You've got the power!

BY KATHERINE ROBERTS, MD, FACE, ECNU

As a clinical endocrinologist caring for people with diabetes, I frequently hear stories about the difficulties my patients encounter in securing the proper tools to optimally care for their condition.

Diabetes patients are faced with daily challenges associated with blood sugar monitoring, medicine dosing and carbohydrate intake, not to mention sometimes dealing concurrently with the many medical issues that accompany the disease. Imagine then also facing problems related to access, reimbursement and quality of diabetes testing devices, medicines and supplies.

Below are some scenarios and strategies you can use to overcome such obstacles.

Scenario #1:

“Dorothy” came in to see me last week and was justifiably proud to report her blood sugars levels: none had been over 200 mg/dl (milligrams per deciliter) since her last visit. This was after a year of struggling to get her blood sugars under 300 mg/dl, despite a number of medication adjustments and visits with the clinic’s registered dietitian. However, when my medical assistant checked Dorothy’s blood sugar in the office, it was 495 mg/dl. How could this possibly happen? Her blood sugar level had been really good for months, and she was checking it twice a day at a minimum, as was evident from reviewing her inoffice downloaded meter data. Why was there a discrepancy? Dorothy came in fasting – nothing to eat or drink since the previous night – and she reported no symptoms of an infection or any changes in medication or overall well-being that might cause this problem.

The culprit? It was discovered that the patient was using a glucose meter that was recommended by her insurer/ pharmacy benefits manager. She did not use the control solution that comes with the meter to check for meter accuracy, and the result was her blood sugar values were off.

There are many things to consider when using a glucose meter. Don’t always go for the cheapest meter, as it may prove to be life challenging. To be sure, offers for inexpensive meters and inexpensive strips may sound tempting, but be aware of poor quality. Many insurance providers and pharmacy benefits managers can be quick to recommend items that are inexpensive, but not necessarily what works the very best for you.

What do you have to do to get a reliable glucose meter? Here are a few tips to follow when shopping for a meter:

  1. Call your insurance company and ask about which meters they cover and for what price.
  2. Using that list, call your endocrinologist and ask which ones they recommend as reliable and accurate.
  3. Secure a prescription for all of your blood testing supplies and submit them to your insurance company to have them covered or ask why they are not if your submission is denied. You can also ask for a waiver or a prior authorization. This will require completion of additional forms from you and your physician or your medical team. Prepare to be patient but persistent.
  4. Your physician may be able to provide you with a high quality device at no charge. Ask at your next appointment if he/she has one available.

Scenario #2:

This scenario is about “Jim,” who came in for review of his blood sugar control. He has type 2 diabetes and, despite the addition of several blood sugar control medications, he is only slowly showing a response. He also is gaining weight: previously at a BMI (body mass index) of 30, just at the cutoff of an obesity classification, Jim is now at a BMI of 33, which is considered clearly obese. Understandably, he does not want to gain more weight and is trying his best to make changes by eating smaller portions and fewer carbohydrates. Admittedly, he enjoys food and would like to eventually work as a chef, for which he is training. After discussing therapy options, it was decided that a medication in the GLP-1 RA class (glucagon-like peptide receptor agonist, which effectively lowers A1C and weight while having a low risk of hypoglycemia – low blood sugar) would be best for him. I wrote a prescription for the medication, but Jim called the next day to say he was advised by his pharmacist that the medication was not covered under his insurance, and he cannot afford the out-of-pocket costs.

We came up with a solution to lobby his insurance company to request a waiver, which entailed filling out many forms in order to validate the need for the GLP-1 RA, outlining the many reasons this would be a better drug for his diabetes control and why the accepted ones would not.

Scenario #3:

A firefighter using an insulin pump came into my clinic to review his blood sugar control. His pharmacy benefits manager had automatically switched his short-acting insulin to another brand. This was his first visit since the change in his insulin, and his blood sugars were not consistent. After reviewing his records, matching dates with activities and bolus doses for meals (a bolus dose is insulin that is taken specifically at meal times to keep blood glucose levels under control following the meal) -- nothing seemed amiss. Finally, a look at his pump revealed that the insulin in his pump reservoir and tubing was cloudy. We realized that because he is in the heat a great deal of time, he needed a specific brand of insulin to use in his pump. However, his insurance would only approve his originally prescribed insulin, which included a much higher co-pay than the new insulin.

What’s the solution? I advised him to ask if another medication in the same class is covered. Often a substitution is on the formulary list, so it’s worth taking the time to ask.

Also, ask if samples are available through your endocrinologist. If you can try the medication and show that your blood sugars improve, your weight drops and you need less of another blood sugar-lowering medication, this data can also be submitted on your behalf to request a reconsideration of coverage (also known as a prior authorization). Be prepared to keep records of your finger stick blood sugars and make sure you do them regularly. These records could help support your case.

Each of these scenarios illustrates problems that can arise and how you can be proactive in getting what is best for you. And while everyone is conscious about the cost of medications and devices, the bottom line is that you should have access to the tools that will optimize your diabetes management. So keep records, take notes, and work closely with your doctor’s office to get what you need.

Dr. Katherine Roberts is a clinical endocrinologist in private practice In Williamsburg, Virginia. Board-certified in Internal Medicine, Endocrinology and Metabolism, she attended undergraduate school at the University of Florida and received her M.D. degree from the Medical College of Georgia - School of Medicine.