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If the American Diabetes Associationbelieves they have undone the damage that their 2003 Guideline set in motion; they mayhave another thing to consider. What happened in the 2003 Guidelineswas a recommendation for people with type 1 or type 2 diabetes whouse insulin in multiple daily injections or with an insulin pumpshould self-monitor blood glucose “three or more times daily.” Most payers interpreted this to mean that three tests per day wassufficient for all patients on insulin.
To find out if the new 2013 guidelines hadchanged any minds, I have decided to correspond with my insurancecompany, Medicare, and inquire from a few other medical insurancecompanies that cover part D. I now have a response from the medicalinsurance companies and a brief statement of “no anticipatedchanges” from Medicare. Even the Veterans Administration statedthat there are no anticipated changes. One medical insurance companysaid they are taking a wait and see stance about what other companiesare thinking. My medical insurance company stated that since I don'tuse them for my test strips, they are not responding further. Italked with my agent and he asked. He was told there would be nochanges at present. The last medical insurance company said they arestill asking questions, but anticipate only minor changes ifaccompanied by an order from the doctor.
This made me contact another companyand I was told in a phone conversation that there would be no changesuntil the ADA decided that a certain number was needed. This raisedmy hackles, and I said they did. We discussed the section and I wastold the key words were “many patients” and that until ADAclearly stated for “most” patients, they would continue thecurrent limit. Then I was asked about the Joslin blog of January 16. I stated I had read this. I was told that this also confirmed thecurrent position of no change. This is about as big a slap in theface as you can get. This insurance company said the the Joslin blogis also the reason they will be limiting type 2 diabetes patients noton sulfonylureas to one test strip per day. It had been two per day.
I can also envision insurance companiesrequiring doctors to forward meter downloads to prove that thepatients need as many test strips as requested. I know that this ison the mind of one of the companies I have corresponded with as theyasked if I would be willing to do this. I know many diabetes clinicsand a few doctors do have the software to do this, but most primarycare physicians do not. Think of the cost and if you think they arenot going to pass this on to the patient, you are in for a surprise. Another statement one insurance company clearly made is, “if thiswas that important, why did they (ADA) wait ten years to make a statementlike this?”
I personally think that until ADAincludes more people from the medical insurance industry and a fewpatients (type 1 and type 2), they will continue to be laughed at andnot believed to be setting recommendations and guidelines for thepatient, but in their interests only. In recent years, this seems tobe the trend. Even we, as patients, have to wonder what they aredoing for the patient. They are great at wording that means and saysvery little. This has to be what the medical insurance industrythinks about their wording and their reasoning for no anticipatedchanges. Even though ADA is saying they made some changes, in thereal world, there may not be changes.
One section says the following, “Thefrequency and timing of SMBG should be dictated by the particularneeds and goals of the patient. SMBG is especially important forpatients treated with insulin to monitor for and prevent asymptomatichypoglycemia and hyperglycemia. Most patients with type 1 diabetesand others on intensive insulin regimens (MDI or insulin pumptherapy) should do SMBG at least prior to meals and snacks,occasionally postprandially, at bedtime, prior to exercise, when theysuspect low blood glucose, after treating low blood glucose untilthey are normoglycemic, and prior to critical tasks such as driving. For many patients,this will require testing 6–8 times daily, although individualneeds may be greater.” The bold words is my emphasisand is the wording used by two companies below.
The above is the section quoted back tome by two of the insurance companies, one that will make no changes,and the one that will use a doctor's order and consider the need.
Another area that was also used is,“Because the accuracy of SMBG isinstrument and user dependent, it is important to evaluate eachpatient’s monitoring technique, both initially and at regularintervals thereafter. Optimal use of SMBG requires proper review andinterpretation of the data, both by the patient and provider.”
In reading the section, type 1 isspecifically mentioned, but other areas only use the term MDI(multiple daily injections) and self-monitoring of blood glucose(SMBG). This leaves those of us with type 2 on insulin wondering ifwe will be excluded from obtaining support for intensive testing.
Again, the ADA has played down theimportance for people with type 2 diabetes on oral medications and onno medications of the need for testing and also the need for beingtested more than two times per year by the A1c. This statement istypical of the ADA's attitude, “Theevidence base for SMBG for patients with type 2 diabetes onnoninsulin therapy is somewhat mixed. Several randomized trials havecalled into question the clinical utility and cost-effectiveness ofroutine SMBG in non–insulin-treated patients. A recentmeta-analysis suggested that SMBG reduced A1C by 0.25% at 6 months,while a Cochrane review concluded that the overall effect of SMBG insuch patients is small up to 6 months after initiation and subsidesafter 12 months.”
For me this is almost criminal inboth the attitude and actions they have about not educating thesepeople with type 2 diabetes and then preventing those that know theimportance from obtaining the necessary testing supplies.
And if you doubt what I am saying, whythen would the Joslin Diabetes Center post the blog they did onJanuary 16, 2013 (mentioned above), in which they ask the question,“When Should I Check My Blood Sugar?” “Theanswer depends on the medications you are taking, your current levelof control and what information you are looking for. For example,people with type 1 diabetes who take insulin four times a day need tocheck at least as many times. People with type 2 who control theirglucose levels with lifestyle or lifestyle and metformin may checkonly once, or perhaps twice, a day.”
Patients at Joslin need to be concernedabout the side Joslin is on, as it clearly is not for the patient. This blog seems a clear rebuttal of the 2013 ADA Guidelines. Don'tthink the medical insurance companies won't see it this way (twocompanies have). This is just one more reason they have for notmaking changes. When a well known and prestigious diabetes clinicpublishes information like this for patients, they are not doing usany favors.
The two companies (mentioned above),did have me call them and talk to an office that make thedetermination. They admitted that there will be controversy overthis, but that with a leading diabetes clinic saying only four timesin difference to the ADA of six to eight times, the decision willremain no change until everyone is in agreement. When I asked aboutmeter downloads for proof that a person was testing more frequently,the answer was that this was under consideration, but that not allphysicians would be capable of submitting this information. They didsay that to force this issue now could be considered discriminatory,but that it is under consideration for future years. They said witha doctors order for the testing and the meter downloads beingsubmitted, this could be a factor when everyone is in agreement as tothe number of testing requirements for both type1 and type 2 oninsulin.
In the phone conversations I also askedabout those type 2 people on oral medications. Both companies stressed thatthey will be allowing two test strips for those on sulfonylureas andwill be allowing more if there is a doctors order because of repeatedepisodes of hypoglycemia. Others, to include those on no medicationswill remain on one test strip per day without a doctors order provingthe need for more test strips. They would not discuss what thedoctors orders needed to state.
Then to read another article alsoquestioning ADA's attempt to change the minds of insurance companies,read this from Diabetes in Control. Dr. Richard Grant, incomingchair of the ADA Professional Practice Committee says, "We'retrying to say it's very situation-dependent …. both by the patientand the patient's context." This really says nothingeven if they are claiming otherwise.
This statement really drives home thepoint that ADA has not succeeded, “Withregard to the removal of the three-times-daily number, Dr. YehudaHandelsman (Metabolic Institute of America, Tarzana, CA) expressedconcern that insurers might actually interpret that as endorsing lessfrequent testing for patients who use insulin. How messages areconveyed matters, he said. "It's about how you define the goalsand where you put the emphasis."
According toGrant, the new document was the ADA's best attempt to balance theevidence from the literature with the needs of the individualpatient. "Evidence-based guidelines apply to populations ofpatients with diabetes, but we really need to tailor thesepopulation-level recommendations to the individual in front of us."” In other words, this is why insurance companies aresaying loud and clear, “no anticipated changes” Soforget what ADA claims.
For other perspectives and more hope in others areas of the country, read this blog from Diabetes Mine and this blog from Diabetes Self-Management.
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