LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Monday, November 23, 2009

Victory at Sea

“So,” Nurse Eve said as she stepped into my car for pre-dawn commute to the clinic, “I see you single-handedly brought Presbyterian to its knees.”


“Weren’t you thrilled to get the letter?”

What letter? She-who-gets-the-mail has been down with Swine Flu.

Luckily, Eve had brought her copy of the letter along in her purse, and read it out-loud to me. Letters from Pres always start the same: “Our goal is to improve the health of individuals, families, and communities.” Funny, I thought your goal was to improve the health of your shareholder’s bank accounts. “Informing you about changes in your health plan’s benefits is one way we reach this goal.” Oh really?

“You just received a letter from us that informed you about the coverage of Durable Medical Equipment (DME). We are very sorry for any confusion or concern about your benefit this may have caused.”

Then they wave a white flag. They actually backed off. Like a corporation settling a lawsuit without admitting guilt, they go on to say they don’t have to cover our DME, but will as a “Value Added Service until further notice.”

Wow. It’s over. Just like that. We won. Who’d thunk it?

So my pump is safe. At least for now. Chalk one up for the home team. That’s very good news for me, but I already had a bigger fish to fry (hence the “sea” part of the head line for this post). Things that effect me personally stress me out, and annoy me greatly. But my fangs come out and I really get pissed-off when insurance companies screw with my patients. And Lovelace Health Plan had just screwed with my most precious patient.

I’ve only mentioned her in passing, but my youngest patient just turned three years old. We dx’d her with her Type-1 Diabetes this summer. I can’t help but love her, not only is she my littlest sister, but she’s been under my care since day one; so I’ve really bonded with her. All 32 pounds of her.

We have even developed a number of rituals. I originally got her on-board with the concept of testing blood sugar by doing it together, me always first. Now every time she comes into my office she says “we gots to check your blood sugar, Doctor Lee.” So we get out my meter and check my blood sugar. Then we check hers. She is particularly delighted when mine is higher than hers.

Anyway, since day two she’s been using the NovoPen Jr., a blue-with-green-flowers metal half-unit pen that uses Penfils. Last month, when her mother went to refill the script the pharmacy informed her that Lovelace was denying the medication as off-formulary. What at first I assumed to be an administrative mistake quickly became something much more sinister.

Lovelace “corrected” its formulary. No more pens. Unless you are blind. All diabetics must go back to vials and syringes. I went through the roof.

Forty-eight hours later I had begged, bribed, bargained, and bamboozled my way through mountains of red tape and won my little patient a permanent formulary exemption.

That just left everyone else in the state screwed. I’ve been back-and-forth between pumps and pens as my insurance has risen and fallen like the tide; but I’ve never been forced back to pens and syringes. The thought appalls me.

The more I thought about it, the more pissed off I got. Now, most of my insured patients have Pres, rather than Lovelace. But I had an eerie feeling that there might be some sort of collaboration going on behind the scenes (in fact, on Friday a friend who works for a private practice told me she was having problems getting pens for both Pres and Blue Cross patients; but I haven’t experienced this… yet).

My uninsured patients get pens from Patient Assistance Programs. How ironic. If you are indigent and don’t have insurance you get state of the art. If you work your ass off and pay through the nose for your insurance you get state of 1932 instead. Lovely.

I mulled over my options, my mind first going to the five-guys-with-machine-guns-and-a-wall that I think is the best solution for insurance companies. Then I envisioned press conferences with crying children, marches, and mass mailings of syringes in protest. In the end I did what I do best. I wrote.

My mother told me, “you know you won’t win this fight, right?”

Sometimes it isn’t about whether you win or lose, but how you fight that matters. I couldn’t just take this one lying down.

Of course, where I work you can’t just put something on clinic letterhead and drop it in the mail, not at least without risking your own head. I snuck in to my medical boss’s office first thing in the morning before he got in, left a copy of the letter on his desk and scurried away before he could catch me.

Later in the day he called me in. “Your letter is brilliant,” he told me with a very serious expression, “ and I really admire your restraint.”


“Yes, you actually wrote three whole pages without using the word ‘fuck’ even once.” Then he broke out into an ear-to-ear smile and laughed.

I guess my reputation is worse than I thought.

Later I got my administrative boss’s approval too. The letter went to the three top-dogs at Lovelace here in New Mexico. It also went to the Public Regulatory Commission’s Insurance Division. Maybe later it goes to the press. We’ll see. It depends on what happens. My battle flag is hoisted, I’ve fired a shot across their bow. The ball is in their court now.

Here is the full text of my broad-side:

Ladies and Gentlemen—

I am writing to express my grave concerns about the negative impact on the health outcomes of diabetes patients in our state brought about by a recent decision of Lovelace Health Plan.

When the mother of one of our pediatric diabetic patients attempted to
refill her daughter’s insulin pen cartridges recently, the pharmacy informed her that the claim was denied as an off-formulary medication.

When I called Lovelace, assuming that there must have been some kind of mistake, I was informed that the carrier would no longer cover insulin pens of any kind, and that those of us in the field would be required to migrate our diabetes patients back to the archaic vial and syringe method of insulin delivery.

Needless to say, I was shocked. Insulin pens are the global standard of care in evidence-based diabetes treatment. Scientific studies have shown that the use of pens over vials and syringes reduces dosing errors, increases efficacy, increases patient compliance and satisfaction, and saves significant amounts of money in overall health care dollars.

Additionally, I can tell you that from my own clinical experience, it is far easier to “start” diabetic patients on insulin using pens. The syringe carries a symbolic fear factor, largely due to the inter-generational nature of diabetes in our state. Patients remember their grandparents taking “shots” followed by poor outcomes.

Due to this inter-generational fear of “the needle,” syringes significantly increase patient resistance to starting insulin, our most effective glucose-lowering agent. Additionally, syringes take a much greater period of time for patient training than pens do, increase the risk of medicine errors, and greatly reduce patient compliance—especially when injections are required in public places.

Simply put, syringes scare patients. Pens do not. And, I feel, it is cruel to force patients who are doing well on a given therapy to revert to a more primitive, more challenging, and demonstrably more dangerous technology. Beyond cruel, it is simply bad medicine.

While it is true that in many patients, using syringes over pens can save a small amount of money in prescription costs
only, Baldrishman, et al, at Ohio State University demonstrated in a five year study that overall health care costs are dramatically reduced in patients using pens over syringes (Clinical Therapeutics, Aug. 2007). A review of third-party managed care data by Lee, et al, confirms this cost savings (Clinical Therapy 2006; 28).

et al, looked at patient satisfaction, safety and efficacy outcomes, and cost savings in pens vs. syringes in insulin “starts” in hospital environments, and found that patients started on pens where much more likely to continue therapy on discharge. The researchers stated that “A substantial cost savings was projected for patients in the insulin pen group…” (American Journal of Health-System Pharmacy, Oct. 2008).

In the journal
Diabetes Care (Jan. 1999) Lteif and Schwenk found that at low doses, pens are more accurate in their delivery than syringes are; showing that forcing pediatric patients, who are already disportionately more sensitive to small amounts of insulin, to use syringes, places them at higher risk. Possibly to the point of medical liability.

et al, looked specifically at patients over the age of 60 in a randomized cross-over trial to study the safety, efficacy, and acceptability of pens and found pens “safe, efficacious and highly accepted…” (Diabetes Research and Clinical Practice, Volume 28, Issue 3).

Charles Shaefer, MD, FACP, FCCP, writing in the journal
Insulin (July 2009) reminds us that Rubin and Peyrot summarized the situation well in Diabetes Care. 2008; 31, saying “physicians, patients, and payors (emphasis added) should recognize that making it easier for patients to take better care of their diabetes is not a trivial benefit. Burden of treatment is a significant barrier to improved self-care, and reducing this barrier could make an important contribution to improved diabetes outcomes.”

While I understand that for a typical insulin user, forcing the use of syringes and vials saves about 20%, or $2.50 per day
in pharmacy costs alone for a 90 kilo patient, I question the value of such a short term gain when our best scientific evidence indicates that this approach significantly impacts both dosing errors and compliance: either one of which will assure more expensive tertiary intervention in the future.

Of course, in any patient injecting less than 30u per day, there is no savings what-so-ever, as the excess volume of the vial must be disposed of at the end of thirty-days; a problem resolved with the lower-volume pens.

I hope that Lovelace will reconsider the mandate to abandon insulin pens. It is both bad for patient health and well being; and in the long-run it will not create a savings for Lovelace. At best, it may only gain Lovelace “profit” in the very short term, and at a very great price in patient suffering.

Respectfully, but with grave concern for patient health, I await your prompt response.


Anonymous Carol said...

Hooray! I love it...both the DME victory, and your letter for that little girl (and others like her). Battle on!

9:45 AM  
Blogger Martin Jackson said...

Thanks so much for undertaking this.

I am a new diagnosis (just about a month and a half ago), and I don't know what I would do without my pens. They helped immensely in terms of ease of use and getting acclimated to the discipline. The thought that someone would take those away is ... breathtaking.

Please let us know how the battle goes!

5:13 PM  
Blogger Jonah said...

Good going!

My pen use lowers my insurance's costs simply because the pen cartridges contain 300 units and the vials 1000 units. They both expire in one month. I use about 10 units of Lantus per day. If I use a vial, I throw away 700 units per month. If I use a cartridge, I use the whole thing. My insurance ends of paying for 1500 units every five months instead of 3000 units every three months. Saves them lots of money.

The pen needles cost them 1 cent more per needle than the syringes do.

And as a last note, it is possible to refil a cartridge using a syringe and the insulin from a vial- but I suspect that puncturing the same cartidge too many times could lead to problems.

6:44 PM  
Anonymous Anonymous said...

Good going!

In my area the pen is king, and no insurance hassles that I am aware of.
That said, apparently I am one of the last few around here who still prefers a syringe over pens. My last (not final, but last time I was there) visit to my endo I ended up with every sample syringe she had becuase I was the last hold out and "no one gets started on a syringe any more".
I've never had a syringe phobia, so having to jab myself was of no consequence. My beef with the pens is that I can only adjust my dosage in full increments. If I need a little more fast acting, I go a hair over, or a hair under as needed based on readings and what I've got planned/have done. The pen doesn't afford me the luxury of minor tweaks, if I go +1, hello sugar snacks. -1 and it'll be high bs if my activities are not as intense as expected. I've tried to give them a fair shot over the years. Convenience factor is great with pens, but I keep going back to the syringe just for the ability to do minor tweaks.

Now, if they would only sharpen the needles on the syringes as well as the pen needles I'd be really happy.

Stuck in the past. 1932 apparently. =-)

5:20 PM  

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