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Beyond insulin: Insurance rules can slow down the delivery of essential diabetes products: shots



Ric Peralta and his wife Lisa can check Ric's blood sugar level at any time with the Dexcom app and an arm patch that measures the values ​​and transmits the information wirelessly.

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Ric Peralta and his wife Lisa can check Ric's blood sugar at any time with the Dexcom app and an arm patch that measures the values ​​and transmits the information wirelessly.

Allison Zaucha for NPR

Ric Peralta managed to lower his average blood sugar level by three percentage points in the first three months after receiving his Dexcom glucose monitor .

-managed blood sugar to something that was handled incredibly well, "says Peralta, a 46-year-old optometrist in Whittier, California, who was diagnosed with type 1 diabetes in 2008.

Peralta was so excited that he became an enthusiastic doctor "Dexcom Warrior", a kind of base spokesperson for the product – his new monitor has become an integral part of life, allowing him to follow the trends in his blood sugar on his smartphone 24 hours a day however, he spent weeks without the device last year because he had problems with insurance restrictions, and groups of physicians and patients consider these rules excessively stressful, but insurance groups are defending them as necessary.

Diabetes activists and legislators have begun d Focusing attention on the rising price of insulin, which has led to legislative bills, court hearings and hearings in Congress. However, insulin is not the only thing that people with type 1 diabetes seek. The treatment of the disease requires other important, often life-saving medical aids. And patients often have difficulty getting access to these consumables – hurdles put by insurance companies.

A Life-Changing Device

Peralta learned his patient from the mother of one of Dexcom's continuous blood glucose monitors. He visited the company's website and within two weeks the device was delivered to his door. "I still did not know 100 percent how it would change my life," says Peralta. "It was amazing."

At her home in Whittier, California, Lisa Peralta Ric pats the Dexcom sensor to make sure he stays on his arm. Before he got the device, Ric had to check his blood sugar every few hours with several finger prints and plastic test strips.

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Typically, people with Type 1 diabetes check their blood sugar by removing a drop of blood from their finger and placing it on a disposable test strip that is read by a blood glucose meter. Doctors suggest controlling blood sugar four to ten times a day in this way. These values ​​are critical to helping people with diabetes control their blood sugar. They prevent it from becoming too low, which can lead to sudden seizures and loss of consciousness, and that it becomes too high, which can lead to vision loss and nerve damage, even leading to amputations over time.

Instead, Peralta's continuous glucose monitor gave accurate blood glucose readings every five minutes. That's 288 readings per day or 278 readings more than the most conscientious patients.

"When I had to do the old-fashioned fingerprint test, I did that just before eating so I could see how much [insulin] I should take," says Peralta. (People with type 1 diabetes need to take insulin several times a day to keep their blood sugar within normal limits, as their body does not produce the naturally occurring hormone.)

Peaks and valleys between meals, "says Peralta. [19659010] Stricter control of blood sugar can reduce the risk of heart disease, kidney failure, and nerve damage, and it was also reassuring for Peralta.

The monitor alerts when its blood sugar becomes dangerously low Peralta says his staff are giving him sugary snacks If he hears the alarm to help him get his blood sugar back to normal, if he takes his family on road trips – a favorite pastime – he does not have to worry about fainting while he's driving. [19659010] "It even fits my car, so all I can say is:" Siri, what's my blood sugar? " And it will come over the car stereo, "says Peralta." I'm safe for my family. "

Prior authorization

Preventing common chronic conditions such as diabetes well prevents this Deteriorating the disease and saving money on the healthcare system and the healthcare patient.

But Peralta says his efforts to consistently use this new tool to treat his diabetes have been hampered by insurance issues that started about a year ago which sends the readings of the sensor wirelessly and a receiver that displays these readings on a screen.

Blood sugar testing now includes three devices, says Ric Peralta: (left) Peralta holds the applicator in his hand holding the Measurements Contains the Dexcom G6 Sensor and Transmitter Attaching It Right on the Arm Positioning the Dexcom Sensor and Transmitter (Right) Peralta checks the Dexcom app on his smartphone to see his glucose level before eating.

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For each of these parts, Peralta requires a so-called "pre-approval" from its insurer – a requirement from its insurance company that requires its doctor to seek approval from the insurance company before prescribing the device Peralta's insurance allows him to buy a three-month supply each. However, he must also obtain prior approval for each delivery, which means that his doctor must reconfirm with his insurance company every three months that the sensors are medically necessary. The same applies to the transmitter of the device – the each last about six months.

"I have to jump through tires and they have to jump through tires to get information from my insurance company to get approval," Peralta says in frustration. He added, "Last year, basically, there was something that went wrong every time."

"Previous approvals exist to protect patients, improve safety and ensure that care is as safe as possible and as affordable as possible," says Kate Berry of America's Health Insurance Programs.

For Ric Peralta, however, the demand is a burden.

The last Snafu occurred in March. Peralta ordered a new shipment of sensors directly from Dexcom, but announced that it had also applied for approval from a new broadcaster. And because his insurance company approved the sensors and transmitters in different authorization periods, the entire claim was rejected. Peralta estimates that over the next month and a half, he spent four hours calling Dexcom and his insurer to clear things up. During this time he had to resort to finger-stick tests.

"It's crazy," says Peralta. "If I am unable to cope with this disease, I will die from it and they will make it as hard as possible for me."

Peralta says he is a "Dexcom warrior" – a sort of grassroots spokesman for patients with diabetes who routinely remain in limbo waiting for their insurers to approve medications prescribed by their physicians.

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Burden on Doctors

Earlier drug approvals have become a major concern for doctors across the US healthcare system, according to a December 2018 American Medical Association survey.

Of the 1,000 physicians surveyed, 91 percent stated that prior approvals "have a negative impact on patients' clinical outcomes". Seventy-five percent said that "at least sometimes patients may discontinue the recommended treatment." Twenty-eight percent said the previous approval process had "resulted in serious or life-threatening events for their patients. Authorization and treatment with insurance companies," says Dr. Bruce Scott, a Kentucky ENT specialist and deputy spokesman for the AMA House of Delegates. 19659049] "Prior authorization is a burden for providers and redirects valuable resources," says Scott. "That's a problem."

The AMA has even created a website that catalogs stories of patients and providers that are experiencing difficulties had access to major medical devices and procedures because they had problems obtaining prior approval from insurers – all because of pain medication for a cancer patient to have an X-ray in the emergency room. "According to Scott, the AMA does not expect insurers to meet the requirements completely cancel a prior authorization, "but we believe that they should be focused and better planned ".

The American Association of Clinical Endocrinologists – an organization of "We believe that physicians specializing in endocrine disorders do not need to complete prior approval for endocrine treatments," says Dr. Endocrinologist from Atlanta and member of the Board of Directors of AACE.

"It's a huge burden on the patients trying to sort it out, sometimes it's bureaucracy, sometimes it's a real rejection," says Isaacs. "It's an enormous burden on the doctors, and the doctors are angry."

Berry of the insurance group AHIP admits that the previous approval process can be improved even further. In fact, in January 2018, AMA and AHIP signed a consensus statement setting out five areas for improvement. It was co-signed by the American Hospital Association, the American Pharmacists Association, the Blue Cross Blue Shield Association and the Medical Group Management Association. Who bears the biggest burden? The ultimate burden of having all these prescriptions filled is with him and patients like him.

After swapping the sensors for the last time in March, he discovered his transmitter's battery was dead.

Peralta was once again frustrated with Dexcom and recently received a free channel that puts him back in the system while his formal order goes through the approval process.

"I'm pretty nervous about what's going to happen again in two months, if I have to call again command," says Peralta.

"Do I have to go through this again?"

This story is part of NPR's reporting partnership with Kaiser Health News. Bram Sable-Smith is a freelance reporter based in Madison, Wisconsin, who often deals with health care. Reach him on Twitter: @besables .


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