Just curious, but for those of us that do insulin injections, why is there not more that use a pump? When I was first put on insulin, I thought the pen was great, but a type 1 friend of mine got me to use a pump, and now I have great control on my daily numbers and my A1c. Just curious.
Some insurers are more reluctant to cover the cost of an insulin pump if one has Type 2. I agree, unfair.
Another issue is that, in general, many people with Type 2 utilize a much higher TDD than do many people with Type 1, so pump reservoir capacity can be a major issue.
My husband is a Type 2 and went on the pump about 8 years ago. It was thought that the insurance was not going to approve it, but I think since his A1c was 11.6, they did. We have gotten it down to 6.5 so it is definitely worth it.
My insurance rejected a pump for me, because my A1c was not over 9.5, and I did’nt have “regular” numbers over 500… HOWEVER, through a bot of luck (I suppose), I managed to get a pump (originally, the Asante Snap, now the Animas Vibe). The insurance didn’t pay for the actual pump (long story, which I can repeat, if needed), but they have happily paid for pump supplies.
My A1c hasn’t changed much since going on a pump, since I already had fairly good control; however, my TDD dropped by 35% immediately after going on the pump, and I was able to stop the regular lows I was having without sacrificing my BG management otherwise.
For the most part insurance companies (and Medicare) have adopted criteria that make it much harder for someone with T2 to get a pump. Most insurance companies simply follow Medicare. The primary difference between T1 and T2 is that as a T2 you are required to have a low c-peptide, less than 110% of the reference population. The challenge is that if you have T2 you may be (very) insulin resistant which makes even “normal” c-peptide levels insufficient. The criteria has nothing to do with insulin deficiency.
My insurance (Aetna) has fortunately removed the discriminatory c-peptide criteria but they still basically require you to demonstrate uncontrolled diabetes to qualify.
In my case, insurance coverage is simply not available, period, so it would have to be out of pocket and that’s just not happening. Also, the idea of pumping doesn’t appeal to me much, for a whole host of logistical reasons. This isn’t the place for that debate; it’s been developed at length in other threads. Just answering the question from a personal, individual point of view.
I think another issue that stands between a T2 and a pump is the general practitioner. Most are very reluctant to prescribe insulin much less a pump. My own GP will not prescribe a pump or the insulin vials to use with a pump. He will gladly prescribe insulin in pens for me to use. When I decided I wanted to pump I had to start seeing an endo. General practitioners just don’t like managing a pump, mine will not.
That’s the irony for me – my c-peptide is well below normal and easily meets the Medicare criteria for a pump; however, UHC does not use that criteria. Instead, they have this “seriously uncontrolled” criteria. My endo tried to argue that I needed a pump to help stop the regular lows I was having (which would seem to be reasonable); however, UHC argued that only HIGH BG’s (over 500, “regularly”) or an HbA1c over 9.5 qualified for a pump – for low BGs, they approve CGMs. Exactly one week later, they also denied my request for CGM coverage with the reason that “this technology is experimental for your condition.”
It’s the actuarial game: there are too many people with T2D - if they ALL were approved for pumps, the cost would be too excessive for the insurance companies. Sure, complications are much more expensive, but THEY are willing to take the risk (on our behalf…) Nice of them, isn’t it?
My GP does not fully “understand” pumping, and so, like yours, he is reluctant to prescribe a pump to anyone. If I needed it, though, he would give me prescriptions for insulin in whatever form factor I request. As it is, I prefer getting insulin in pens, even though I use a pump, because (a) they come in boxes of 1500U, instead of 1000U vials, so i tend to get a little extra to account for errors/spillage, and (b) I can take whatever is left in the last pen I used with me is a backup, in case the pump fails while I’m away from home. I know it’s not the recommended approach, but I find filling my pump from a pen to be a VERY simple process with almost no problem with bubbles, and very little guesswork regarding the number of units I’m using.
I suppose that’s one more bit of “baggage” I carry from being an Asante Snap orphan – I learned some very useful “bad habits” that I’m not willing to forgo…
Is this really a difference between Type 1 and Type 2? I don’t think my GP would prescribe “advanced” regimens like pumps and CGMs, he just doesn’t know enough about them to be able to prescribe them. I highly doubt he would touch my insulin regimen, either; I suspect he’d tell me to go talk to my endocrinologist. All Type 1s I know who have these devices received the prescription from an endocrinologist, not a GP. Most Type 1s see an endocrinologist to manage their diabetes anyway.
In the practical sense, I think Gary is right.
Jen, your analysis is spot on, but if I may take the liberty of putting words in his mouth, I think his point is that most T1s do see an endo and the overwhelming majority of T2s, don’t. The consequence of that is inevitably going to be that the T1 population’s doctors are more likely to be familiar, comfortable, and competent with pump management.
I agree @David_dns. My GP was happy to prescribe insulin to me, when it became clear that the other Type 2 meds were having too many adverse affects on me; however, a couple weeks after starting insulin, he and I discussed moving forward and some of the issues I was having, and we collectively decided that I should see an endocrinologist. It was only then when other options/technologies (CGM first, then later pump) were discussed.
David is, as he said, putting words in my mouth and he is dead on correct, most GP’s will quickly send their T1 patients to an Endo without question. It is not the same with T2’s, general practitioners will hold on to their T2 patients. I believe that’s the reason you see outdated insulin regimes such as sliding scales used often for T2.
My GP is more than happy to treat me with MDI but will not touch my pump. Had I not requested to see an endo I would still be on MDI.
If someone with Type 2 isn’t able to get good control of their blood sugars and isn’t referred to an endocrinologist, then they have a right to be upset. It seems to me that a GP even prescribing insulin might be over-stepping boundaries in terms of knowledge. It would make sense to me that anyone taking insulin (a hormone) should be seeing an endocrinologist. It sounds like in the above cases a referral was made, which seems totally appropriate to me, even if it did delay getting a pump/CGM.
So between insurance and GP, s, type 2’s kind of get sidelined for pumps.
This makes sense now, as a general issue. I thought you were complaining about your GP not prescribing advanced equipment (which I personally wouldn’t expect them to), but it seems to be more of a complaint of GPs in general not making a referral when appropriate.
Thank you for this discussion. So generally CGMs come before pumps on type 2 's? I wouldn’t want a pump myself. But wonder about CGM.? Nancy
You are correct, my GP started me on insulin in stages first on basal insulin with minimal instructions, when that wasn’t enough he introduced bolus insulin but did not give any instruction other than to use it before meals. I’m sure he lacked the knowledge to correctly instruct me on basal insulin. For that reason I believe its inappropriate for most GPs to even try to prescribe insulin. All T2 needing insulin should be referred to an endo just like they do their T1 patients.
I agree, I can’ find even if I wanted to a GP here who will manage my diabetes as a type 1. Its go see an endo. Especially if you, which who doesn’t want to be on all the newer insulins and as you stated the technology that goes with it. I think PCP’s are more comfortable managing type 2’s even if the management is outdated. Sadly, probably why in the general diabetic population so many type 2’s don’t have such good control. It’s simply take a pill and check your blood sugar at least once or twice a day. My insurance also requires that an endocrinologist is the one who is requesting a pump. Once again probably because endo’s are going to have much more knowledge regarding how to manage a patient using an insulin pump. I think type 2 also tends to be a little harder to manage due to a lot of times the severe insulin resistance and needs either for much higher TDD’s or the need for much stronger insulins U-500 for example. When you are talking a device that can cost $7,000 and up, everyone including insurance is going to want to make sure its being utilized correctly. My insurance does cover type 2’s for insulin pumps I believe. But yeah it gets to be a vicious cycle between different plans and their coverage, and so many type 2’s and lack of referral to endo’s for proper management all around.
When I was diagnosed with Type 1 as a kid, this is how my insulin was introduced. First basal only (with extremely high blood sugars as a result—300s-500s) gradually increasing the dose, and then short acting insulin added later. Granted, “later” was two or three weeks. Things may well be different today when starting a true MDI regimen, though.
I agree totally that anyone using insulin should be seeing an endocrinologist.