Tag Archive: health insurance


Well, I’ve had a couple of good days. First was the email Thursday that Tourist Trap was a finalist in the Reader Views Literary Awards. Yes, that’s the same one Homecoming received last year.

Then I got a phone call from the clinic saying the box of replacement sets had arrived, and I picked them up Friday, thus ending a very nervous couple of weeks.

Replacement sets?

The other end of that plastic cord feeds into me.

I use an insulin pump. It’s about the size of a small stack of business cards, and it normally lives in my pocket. It contains a reservoir of insulin, which theoretically should be changed every three days. (I normally average about six, because that’s how long a full reservoir lasts me, and I have yet to see any drop in effectiveness after six days at body temperature.) The pump gradually pushes that insulin out very fine tubing a couple of feet long to a set, which is fastened to my body by a piece of adhesive and has a fine Teflon cannula piercing my skin and delivering insulin into the subcutaneous tissue. The set has a needle which is used to insert the cannula under the skin, and is then removed. The set has to be changed every three days – any longer than that in the skin, and scar tissue starts to build up and insulin no longer gets through. These sets are not reusable; in fact they become medical waste.

I’m lucky to have very good supplemental insurance as well as Medicare, and every 3 months I get shipped 30 sets. A couple of weeks ago the shipping company called me to check how many sets I had.

“Two. When are you going to ship them?”

“We did, a couple of weeks ago.”

I have them ship to my doctor’s office, because in my experience mail order pharmacies never adequately package temperature-sensitive medications being shipped to regions where 40-below temperatures are common, and in some shipments I get continuous glucose sensors which must not be frozen. So I called the clinic, which usually calls me when a package arrives for me.

They couldn’t find the box.

By that time the pharmacy was closed, so when I called back the next morning I got the details of the shipment. They insisted it had been signed for at the clinic and gave me the exact time and date of delivery.

I called the clinic back. I think it took about a day before they finally said that yes, they had received the box. The person who signed for it remembered it. So did several staff members. But they couldn’t find it, and they’d looked everywhere. They said they’d call the mail-order pharmacy back and pay for a replacement shipment. (This is stuff no local pharmacy carries.)

The mail order pharmacy said that Medicare rules did not allow them to send out a replacement shipment – never mind that it was the clinic, not me, that verified I had never received the sets that are essential to my life, or that the clinic was willing to pay for the replacement shipment.

The clinic combed the offices of the doctors that treat diabetes, and managed to come up with a few sets to tide me over. They also called the pump (and set) manufacturer. The manufacturer FedExed me a few more sets. Finally, Thursday, the clinic called and said they had the sets from the manufacturer, and I picked them up yesterday.

I realize that Medicare does have a huge fraud problem. But in this case the clinic was offering to pay for the lost shipment, so what kind of fraud did they think was involved? It’s not as if the sets were valuable to anyone else, but they are life or death to me.

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Continuous Glucose Monitors (CGMs) are a relatively recent development in diabetes control. They are still controversial with many insurance companies, though prevention of even one high-cost ambulance trip to the emergency room should make them cost-effective. But they do have problems.

There are three devices that I am aware of, worldwide, and others in development. The best, according to users, is the Navigator – but it has been withdrawn from the US market. This leaves the Dexcom and the Medtronic sensors. My own experience has been entirely with the Medtronic sensor, but all three work in basically the same way, on interstitial fluid, and all are subject to the same problems of time lag.

Medtronics transmitter (white) and the visible part of the sensor (clear) with a U.S. quarter for scale. I use IV 3000 to hold everything in place.

The sensors available today consist of some kind of reusable transmitter, a receiver, and a disposable needle which injects a small disposable sensor under the skin. The sensor is then connected to the transmitter, which lies against the skin.

The sensors are expensive. The price today at the Medtronic store is $42 a sensor, with an official life of 3 days. (Most people actually manage to use them longer, and in fact I find they are most accurate on days 3-5, though I rarely get one that lasts more than a week.) The big advantage of the Medtronic system is that the Medtronic insulin pump (the kind I have) acts as the receiver, though separate receivers are available. The official life span on the Dexcom sensor is 7 days, though I understand they are correspondingly more expensive. Comments from users of the Dexcom are solicited!

A continuous sensor is extremely useful in that it allows you to see how your blood glucose varies between finger sticks, and also allows you to see whether it is rising, falling or staying reasonably constant. The Medtronic sensor allows you to choose whether to see a 3-hour, a 6-hour, a 12-hour or a 24-hour graph of your blood sugar, or download values about 5 minutes apart to a computer, and I believe the Dexcom sensor is similar. On the negative side, CGM accuracy is highly variable, and it needs regular calibration with a finger-stick meter. There is a further problem (at least with the Medtronic system) with alarms.

I used to eat protein bars for breakfast. They had a good balance of protein, carbohydrate and fat, they took no weighing, and they were consistent day to day. They also produced a considerable spike in blood sugar in the hour after breakfast, easily identified on the CGM graph but missed in finger-stick testing. When I switched to Greek yogurt with fruit, also a good balance of protein and carbohydrate but without the fat, my blood sugar graph leveled out. In fact, the CGM has allowed me to identify many regular meals as causing spikes or delayed rises in blood sugar. (The fat in the bars was not the problem; in fact fat delays the absorption of carbohydrates, but much of the carbohydrate in the bars was fast-absorbing sugars.)

I am not alone in finding trends more useful than absolute numbers. A high blood sugar (within reason) is not really a problem if the blood sugar is decreasing, nor is a moderately low reading with an upward trend. On the other had, a high reading going up or a low reading going lower is cause for immediate finger-stick confirmation and treatment if the reading is confirmed. A low reading at night or if I’m planning to drive is always reason for finger-stick confirmation.

What the sensor actually measures is a slight electrical signal, and this must be calibrated with a finger stick measurement to get the actual blood sugar reading. The calibration constant changes over the life of the sensor, and can drop very fast toward the end of sensor life. Consequently the sensor must be calibrated a minimum of twice a day, preferably when your blood sugar is fairly steady, and may give a lot of false low alarms near the end of its life.

Another problem is that the sensor measures the glucose concentration in the interstitial fluid, that is, the fluid between the cells. While this follows blood glucose, there is a significant time lag. My blood sugar can drop very rapidly, especially during exercise, and as a result CGM measurements during exercise can be much higher than my actual blood sugar. This time lag alone makes me very dubious about using this type of sensor for any closed-loop artificial pancreas.

My biggest complaint with the Medtronic system is the alarms. Ideally, to be most useful the CGM system should wake you up if your blood sugar starts to drop. In fact, the alarm is so low in volume and so high in frequency that I almost never hear it unless I am in a very quiet environment and there is only a layer of cloth between my ears and the pump, not a down comforter. This is partly my hearing, as others will sometimes point out to me that I am beeping. Yes, it does start vibrating eventually if I do not respond, but I feel the vibration only if the pump is tight against my skin. I usually feel it driving (well after I start going low) but often not at night.

Is it worth it? Yes, for me. But it definitely needs some improvements.

Measuring Blood Sugar

Back in the middle of the 20th century, long before I had diabetes or even thought much about it, I saw a magazine ad that talked about diabetes. It might have been an insulin ad. What I do remember was that it featured a Russian troika – a three-horse hitch – and likened controlling diabetes to driving a troika. Three things have to be balanced: insulin, food and exercise, and misjudging any of the three can throw you to the wolves.

That balancing act is hard enough today, with all the tools we have to help. It was a lot harder 42 years ago, when I was diagnosed. And I hate to think of what it must have been like at the time of the ad.

The key is being able to keep track of your blood sugar. Really high, and you need insulin – exercise may actually push you higher. A little high, and aerobic exercise may bring you down. Too low, and you need food, preferably fast-acting carbohydrates. But at the time of the ad, measuring blood sugar meant several hours of lab work, and you might hear back from the doctor the next day. In order to utilize food, insulin and exercise optimally, you have to have some idea of what your blood sugar is right now, and whether it is rising or falling.

There are some symptoms. Sweating, shaking, blurred vision, and tingling lips can all be symptoms of low blood sugar. They can also be due to other things. (I was put on hormones at menopause primarily because I could not tell the difference between a hot flash and low blood sugar.) But those symptoms tend to decrease with years of living with diabetes.

Symptoms of high blood sugar are even subtler. I may start feeling a little odd when my blood sugar is three or four times normal, but my feelings were certainly not enough to tell me when I was high. Anyway, in those days doctors normally prescribed a fixed amount of insulin and a fairly rigid diet, and pretty much ignored exercise.

My current glucose monitor

What was desperately needed was a way for diabetics to find out what their blood sugar was, preferably without slashing their fingers with a modified razor blade. (That’s how they used to get blood samples.) Eventually, and over the initial objections of some physicians and regulatory agencies who were afraid that patients would self-treat, glucose monitors were developed. From the point of view of most diabetics, the objections were just plain silly. We have to treat ourselves. We give ourselves shots of insulin (which cannot be taken by mouth because it would simply be digested.) We exercise. We eat. Doesn’t it make sense that the more we know about which of the three we need, the better?

The first monitors were reportedly large, clunky and slow. They improved rapidly, and by the time I got my first one, in the late ’80s, they were pocket sized (if you had large pockets.) My testing kit today fits easily into the belt pouch I use as a purse. I still have to poke my fingers many times a day, but I get results in five seconds. One important thing is not covered, though – I can’t tell whether I’m going up or down from an instantaneous reading.

There is also a problem of expense. Tight control means testing before each meal, at bedtime, before you drive, regularly during driving, and every 20 to 30 minutes when exercising. Test strips are not cheap, and there is a real problem getting insurance companies to cover enough strips.

I’m not the only person with diabetes to feel this way, and there’s been a good deal of research on continuous glucose monitors. The first one I tried was the glucowatch. This used a patch sensor on the arm or wrist, and gave the blood sugar on the “face’ of the watch. It could also be read by a computer. Drawbacks? Many. First, it would only operate for 12 hours, and took a while without readings to initialize. Second, the patch was very irritating to my skin. I invariably had a major welt that lasted a week or more when I removed the watch and patch. Third, any sweat made the readings unreliable – and sweating is a symptom of low blood sugar. The watch did confirm that I was having low blood sugars at night and that I responded by “bouncing” high – a fairly common reaction, and much better than staying low with possibly fatal results. But the combination of problems led me to stop using it.

Modern continuous glucose monitors are much better, though by no means perfect, and I’ll talk about them, and the problems with getting insurance companies to cover them, in the future.