later.
I really, really, really hope you don't get offended and upset at my having a different opinion about this, and feeling entitled to share it here.

I'm highly skeptical of this view. I look at smokers, and the intensive campaign our society has had over the last 50+ years to discourage this suicidal habit on the sort of motivation you speak of above, and it has been pretty much ineffective.

Far more effective has been social acceptability/stigma. There are quite a few studies over the past decades trying to figure out why the billions spent on "it's bad for you", "look at the scary things you're facing down the road", etc. basically didn't work.

The answer is, deferred consequences. The problems associated with smoking are just too distant, abstract, and uncertain. People often will put it off, forever, saying, "I'm gonna quit next week" and then never do.

The high addiction potential of nicotine isn't the reason -- sugar can be just as addicting, and food generally has a strong attraction for situations other than basic nutrition (where did the phrase, "comfort food" come from? :-))

The point is, most people are pretty much "don't care" about things that are not immediate or near-term problems. It's human nature. Resources, time, energy, etc. are limited... it's hard to get people to focus on things that are abstract possibilities.

The problem is, even for diabetics the stats are not that scary. A relatively small proportion of T2s with reasonably controlled BG (a1c <8%) never get any complications worse than some mild neuropathy. The large majority never have kidney failure, heart disease, eye problems, strokes, vascular issues, amputations, and all the really bad bad complications. If simply told the truth, most diabetics are likely to shrug and take their chances. Again, human nature. I simply disagree with Jim (and perhaps you, and some others) that large numbers of current T2s would be knocking down the barn door for CSII and pumps, CGMs, etc. if only they were better educated about the disease. What's being proposed here is trying to convince people who's lives are relatively unaffected by their diabetes to take on all the issues we insulin-using diabetics complain about regularly, the intrusion into their lives, etc., for what? Reducing a1c by 1-2%, reducing their risk of nephropathy from 1% to say 0.5% ("Although people with diabetes remain the largest clinical category on the dialysis register,[15,16] probably < 1% of type 2 diabetes patients will reach end-stage renal disease and require haemodialysis or transplantation" Medscape).

Short of dialysis, treating kidney impairment for the vast majority of T2s consists of taking a pill. Again, try to convince someone to hook up to a pump, wear a CGM, start counting carbs, deal with hypos now and then, etc. etc. etc. instead of just popping a pill once or twice a day. Not gonna happen.

We are a self-selected group here. Hardly representative of the average PWD. We take an interest in this condition, and a fire in the belly to treat it as best as possible, that the vast majority of PWDs don't. Including those Kings and Queens T1s jim refers to. Outside of this forum, there are plenty of reckless T1s, people who aren't interested in a CGM and/or pump. Heck, getting them to simply inject and dose insulin properly at all is a quite a project for their doctor, family, and friends.

So understand that I'm not arguing the point that all diabetics could benefit from the use of these treatments. Anyone that's been reading my posts around here over the last year know that I advocate as much. I agree with that opinion completely.

Where I differ is in the, in my opinion, (vastly) overly-optimistic view that the rest of the D world is more or less similar to our tiny enclave here on TuD. My experience with people generally, and other diabetics "in the wild" more specifically gives me absolutely no confidence, at all, that what's missing for them is information. Rather, the problem is their own priorities, and that's about it.

48

I don't disagree that many people wouldn't take any better care of themselves if the equipment were available. What I'm objecting to is that people with T2 who DO want to achieve the best control they can are being denied what they need SIMPLY because they're T2. This is where doctor judgment comes in. And I would rather see it in doctors' hands than in bureaucrats' hands. For example, if a T2 is on insulin, but has a C-Peptide in the "normal" range, they don't get a pump from Medicare, but maybe a highly motivated person really COULD benefit from a pump instead of taking 8 shots a day. There IS the quality of life issue, and the pill-poppers may not need much (although their pills ARE expensive), but a T2 on insulin shouldn't be denied the pump that he wants simply because he's a T2. That's really what I'm getting at.

49

Natalie wrote above: There IS the quality of life issue, and the pill-poppers may not need much (although their pills ARE expensive), but a T2 on insulin shouldn't be denied the pump that he wants simply because he's a T2. That's really what I'm getting at

Natalie, I do so much agree. It seems both unfair and senseless to me, too. Those type 2's who do want to get in good control are not allowed to do that with the best technology available, simply because they are type 2.

50

Natalie_C:

Thank you for your excellent comments that help reach beyond my frustration and heated response. I believe you have caught the essence of the discussion.

Type 2's really need the discipline and skills learned by T1's to manage their disease. There is no excuse for slopiness or bad discipline.

In the end a 30 year type 2 faces very serious challenges to keep mess under control and when using insulin and one strip a day ain't it!

Emotional shortsighted conclusions and frustrations have no place in that war!

Once again, thank you as always!

51

I agree 100% with both of you. 100% -- as Natalie decribed it. I note this is pretty much what I was saying (i.e. T2s should have a few more hoops to jump through to get these technologies), but they should be available.

Well, they are, right now, with some extra hoops to jump through. I'm a T2, I meet the descriptions of the "extra hoops" we're talking about here, and Anthem Blue Cross approved me a year ago for CSII with the Omnipod and the Dexcom G4.

It was exactly the scenario you're talking about, Natalie: My doctor (endo), saw that I was genuinely motivated and very serious about tight control. My control was terrible. She advocated strongly for me, and got it approved.

Here I am a year later with an a1c of 6.2, down from 11.

The complications risk argument is easy to make going from 11 to 6. My endo says we could have done this dropping from 8 -- insurance would have approved if she'd pushed under those conditions.

The main thing was me: She wasn't going to do any of that, and burden A/BC's policy holders with the expense, if I was like the vast majority of her T2s. We discussed this.

In any case, this has strayed far from the point of this original discussion: Making these technologies more affordable. Which led to economies of scale arguments. Which led to making them widely available to all diabetics through insurance to encourage those economies of scale. Which led to the argument, that I started, that thats a tough sell given all the issues I've raised.

Which only artwoman ever directly addressed and discussed. Others side-tracked the discussion and got into some pretty shocking personal attacks and blatant insults, simply because I don't agree that the public, generally, will ever be willing to pay for these things for all diabetics generally, without some constraints.

Which elicited more attacks and insults.

Bottom line, Natalie, Brunetta, Artwoman, Melitta: I agree with what Natalie said above. It's precisely what I said a few posts back, that Natalie was responding to.

For some reason, Natalie is praised. I'm questioned as to whether I'm a shill for some doctor, and all sorts of other vituperation for saying the same thing.

Boggles the mind.

52

I know that Medicare monitors c-pap machine (to treat sleep apnea) usage via the hardware chip. If the person is not using the machine at a minimum level then Medicare stops paying. Perhaps this is a model that could be used for Medicare (and other payors). If you have diabetes, no matter the type, you should be covered by private insurance and/or Medicare.

If you then don’t use it then there should be some kind of economic penalty. This is better than simply denying T2Ds based on c-peptide. There are several T2Ds here making excellent use of their pumps and CGMs. They have just as much right to the technology as anyone!

Unfortunately, not everyone will use all their D-tech as intended. These people, at a minimum, should be required to return their hardware.

53

You know Natalie, I am almost sorry I posted the original post. I was hoping it would be good news, that finally "policy makers" might realize it is an economically sound idea to make accessible the best that's out there. Instead, it looks like I opened a can or worms.

Your statement about denying people with type 2 tools that they could and would use is spot on. In my (little warped) mind is stems from the overall "blame the PWD" attitude of not just the general public but the medical establishment (and I am including govt and insurance plans along with many Med'l folks)as well.

And among those tools is adequate correct diagnosis and education. When I was firswt Dx'd - 30 years old - they only used the age criteria. You've all red my history in other posts (in particular Melitta's excellent report on rapid onset type 1 in adults) I was sent home with the vague "eatch weight, get more active, make better food choices". It took being found in a coma from SDKA to get the correct Dx. I hate to admit it but I am grateful for the "mrs Kravitz 9remember Bewitched) nosy neighbor who found me. While considered type 2, I finally got some insulin 15u once a day. No info that that was gonna change, and no instructions for follow up. My point (aside form whining) is that patient education is key - let PWD's know what's out there. And encourage people to do their best.

There are so many battles and discriminations that mkight very well be won if general public education happened as well. I know ther was a comment about people with type 1 insisting they can do anything they want. For me the source for that behavior is belief that 1) we're too fragile to be hired or 2) how can we possibly be promoted if we don't have enough responsibility to take care of ourselves - after all we ourselves diabetes.

Together we can prove the naysayers and blamers wrong. At least that's my hope

54

"nudge them" ??? Hell, they need to be slapped up side the head with a 2x4.

55

Terry & Natalie,

A bit late in the posting here, but I'm about to transition to Medicare this July-2015. I'm T-1 since 1967, been wearing pumps for 25+ years and CGMS devices for 5+ years. I have to wear mine 24x7 as I can't detect low BGs anymore.

You've indicated that your "Supplemental" insurance (I'm guessing it is a Plan F offering) that is covering your CGMS product. Could either or both of you send me some details about such and (if your prefer) via PMs. Terry & Natalie - It seems that you are carrying your former (non-medicare supplemental) as your secondary coverage after Medicare Part A/B and that you have not subscribed to a Plan F (or similar) offering..??

Thanks in advance.

Cheers,

Nolan Kienitz

56

What is a plan F? My secondary is covered by Washoe County School District (Northern Nevada -- I live in Reno)and part of the original contract was that I would pay into Medicare but that my school district insurance would be my secondary. They are wonderful about covering what I need.

57

Plan F and Plan G and the like are all Medicare Supplemental plans. You have clarified that you are on Medicare Part B and that your school district is providing your Supplemental.

That is not my arrangement. What if your school district makes a decision to stop providing Supplemental coverage?

My wife’s Mother had that happen to her a number of years ago when the company she retired from made a decision to stop all medical coverage plans for retirees. Heck of a learning curve to get her on Medicare coverage that would be accepted by the local (rural) doctors and hospitals. That worked for about a year until all the local doctors/hospitals stopped accepting any/all patients on Medicare plans. My wife and I then had to make 200 mile r/trips to get her to/from doctors/medical facilities here in the Dallas area that were still accepting patients with Medicare coverage.