Why Medicare’s Attitude Toward Diabetes Could Kill Senior Citizens

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I, like many people who care about people with diabetes, have a real bee in my bonnet about Medicare’s attitude toward diabetes — particularly in reference to its newly implemented national mail-order program for diabetic supplies. So much so that I actually just said “bee in my bonnet,” which I believe is the very first time in my life that I have ever used that expression. 

Why, you might ask, is my bonnet so bee-filled? Because the reduced access to high quality blood glucose meters is putting seniors’ lives at risk. Yeah, that’s right: if you love anyone who’s got diabetes and is over 65, the unintended consequences of this program could kill them. Here’s the issue in a nutshell: 

1. On July 1, 2013, Medicare implemented a mail order program for diabetes testing supplies nationwide. Translation: If you’re on Medicare and you want to get your diabetes test strips by mail, then you must use a Medicare-approved supplier for those test strips. (Important note: if you don’t mind going to the pharmacy, you can get your strips from a Medicare-contracted pharmacy — but it may end up costing you more, and is also obviously less convenient.)

2. Medicare only gave contracts to about 2 dozen suppliers (not all of which are available in all geographic areas, so your choice of where to get your test strips is limited). Perhaps even more importantly, it reduced the reimbursement rate for diabetic test strips by about 72 percent. This was meant, obviously, to reduce costs. But this rate was so low that it can’t pay for strips from some of the big test strip makers — like Abbott, Roche and Accu-chek. As a result, suppliers are switching many Medicare recipients — often against their will — to generic meters and strips instead. (Really important note: They’re not allowed to do this! If you’re on Medicare, you have the right to stay on the meter prescribed by your healthcare professional. For more details, scroll down a bit on this page.)

3. Blood glucose meters are not interchangeable. This is partly because different people — particularly seniors — have different needs (for example, you might need a meter with large type, or a meter that speaks to you in case you have poor eyesight and can’t see the number, or a meter that is particularly large or small, etc), and partly because . . . 

4. . . . Diabetes test strips and blood glucose meters are not all equally accurate. This might come as a surprise to many people — I for one had previously assumed that a meter is a meter is a meter — but there are many meters on the market that do not consistently give accurate results, and generic meters, particularly those produced overseas, are particularly problematic. (Read my article, Why You Should Worry About the Accuracy of Your Blood Glucose Strips, for more information — as well as my post, Why You Should Be Depressed About the Government’s Attitude Toward Diabetes.) Guess which meters the Medicare-approved suppliers are pushing on seniors? The cheapest ones possible — i.e. the very generic meters that are the most likely to be inaccurate. What’s more, there is also no program in place to make sure that meters and strips that get cleared by the FDA continue to maintain the same levels of accuracy once they’re on the market. (For more on this issue, check out StripSafely.com.) 

The dangers posed by inaccurate meters and strips should be obvious: if you use a meter to dose insulin, and if your meter is wrong, then you can take too much insulin — and you could die. Senior citizens need access to accurate blood glucose meters. (As do ALL people with diabetes!)  This is not a push for a particular brand or company — if we can get accurate meters for less money, that is great. But cost reduction should not threaten the lives of the very people it’s meant to help. 

I’m going to write an article about the American Association of Diabetes Educators’ recent investigation of the competitive bidding program for diabetic testing supplies (spoiler alert: suppliers are not providing what they promised). But for now, I bring the subject up because Manny Hernandez of the Diabetes Hands Foundation/TuDiabetes just tweeted an article that I very much hope the powers that be at the Centers for Medicare and Medicaid Services (CMS) pay attention to: an article from US News and World Report titled “Elderly Diabetic Patients on Insulin Most Vulnerable to Low-Blood-Sugar Trouble.” If I may quote: 

“A new look at diabetes patients in the United States who use insulin and wind up in the emergency room with low blood sugar shows the dangerous scenario is more than twice as likely to happen to those over 80 years old.

“Not only that, elderly diabetes patients are five times more likely to be hospitalized than younger patients as a result of the low-blood-sugar episode, the study found.

“‘Managing insulin can be a complex endeavor,’ said study author Dr. Andrew Geller, a medical officer at the U.S. Centers for Disease Control and Prevention. ‘We knew it would cause a lot of emergency-department visits for adverse events, but we didn’t expect the full severity of these events. Almost two-thirds involved things like passing out and seizures.'”

Geller and his colleagues “were able to estimate that just less than 98,000 emergency-room visits occur in the United States each year due to insulin-related low blood sugar,” and that “almost 30 percent of those emergency-room visits resulted in hospitalization.”

Putting aside the obvious health risks posed by severe hypoglycemia, I’d note that 98,000 emergency room visits per year likely cost the government (and health insurers) a hell of a lot more than the price of an adequate supply of accurate blood glucose meters and strips. 

Judging from comments I heard from CMS at the Diabetes Technology Society’s meeting in September,  however, I anticipate that CMS would interpret the findings of this study quite differently — namely, they’ll see it as evidence not that blood glucose meters need to be accurate, but that fewer seniors should be on insulin.

What this interpretation would miss is that these are two separate issues. We in the diabetes community are not talking about whether a senior citizen should or should not be on insulin. That is a choice that should be left to the person and his or her doctor. What the diabetes community is saying is that a blood glucose meter is only a blood glucose meter if it is accurate. If it is not accurate, then it cannot be used to dose insulin or “make therapy adjustments,” if I may quote CMS itself. And if a meter cannot be used to “make therapy adjustments,” then it cannot be considered to be Durable Medical Equipment (DME) and therefore cannot legally be covered by Medicare

If you think this issue is important and would like your voice heard, here’s some good news: the FDA is accepting (and encouraging) comments from the public on its new draft guidance for blood glucose meters. (FDA is not responsible for competitive bidding — in fact, the FDA appears to have quite an enlightened view toward diabetes devices — but since CMS often looks to FDA guidance to make decisions, it’s important for us to make our concerns and suggestions known to the FDA.) Check out the sample comments the StripSafely team and I put together — complete with easy-to-follow instructions and links — here. (Pay particular attention to the suggested comments about “durable medical equipment,” since that is the part most likely to impact CMS and the coverage issues brought up in this post.) 

I also recommend that you consider sending a letter in support of calling a Congressional hearing to ensure that the meters provided under Medicare’s competitive  bidding program live up to the accuracy standards of the FDA. We’ve put together a sample letter — again, with instructions — here. It’s really easy, and could make an enormous difference.

Lastly, if you or your loved ones experience any sort of adverse effect of Medicare’s policy toward diabetic testing equipment — whether it’s a problem with the meter or test strips themselves, or a problem getting access to them to begin with — I strongly encourage you to complain directly to CMS. You can do so via this link. Heck, I recommend filing a complaint regardless, pointing out the issues raised here and on StripSafely.com. And while you’re at it, why not contact the Inspector General of Health and Human Services, the government agency responsible for investigating Medicare Fraud. Point out that if Medicare is reimbursing suppliers for testing equipment that can’t be used to make therapy adjustments — and that therefore cannot be considered to be Durable Medical Equipment — then those suppliers are defrauding the government by receiving reimbursements for equipment that should not technically have been covered. (More on this line of thought later.) 

If you tweet this article, or anything about it, please use @medicaregov and @OIGatHHS (the inspector general) so that they are aware of our concerns. And if you can throw in a little @stripsafely as well, that would be superb. 

Thank you for reading this. If we work together, we may be able to save people’s lives.

 

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Comments (10)

  1. Fred Wuensche at

    This is the same CMS that has now decreed that 3 test strips a day are adequate for insulin-using diabetics. In theory a patients Doctor can order more, but the documentation burden on both the patient and physician is daunting. 

  2. Les Bonde at

    44 years of taking insulin & no cure insite.
    Meters are part of a supply business model. 
    I want to go back to peeing on a strip; better than jabbing my fingers 4+ times a day & enriching the drug companies to provide inconsequential results, averages & trend reports.
    10 years ago today, a Canadian company in Nova Scotia developed a pad fitted under any watch to give sugar results.
    The company suddenly closed & disappeared.
    We found that a pharma company killed the research & proceeded with meters, expensive test strips etc.
    Diabetes is a business- it is not allowed to be cured; after 44 diabetic years & billions of no result research dollars- I am convinced I will die being unable to afford Obama’s cheapie test strips…

     

  3. JoyceK at

    Often policies adopted by Medicare often end up being adopted by health insurance companies, so this is something that all of us should be concerned about.

  4. And let’s not forget that Medicare also (currently) will not pay for CGMs/continuous glucose monitors! Sue (http://testguessandgo.com/2014/03/10/unfavorable/) has been waging a battle for her husband to get it covered since he went on medicare, and seems to be fighting a losing battle. Why does it seem the government WANTS our senior citizens’ lives to be at risk?? One day, WE will be those same senior citizens….so let’s hop in on the fight NOW!!

  5. pagan one at

    Meters shouldn’t be allowed to be sold unless they meet stringent accuracy and reliability functions. Peoples lives and billions of dollars of medical money  are at risk.
    The foolishness of saving  a few bucks on unreliable equipment will be overwhelmed by the cost to us all of caring for those with issues that could easily have been prevented. 
    Perhaps this is governments attempts to guarantee a steady flow of patients through the the hospitals wards. 

  6. Thanks for writing this, Catherine. It’s absolutely terrifying. 

  7. Gianna Lascola at

    Regarding the poster, who wrote that he would rather go back to “peeing on a stick,” that is not as safe as self-monitoring blood glucose, via blood and test strips. The goal for diabetics is to prevent glucose from showing up in urine, for the following reasons:  

    Most health-care professionals prefer SMBG because of the following limitations of urine testing:

    You cannot test for low blood sugar (hypoglycemia) with urine testing.
    Sugar shows up in urine only when the blood glucose level exceeds the kidney threshold, and this threshold could be high.
    Because urine collects in the bladder over time, urine testing provides general information on blood glucose level over a few hours, rather than exact information on the level at test time.

    Reference:
    http://www.umassmed.edu/healinghandbook/chapter5/index.aspx
     

  8. Onoosh at

    Another very informative piece, with important information, even for those of us whose testing supplies are covered by other plans. Medicare is often the canary in the mine, and all of us need to pay attention…and stick together. Thanks for writing, and for the very helpful and convenient links.

  9. Gretchen Starke at

    I am a T2 Diabetic diagnosed when I had my “Welcome to Medicare” visit as recommended by Medicare.  The doctor prescribed the Accu-Chek meter and testing strips, and I take Metformin.
    I became very proactive in researching my disease and made many dietary changes with excellent results, bringing my A1C down from 12.7 to 6.0 in 9 months, losing 30 lbs in the process.
    Medicare will not allow your physician to prescribe more than 1 test per day, unless you are on insulin.  It is impossible to learn how various foods impact your blood sugar by only doing one fasting BG test per day.  As the Accu-Chek strips are very expensive, and my prescription for 50 strips can only be filled every 50 days, I have had to resort to buying WalMart’s ReLion meter and strips (which are $9 for 50) so that I could test my blood glucose pre- and post-prandial. I do not test as often now, I have a pretty good idea of how various foods affect me.   But you cannot expect anyone to adequately manage their diabetes doing only one test per day.  And in the first year or so after diagnosis, the patient should be encouraged to test up to 7 times per day (fastingi and before and after each meal).
    I think Medicare needs to allow more frequent testing for all diabetics, not just those on insulin, and it is imperative that Medicare not allow the prescribing of any meters that cannot pass rigorous testing for accuracy.
     

  10. Catherine,
    Thank you so much for writing about the problems created for Senior Diabetics by the Competitive Bid Program. Our family mail order Diabetic Supply Company at http://www.diabeteshomecare.com was one of the 50,000 providers forced to stop serving Senior Diabetics when CMS selected only 18 providers (Now just 14) to serve over Seven Million Senior Diabetics at a unmanagible reimbursement rate of $10.41. I agree with the comment, “It’s all about saving money, not treatment or care” As a Diabetic family and Provider we work every day to seek solutions and help diabetics. Informing the diabetic community through your Blog is appreciated.

    Gary Buchan

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***The opinions and views expressed in this blog belong to the individual contributor and not to ASweetLife or its editors. All information contained on this blog is intended for informational purposes only. The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.