My Dog, Skip, Probably Has Better Healthcare Than You

My beloved Guinea pig, Reese, came home from the pet store with the rodent version of “kennel cough.”  We have been frequent fliers at the Vet as a result of this.  Thankfully, our Vet’s office is a fun place to visit.

When I call to book appointments, the service is prompt and the availability accommodates my work schedule.  When we arrive at the front desk, we are greeted with a warm welcome.  There is not palpable tension in the waiting room. Rather, a few smiles are exchanged amongst the visiting patrons.  Reese’s “white coat” anxiety is soon put at ease by the kindhearted Vet technician who spoils her favorite Guinea pig.

The Veterinarian’s examinations are thorough and careful to keep Reese as calm and comfortable as possible.  The Vet never rushes me through my laundry list of talking points saved in my phone, similar to my notes for my own healthcare appointments.  Instead, she actively listens and even expresses gratefulness that I have done my homework when it comes to raising a Guinea pig.

The cost of care is reasonable given the attentiveness and the results.  I do not cry at the pick-up counter of the pharmacy, as I am not sticker-shocked, vulnerable, or frustrated.  The pharmacist even adds extra banana flavor to make Reese’s medicine-taking process a little more bearable.

I received an email asking if I would like to sign up for an electronic health record (EHR) website, which will be personalized with Reese’s pertinent health information, photo, and Vet appointment schedule.  Although I am on the fence as to how necessary it may be to exchange all of that personal information considering that we will (hopefully) only make annual check-up appointments, I so appreciate that the Vet EHR is a possibility for Reese if and when we want it.  I cannot always say the same for my own human care.

^ The happy face of a creature who has easy access to empathetic care, and her own health information.

Whenever I visit a famous diabetes clinic affiliated with an even-more-famous Ivy League university medical center, the norm has become that it takes approximately six weeks to receive my lab results after the appointment.  While I have bemoaned this publicly on Twitter, I do not do so simply to hear myself talk.  This is not a unique situation to my healthcare experience, this clinic, nor other humans in the American healthcare system.  The plague runs rampant.  But is there really any excuse for it to keep spreading?

I am of the opinion that if said clinic’s nurse has poked the vein in my arm to draw blood, if I have lost my dignity by peeing in a cup and then holding it up to the light to squint– praying that somehow whatever is in that cup will be as okay as healthy-looking-urine can be!–, then I have earned the right to access my own medical information in a timely, effective fashion.  It is my data.  Who, what, when, where, why, and how I share it should be up to me, in an ideal world.

When said clinic advertises its new and improved EHR for years, only to continue solely updating occasional appointment reminders while the highly-acclaimed EHR remains devoid of labs and notes, something’s gotta give.  If this is happening in the “Mecca of healthcare,” where the biggest and the best EHR companies and universities spread their wings, how on earth can we expect the continuum of care and the quality that we know we are capable of achieving to improve healthcare?

This is not anyone’s fault in particular.  We have a healthcare system that remains convoluted and disjointed, no matter which political party attempts to restructure it.  We must ensure the utmost privacy while simultaneously allowing data to be useful and accessible- not an easy feat by any means, especially with hundreds of entities vying for this business.

My healthcare provider’s ultimate responsibility is to care for her patients.  If we are asking her to become an IT wizard on the side, we are asking her to make sacrifices elsewhere; ultimately, those sacrifices will come in the form of time lost treating patients with a high-quality level of care, which is contrary to what any good doctor stands for.

On the administrative side, more training needs to occur to ensure a smooth transition of care and patient data.  There will always be bumps in the technological road, but we cannot overlook commonsense.  For example, when a patient has blood drawn, either mail the labs shortly thereafter (in and of itself an archaic method of communication considering privacy and efficiency), or, use the #$%^*&@ patient portal to the best of its ability- to provide patients with the information they need to be informed and engaged in their health condition management.  Contrary to what the insurance industry may imply, we cannot scapegoat outcomes on patients and providers since we only provide rusty tools in their toolboxes.

“THESE ARE MY KIDNEYS!  I want to know- good or bad!” I dramatically proclaimed to my doctor when I finally got fed up enough to send an email requesting overdue lab results, circumventing the clinic and going directly to a source who cares enough to help. (Everything is fine, but it’s the principle of the matter.  If things were not fine, we want to proactively take action as soon as possible.  Lab results that are MIA for 6 weeks are a missed opportunity to intervene, and if we add up the totality of those missed opportunities and multiply it by the totality of the patients affected and the totality of the healthcare providers and admin. executives unnecessarily getting burnt out because we make this process unnecessarily harder than it was ever intended to be, well, you get the picture!!!)

My doctor answered my email pleas late at night on her day off, showing me she wants to make this situation with the clinic better for her patients.  She gets it, agreeing wholeheartedly that we need quick access to my health information in order to form the best game plan for treatment.  Much like Reese’s Vet, she listened and allowed me to express everything that I needed to.

The only way things are going to get better is if we continue to voice these issues and work together.  I believe strongly that clinics should hire firsthand patient consultants to come in and advise.  They offer expertise that cannot be seen without the lived experience, and their hearts are in the right place to make improvements for everyone who will come after them.  Many have professional and graduate level education experience in the healthcare field, further enhancing their value to this discussion.

Such constructive feedback can be a path that makes all healthcare players happy.  Costs may decline, quality may increase, outcomes may be better, human beings may spend more time living and less time surviving– and all from simple tweaks that do not require much investment aside from simply listening to those who are fighting for their health every day, and being open to changing accordingly.

Hey, humans!  Let’s get on the same wavelength as veterinary care, in which we hone in on empathy, communication, topnotch organization in our administrative duties, and a healthcare team that works together with living, breathing creatures of all backgrounds.  So, what do you say?

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Docto Interview

Many thanks to Docto for our fun interview, which can be found here.  I enjoyed learning more about the Docto app, which uses algorithms to predict blood glucose levels an hour in advance (docto.me)!  I believe there is great potential with this app not only in terms of physical health outcomes, but also in easing the emotional concerns that go hand-in-hand with diabetes.

Having detailed knowledge as to where my blood sugar might be headed an hour from now would allow me to make more informed insulin dosing decisions.  It would also mitigate my anxiety in that the unknown, sometimes-scary diabetes stuff will become known before it even happens.  Docto literally makes the unpredictable more predictable, which is music to my ears from a holistic diabetes management perspective.

Docto did not ask me to write this blog post, but I want to say it:  I am impressed with Docto’s dedication to making diabetes management better for our community, as well as their genuine interest in learning more about the diabetes experience from those who live it firsthand.  Our interview renewed my hope that the diabetes burden will become lighter for all of us in the future thanks to healthcare innovation and teams like Docto.  I encourage readers to visit docto.me to learn more.

Ah-Ha!

Video of our 2016 Stanford Medicine X panel, Ah-Ha! moments in mental health and chronic disease management, can be viewed here.  The panel speaks for itself; it was brave to participate; it was brave to be a member of the live audience- at Stanford and/or online; it is brave to watch the video; it is brave to reflect on mental health and chronic disease management.

Many thanks to Charlie, Danielle, Sarah, Mark, and so many others in the MedX family for making our 2016 panel such an empowering and enlightening experience for so many.

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Photo credit: Stanford MedX Flickr

 

Featured image photo credit: Mark Freeman

Coffee Date # 3: Lilly Diabetes Takes The Mic

Julie Herrick Williams, Communications Manager at Lilly Diabetes, joins VLNS as the third Coffee Dates guest.  When I requested diabetes industry/pharmaceutical entities to discuss insulin here, two people rose to the occasion- to my pleasant surprise.  Thank you to Mike Hoskins for encouraging this interview, and to Julie and Lilly Diabetes for your candid participation.  Without further ado, let’s pass the mic to Julie.

 

A:  Insulin access and affordability are currently hot topics in mainstream media coverage, as well as diabetes social media conversations. Manufacturing, research and development (R&D), and marketing in pharmaceuticals are all complex. Can you explain how these -or other- factors tie into the pricing of Lilly Diabetes’ insulin?

J:  Many factors go into the list price of Lilly insulin, and that’s true for all of our medicines. Developing and manufacturing insulin actually is very expensive and scientifically precise, so only a few companies invest in it. Billions of dollars in costs (from R&D to technology to capital) and expert scientific and technical know-how are required. Lilly has built state-of-the-art insulin manufacturing facilities around the globe—and, in 2013, we decided to invest another $1 billion to ensure our facilities efficiently meet increasing needs for insulin as the prevalence of diabetes grows. We’re committed to meeting patients’ needs with the highest standards for quality and safety—and to addressing affordability issues for people taking insulin.

 

A:  Insurance plans and pharmacy benefit managers (PBMs) also impact what the consumer pays for insulin. Lilly recently coordinated with Blink Health to make insulin more affordable and accessible for some people with diabetes. Please tell us how this program works and who may be eligible. 

J:  We’re working hard to address concerns about the cost of insulin. On January 1, 2017, Lilly introduced a new insulin discount program. In partnership with Express Scripts and using Blink Health platforms, we’re offering a discount of up to 40 percent off most Lilly insulins for people who pay full retail price at the pharmacy (those without insurance or in high-deductible health plans). For more details, see blinkhealth.com and the attached patient brochure.  Since this is a discount program, not insurance, people should check their insurance before making a purchase through Blink Health.

 

Source: Lilly Diabetes

 

A:  I inquired of a fellow healthcare advocate which question she would ask if given the opportunity to have you answer it here. Her reply: “My main question: ‘Why?’.” [To paraphrase: Putting aside the R&D or insurance influences for a moment, why raise the price on a product that keeps us alive by hundreds of percentages over time?]

J:  It’s important to note that the price people pay at the pharmacy is the result of many different factors, most notably their insurance benefit design. While list prices for insulin have gone up, Lilly’s average net realized price for Humalog (the amount we receive after rebates and fees are paid) has been flat since 2009. A big reason is that we pay rebates and fees to PBMs and health plans to keep our insulins available on formularies. Unfortunately, people with high-deductible insurance plans do not benefit from these rebates; instead, at the pharmacy, they’re forced to pay list price, or “sticker price.” We’re working with others across the healthcare system to ensure that insulin is affordable for all who need it; our discount program is just the first step.

 

A:  What about the healthcare advocates who will say that more can be done, that perhaps we should not need a discount program to begin with if insulin could be more reasonably priced from the get-go? Are there any ideas in the pipeline to make this more of a reality?

J:   While our offer of discounted insulins through the Blink Health platform was an important first step, we know that we must do more. We need a broad-based, long-term solution. Through conversations with stakeholders—from payers and employers to patients and advocates—we’re seeking a multi-pronged approach where we assess and improve health insurance design, out-of-pocket costs, rebate streams and transparency in drug pricing. We want to be part of the solution—to improve care, increase efficiencies, and lower costs.

 

A:  Previous Coffee Dates have discussed what the term ‘transparency’ embodies for those who rely on insulin to live. What does transparency mean from the Pharma perspective? What improvements can be made to ensure all sides of the healthcare equation are well-informed and able to access resources for optimal health?

 J:  Over our 140–year history, Lilly has strived to enhance the public trust of our company and industry by being forthright and ethical in the conduct of our business. For instance, we believe our process of openly reporting financial interactions with healthcare providers builds trust and confidence with those providers, as well as with patients and caregivers. Yet, we realize more can be done to respond to society’s fast-changing expectations, so we are constantly working to improve. (By the way, participating in this blog chat is just one way that we like to be transparent!).

 

A:  Will biologics and biosimilars help to drive down insulin costs in the future? What are the options if the element of consumer choice in treatment is affected by insurance coverage of certain products?

 J:  The launch of Basaglar in 2016 as the first follow-on insulin did, indeed, introduce additional competition into the basal insulin marketplace. Fortunately, that should reduce some healthcare costs. But most of those healthcare savings are realized on the net cost level to PBMs, health plans and others. What a person pays for insulin at the pharmacy is the result of many factors—most notably, their insurance benefit design.

While we are strong advocates for treatment choice, we recognize that healthcare providers and insurance plans ultimately select the treatment options for people. Consumers will need to talk to individual insurance companies or pharmacy benefit managers about their list of covered medicines.

 

A:  Does Lilly have charitable programs for those who need insulin outside of the U.S.? Where can readers go to learn more about these options?

 J:  Yes, we are deeply committed to the International Diabetes Federation’s ‘Life for a Child’ program in developing countries. The program provides insulin and syringes, blood glucose monitoring equipment, clinical care, HbA1c testing, diabetes education, and technical support for health professionals. Over the past decade, Lilly has donated more than 1 million vials of insulin through this program, helping thousands of children access the care they need. To learn more about ‘Life for a Child,’ email lifeforachild@idf.org or click here: http://www.idf.org/lifeforachild/contact. And, the Lilly Cares Foundation’s Patient Assistance Program provides medicines at no cost to qualifying U.S. patients. To learn more, please go to www.lillycares.com.

 

A:  Finally, inquiring minds want to know: What is Ryan Reed’s lucky coffee order on race day?

J:  It’s pretty simple: he likes regular coffee – black!

 

2.

My 2-year-return-to-insulin-shots-anniversary came and went a few weeks ago.  The anticlimactic day was all the validation I needed to know that this was the right choice for me.  I no longer count down the days, weeks, or months on shots; they are my new normal until I switch things up again or diabetes is cured.

People probably wonder why I still harp on my defective insulin pump saga, and the truth of the matter is that one can talk as much or as little about trauma as one sees fit.  Medical trauma is particularly cruel; our already-limited “control” further fades away as our cells cry out for insulin.  I continue to harp on this because the wounds are still fresh, however many years after the triage.  Yet the bandages of an engaged healthcare team have eased the pain, and I finally feel better.

Two years ago I feared that I would die of ketoacidosis while sleeping on my couch.  I worried that the graduate school experience I had always dreamed of might slip between my fingertips.  Or worse, that the mental desperation would become too much- that in my attempts to be heard my voice would eventually fade away.

Multiple daily injections (MDI) are not always pretty, but they are a guarantee that insulin is getting into the body.  MDI is literally and figuratively another shot at life.  (More to follow, but not everyone has this guarantee currently; they deserve a chance, too.)

Two years later and I have successfully completed my Master’s degree.

I flew to California twice to participate in Stanford Medicine X.

I didn’t die on my couch.

And I was too busy living to remember that it was my 2-year Shotoversary.

Insulin makes it happen.

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Reese’s Cups and Hamster Wheels

I first fell in love with memoir as a junior in high school during a course aptly titled Rewriting A Life.  There, I was introduced to the work of Mary Karr, and to this day I soak up her words like a sponge absorbs a misplaced glass of cabernet: fully, and scattering droplets where they are most needed (the only clean part of the carpet, for example).

Here’s a droplet:

When you’ve been hurt enough as a kid (maybe at any age), it’s like you have a trick knee.  Most of your life, you can function like an adult, but add in the right portions of sleeplessness and stress and grief, and the hurt, defeated self can bloom into place.

-Mary Karr

That’s sort of how I feel lately.  The perfect storm of life stressors- past, present, and future- has left me questioning my moral successes and failures, my worthiness as an advocate, and where to go from here.  The answer is that there is no black or white response- only more questions, and more places to go.  The best work I can do at the moment is simply to voice this.

I am angry that our fellow people with diabetes are dying because insulin is inaccessible and ludicrously expensive.  I am angry that the people who can afford insulin- myself included- are under the constant pressure of maintaining positive disease outcomes with rusty toolboxes.  I am angry that we do not have a cure.  I am angry that we are so fragmented as a community, that when we voice dissent we are quickly hushed by the status quo of comfortableness and the diabetes industry- luxuries that so many others do not have.  Finally, I am angry that I am angry, that I have scapegoated much of my anger on diabetes, and that I have not always handled life’s difficulties with the grace and dignity that I know dwell within my heart.

However, I am grateful that despite the bad stuff, there are friends and supporters who still believe in the good stuff.  Their love has never wavered, and has inflated into a life raft when needed most.  (Thank you).

Rewriting A Life does not mean you get to copy and paste a Cinderella ending to your story.  You simply get to live it, and to describe the good and the bad in detail that has the potential to resonate with someone else who desperately needs to hear you.  Perhaps you desperately need to be heard, too.

Recently, emotional and physical health have felt like running on the hamster wheel while nursing a sprained ankle and a hangover.

So, I switched things up and adopted a guinea pig.

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This is Reese.  She is colored like a Reese’s cup.  

She is currently petrified of me, but I hope the same thing that I hope for you, or me, or any living creature: that she feels loved nonetheless.  

 

 

 

Insurance Sans Reassurance

Insurance isn’t all it’s cracked up to be.  We’ve been over this on Twitter.  Out-of-pocket expenses remain ludicrously high for many of us, and in my humble opinion insurance gets off the hook way too easily while the media yells at Pharma (which is, of course, its own beast of an issue- but that is an argument for capitalism that goes beyond the intent of this blog post).

It is open season for insurance enrollment, so you would think that the necessary information consumers need in order to select a plan that suits their needs would be front and center.  Far from it.

I am under the impression that no one is an “expert” in healthcare anymore.  Healthcare is too complex, and varies too much by individual situation, for anyone to truly grasp each nuance at a level of expertise.  I am certainly not an expert.  But I do have lots of healthcare experience at a young age, having worked in healthcare for many years, lived it as a diabetes advocate, and earned a Master’s degree in healthcare administration while graduating at the top of my program.

Despite all of the above, healthcare remains a Rubik’s cube of complexity, and I have grave concerns with where we are heading from here.  How on earth can we expect someone who doesn’t live and breathe healthcare as a total nerd to ever figure this stuff out?  We don’t.  And that is how insurance banks on us.

Ever since news broke of CVS Health’s  ridiculous 2017 formulary removals, which included Sanofi’s Lantus, I have scoured the internet for more information.  Would my current insurance provider (which consults with CVS Caremark as a mail order pharmacy supplier) be offering any coverage for my trusted Lantus?

Insulin, too, is its own monster in the healthcare market.  While we need more affordable, accessible options for diabetic folks all over the globe, this has created a pharmaceutical conundrum.  Pharma companies have answered the call with biosimilar development promised to be more reasonably priced than the name brand options.  The Affordable Care Act encourages cost containment, so we cannot be surprised when companies make moves to curtail costs.  My main concern with both the ACA and pharmaceutical development, though, is that consumers must still have an element of choice if we expect them to achieve positive outcomes (and, therefore, to control costs in the long-term).

Despite however biosimilars are marketed, we do not know for sure that they are bio-exact.  I have worked too hard to relearn the insulin wheel since ditching my defective insulin pump to return to multiple daily injections, and I am not interested in being a biosimilar guinea pig right now.  Why mess with the good thing that has been a lower A1c and better quality of life on Lantus?

Bottom line: If I am going to stick with my current insurance plan and provider in 2017, I absolutely need to see in writing if the insulin that keeps me alive each day is covered.  A 45-minute call with a Caremark representative this week had us both scratching our heads and simultaneously sleuthing around on the internet and insurance website, desperately trying to find formulary documentation for 2017.  Google yielded last year’s list, and searching “formulary” or “Lantus” on the insurer website came up with no matches.

Finally, the Caremark rep found the formulary list buried under a certain tab on the insurance website.  My hunch is that insurance companies do not actually want us looking up this information for fear that we may hop over to a competitor offering better coverage of our medications.  The good news for me is that Lantus will be covered for me next year, albeit at a higher price.  When all is said and done, the biosimilar version (Lilly’s Basaglar) is not that much cheaper…

What a convoluted runaround for not that much gain, which is the moral of the insurance story in recent years.

 

 

*If you use FEP Blue, I highly suggest clicking here, here, and, especially, here to learn about 2017 coverage.