In its May bulletin to healthcare providers, UnitedHealthcare (@myUHC) announced that, starting July 1st 2016, Medtronic would be its “preferred” in-network provider of insulin pumps for its adult customers with Type 1 diabetes. This means that, with a few exceptions, if you’ve got Type 1 diabetes and health insurance from United, your next pump is going to be Medtronic. And since United is the nation’s largest insurance company, it’s conceivable that other insurance companies will follow suit.
The policy, which unfortunately is already in effect, is bad news for people with diabetes. Equally unfortunately, United appears to have made its decision without input from people who actually wear insulin pumps. This was a mistake.
Many diabetes advocates have already written about this issue (for example, see here, here, here). I’m weighing in here with my own response, to do what I can to help the United executives in charge of this decision understand why we are so upset, and to encourage them to reconsider the policy.
The cynical view of the situation is, of course, that this was purely a financial decision—that Medtronic offered a big enough discount for being the “preferred provider” that United decided it was worth it to restrict coverage, whether or not the decision was beneficial for people living with diabetes.
My hope, however, is that the UnitedHealthcare executives who made this decision have actually been surprised by the outcry their new policy has provoked. In addition to whatever discount they’re getting from Medtronic, I would like to think that they also are motivated by a genuine desire to provide access to good care.
Either way, it’s reasonable to assume that the people in charge of the decision were presented with data about how the Medtronic system with threshold suspend (i.e. the one that cuts off insulin delivery when you’re blood sugar is low) can reduce both time spent in hypoglycemia and the occurrence of severe lows. Since both those situations are dangerous to the person (and often expensive to the insurance company), choosing a system that can minimize them would seem to be a win-win.
If this relatively non-cynical take on the matter is true, then perhaps these same executives might appreciate an explanation as to why the diabetes community has been so upset. Who wouldn’t want the supposed top-of-the-line product? So here’s my attempt at communicating why I personally am so upset. Taken together with the other reactions that you have received, I hope it might encourage you to change your mind.
I was diagnosed with Type 1 diabetes when I was 22 years old. That was more than 15 years ago. Since that morning in the hospital, when I arrived dizzy and disoriented, exhausted and emaciated, not a waking hour has gone by where I have not thought about diabetes. I have changed the insertion site for my insulin pump more than 1,800 times. I have pricked my finger to test my blood sugar more than 44,000 times. I have given myself shots more times than I can count.
Insulin keeps people with Type 1 diabetes alive, but it is also dangerous, able to cause seizures, a coma, even death if we misgauge our doses by more than a drop. Consider that a healthy person’s blood contains 5 grams of glucose at any given time (the amount of sugar in a single peppermint) and you will get a sense of what a challenge it is to maintain tight control. But coasting high is not an option: over time, this can cause the dreaded complications of diabetes, the blindness, the kidney failure, the amputations, the strokes.
As anyone with type 1 diabetes can tell you, it is relentless, this disease, and it is exhausting. There is no vacation. There is no break. Diabetes never goes away.
We cope because we have to, and each of us copes in different ways. For me, it’s writing. I write to keep my knowledge up-to-date, and to share this information (and express my exhaustion) to other people with the disease.
But there is something else that keeps me going in the never-ending quest for smooth blood sugars, and it is hope. I have hope that this disease is on the verge of becoming much easier. I have hope that the next generation of pumps and sensors will revolutionize the way we treat diabetes. I have hope that, thanks to new technologies and algorithms, there will soon be a day where I don’t think about diabetes every waking hour. Where my pump talks to my continuous glucose monitor and gives me insulin, maybe even glucagon, all on its own. Where I can eat dinner without calculating carbohydrates. Where I can fall asleep without fear.
Where the emotional burden of Type 1 diabetes is finally lifted.
That is my hope. And we are getting so close.
I have nothing against Medtronic. I am extremely grateful for it. I wear one of its pumps, and it is reliable. If approved, Medtronic’s newest system, currently under review by the FDA, would be the first pump approved to actually dose insulin. That would be amazing. I salute all the people at Medtronic who have devoted their careers to making diabetes easier to live with. Your work makes a difference.
But even if Medtronic’s new system is approved (and I very much hope that it is), it will still not be a true, closed loop artificial pancreas. With all due respect to its engineers, it will be the first in what I hope will be a long succession of continual improvements—a Tin Lizzy to tomorrow’s Tesla.
And here’s the thing: to get there, to create a truly closed loop system, we need competition. We need Dexcom. We need Tandem. We need Abbott and Insulet and Animas. We need Beta Bionics and Bigfoot and all the other small companies that are working so hard. Without the possibility of getting insurance reimbursement, these smaller companies cannot not survive. Restrict reimbursement to just one company, and you take away the motivation and resources that drive innovation.
Restrict reimbursement to just one company, and you take away our hope.
If this sounds dramatic and unlikely to occur, consider what happened when Medicare’s competitive bidding program drastically cut the reimbursement rate for blood glucose test strips (paying little attention to whether the covered brands of strips were accurate): the major test strip manufacturers, the ones that value quality control, the ones that had been innovating, instead began racing each other to get out of the test strip business.
Consider that many people with Medtronic pumps (myself included) wear Dexcom CGMs, and many endocrinologists (my own also included) prescribe Dexcom CGMs to patients who have Medtronic pumps. Why do we do this, when the two brands aren’t compatible with each other? We do it because we feel that Dexcom is designed better, is more accurate, and is easier and less painful to wear. It provides more safety and better quality of life. And quality of life matters.
Consider that insulin pumps, like prosthetic limbs, are not interchangeable. They have different features, different benefits, different downsides, different sizes and different shapes. (Medtronic’s pump is not waterproof, for example, which would have made it impossible for me to have been captain of my high school swim team if I’d been diagnosed with Type 1 when I was a child.)
And consider that if you truly have your customers’ best interests at heart, there is no need to have a “preferred provider” of insulin pumps. We will pick the pump that we prefer and that works best for us—and this, in turn, will reduce your costs.
So please, United, reverse your decision to make Medtronic your preferred provider of insulin pumps. Do so publicly and loudly. Use this as an opportunity to send a message to your own competitors that United listens to its customers and that it cares about their lives.
And the next time you make a decision like this, please include people who actually wear insulin pumps in the discussion. We want to work with you. We are experts in what it’s like to live with diabetes. And we have a lot to say.