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.

graduation-tulips

 

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.

 

 

Diabetic Alert Cat?

Why is Dad scratching at the door like a goofball?  And why hasn’t he given up yet?  I’m so tired!, I mused, finally rousing from bed.

My body moved through hypoglycemia-induced-quicksand as I turned the doorknob.  Much to my surprise, Tootsie, our 12-year-old cat, was the actual visitor.  This was not a prank from a human family member.  In fact, this was not a drill.  My blood sugar had been hovering quite low for an extended period of time.  Tootsie knocked in her own way, and, thankfully, she snapped me out of a deep sleep to answer.

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I gulped down some fruit juice from the ever-present nightstand bottle and crawled back into bed.  Although I am allergic to Tootsie and she usually detests venturing to the second floor of my family’s home on Cape Cod, here she was- settling in to keep watch.

 

She knows.  She knows I’m low!, I realized.

As a child, whenever I would wake up in the middle of the night plagued by nausea, I begged my mother to sleep at the foot of my bed.  Don’t talk to me.  Don’t touch me.  Don’t do anything.  But please just stay with me.  Mom obliged and kept her guard post until I drifted back to sleep.

Tootsie got the same memo.  Normally, she would be purring and climbing all over me; but she now understood that the best way one can support a friend during a hypoglycemic event is to simply be a present observer in the moment.

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Continuous glucose monitors and mg/dL readings and Humalog are all foreign things to Tootsie.  She may or may not have identified the low blood sugar scent that alert animals are trained to pick up.  Whatever the problem may have been, Tootsie seemed to know that something was wrong.  She persisted in her attempts to alert me to the issue.  Tootsie did the right thing, and she stayed the course.

Perhaps the human side of healthcare can learn a thing or two from a cat’s display of empathy?

Food for thought…  Pass the Meow Mix.

 

Localized Empathy

Boston traffic sucks.

Especially in the summertime.

To save myself some unnecessary frustration, I did something that I do not normally do: booked a few local medical appointments here in Rhode Island.

Don’t get me wrong: In my graduate studies I met many nurses and healthcare folks who work in our small state and do a darn good job making patients well.  But, having begun my care in Boston at a young age, I historically stuck with the endearingly-nicknamed “Mecca of Healthcare” for my treatment.

An hour commute is a small price to pay for the best healthcare on earth.  I grew up in the Joslin waiting room, watching families fly in from all over the world to seek help for their kids.  I accompanied my #MedX bestie, Danielle Edges, and her brave daughter, Alex, when they traveled to Boston Children’s Hospital from Phoenix, AZ, earlier this year.  Trust me: Boston has it going on, and I am always cognizant of how blessed I am to live relatively close to these topnotch facilities.

The problem, though, is that my trips have not been an hour commute for as long as I can remember lately.  Between traffic coming from and going to Boston, as well as time with the provider, I am usually gone for 6 to 8 hours per appointment.  The bags underneath my eyes were growing larger by the day, and my attitude was strained.  I needed a break.

So, I made a pact with myself: For reasons of self-care, I would book some “non-essential” appointments back home in Lil Rhody.  While every medical appointment is certainly important, the urgency is not necessarily there for this local stuff, versus the “essential” diabetes tune-ups that I receive in Boston.

One hot afternoon in July, I gulped down my coffee and headed inside a RI dermatologist’s office.  I have experienced itchy-then-painful blisters on my hands since childhood, and no doctor has ever been able to crack the code.  If the best providers in Boston specializing in autoimmune disorders don’t know, how will anyone else? I naively wondered.  But, with the commute being a mere 15 minutes, it was worth a shot.

I arrived early to fill out new patient paperwork as instructed.  Parking had been easy- no expensive, overfilled parking garages.  The receptionist and intake nurse were both friendly.  And finally, it was time to see the doctor.  She was kind and concise.

“Do you have a blister right now?”

“Yes.  It’s healing,” I replied, extending my hand for further inspection.

“Oh, I know exactly what this is.  It’s dyshidrotic eczema- common in diabetics.  I’m actually shocked that you went through decades of your life with no diagnosis for this; how awful!  I’ll prescribe you some hydrocortisone creams which should help,” RI Doctor advised.

+1 for the local expert!  

I am a little miffed that Boston dropped the ball on this for so long, considering I looked like a burn victim who couldn’t hold a pencil in third grade due to the severity of the blisters.  However, I am SO grateful to finally have an answer and effective treatment options!

Then it was time for the mole check.  Melanoma does not discriminate between right arm or left arm, right butt cheek or left butt cheek.  Almost every inch of the body is observed to ensure safety.  Smart, yet still kind of awkward…

“Just so you know, I’m wearing a…” I began.

“A thong?” RI Doctor replied.

We’ve seen it all, honey, the observing nurse thought.

“Actually, it’s a continuous glucose monitor for my type 1 diabetes.  It’s on my…”

*Ten seconds later*

“Oh!  Good thing you warned me!”  RI Doctor exclaimed, having located the sensor where the sun doesn’t often shine.

As odd as it was to have a conversation while naked in a room among new acquaintances, the professionalism and thoroughness of the doctor made the experience more bearable.  I felt at ease knowing that the eczema- which has for years induced a stress response in my body, and, therefore, my BGs- would finally be tamed, and that the funky mole on my ribs was nothing dangerous.

“When were you diagnosed with type 1?” RI Doctor asked.

“Just before my third birthday.”

“And your parents caught it early?”

“Early enough that I survived.  But I was in DKA.”

And then I thought again about the little boy whose name I still do not know, who passed away from complications of T1D diagnosed too late, just a few days before my arrival in the same ER.

“Wow.  That must have been so hard,” RI Doctor wondered aloud.

“Yeah…”

“That must have been so hard.  It is so hard,” she pushed.

“It is…” I admitted.

 

And there it was: the truth, exposed.  Diabetes is hard.  But we’re still fighting.

Sometimes localized empathy makes all the difference.

#weneedacure

 

Feedback to Feed Forward

September will be here before we know it, and I am excited to share that I will be returning to Stanford Medicine X (#MedX) as a junior member of the ePatient advisory panel.  Additionally, I will be presenting in a panel entitled “Ah-Ha! moments in mental health and chronic disease management” alongside wonderful advocates Alan Brewington, Kristin Coppens, Danielle Edges, and Mark Freeman, and moderated by rockstar Charlie Blotner.

Accepted MedX 2016 presentations can be found here.  Our abstract includes the following information, some of which is quoted below:

“Mental health and chronic disease management are often interwoven topics in science. But what about the human side of the story? Whether or not individuals meet the diagnostic criteria for mental diagnoses, we all long for optimal mental and physical health to attain good quality of life.

How do we put a personal face to the feelings that hypoglycemia, or chronic pain, or other physical health struggles invoke in terms of our emotions? What moments have changed the way we think about mental health and chronic disease, and how can we encourage these same poignant healthcare interactions in the lives of others?

This panel will explore just how vital this conversation is in chronic disease and mental health management by featuring multifaceted patient, caregiver, and mental health advocate perspectives. In order to facilitate this conversation for all patients, we must raise the topic from the very source: ePatients themselves. Therefore, this panel is ePatient-centric in its selection of presenters. We will identify crucial learning moments in understanding our own mental health, while promoting a transparent discussion that remains much-needed in humanizing healthcare.

…Ah-Ha! moments relevant to the following topics will be discussed:

  • Why the words we use matter so much
  • Barriers to care
  • Continuum of “before, during, and after” mental health becomes a focus of care management; early intervention in normalizing this conversation
  • Caregiver resources and how to talk to children/teens about difficult health topics
  • Managing multiple diagnoses
  • Curtailing advocacy “burnout””

Source (linked here): MedX 2016 accepted presentations, “Ah-Ha! moments in mental health and chronic disease management.”

In preparation for our upcoming panel, we wanted to reach out to our respective advocacy communities to see if there are pertinent points that you would like us to consider and to possibly discuss in the panel (time-permitting).  I recently wrote about the diabetic online community (#doc) needing to hear more from “The Whole” in diabetes, and this is a good platform by which to reflect upon feedback from multiple sources.  While one presentation cannot represent all affected by health conditions, we can try our best to integrate community viewpoints into what we discuss.

With that said, if you have ideas about mental health and chronic disease of any type, please feel free to contact us.  We would love to listen to your perspectives!  My contact information can be found here, or feel free to comment on this post if you are comfortable sharing your thoughts publicly.

Thanks for your support!  We are so looking forward to MedX!

 

Whole Milk With The Disclaimers

This will not be my most popular blog post ever.

 

You may not agree with me.  That is okay.  In fact, it is a good thing.  If we all nodded our heads along to the beat of the same drum in this world, well, we would be a boring orchestra.  Renza wrote a great piece on this notion recently, which can be found here.

One of the largest issues we face in the United States today is the “battle of the egos.”  We see it play out on our Facebook newsfeeds each morning:

“I’m voting for so-and-so and I must be right because it’s my opinion and I said so and I can scream louder than you!!!”

Yes, we have a right to say such things.  But do we really need to completely write off the other side of the opinion in the process?  If we do, quite frankly, we are only hurting ourselves.  Very rarely in life are issues so cut and dry, 100% right or wrong.  When politics falls into the gray zone, which it so often does, our greatest hope for the best world possible is to hear and consider all opinions, to put aside our personal biases and to think about what truly matters.  We are way too quick to judge.

“He looked like a thug.  He must have done something wrong.  He would have shot first.”

We do not always pause to think of the psychosocial reasons why he is in the wrong place at the wrong time, or why we are in the right place at the right time- safe from injury or premature death, judging from afar.

Or, we roll our eyes dismissively, choosing to believe a social media rant from someone who has never seen combat, or public service in a rough neighborhood:

“The cop had more than a split-second to make a life-or-death decision; his life, or the alleged suspect’s?!  He doesn’t go home at night sick to his stomach about taking another’s life, whether or not the the law supports his defense…”

We do not always concede that maybe, just maybe, in this particular case, we are speaking of a human being who perhaps acted in fear, rather than hatred.

At one point or another, we are all guilty of not placing ourselves in the other’s shoes.  It is easier for us to say that one side is 110% wrong, and we are 110% right.  If only morals and ethics were so mathematically easy…

We do not always think about how unique individuals are, how we cannot check them off like bubbles on the SAT, fitting a prescribed correct answer to each situation.  Maybe there is none.  Let’s sit in the scariness of that idea, together.  Let’s be more loving and considerate than we have been as a society in recent weeks.

 

Admittedly, I have been disappointed in the diabetes advocacy world for similar reasons of us not seeing all sides of the equation lately.  There are days where the #doc rallies and we do something that is so obviously good: honoring Kycie Terry this month, for example.

Regularly, we laugh together, cry together, share our lives with diabetes together.  This is what makes us tick, what gives a distinct purpose to this disease in which we are, despite it all, somehow able to rise above.

My concerns, though, echo Tom Goffe’s wonderful post regarding the impending FDA decision on potentially dosing insulin based on Dexcom continuous glucose monitors (CGMs).

***(Disclaimer: I am not a medical professional; do NOT consider any of this blog post to be medical advice intended for treatment purposes.)

My personal opinion on diabetes management is more of a Libertarian view, if we want to talk politics.  I am perfectly okay with individual patient-centricity in disease management.  Diabetes falls on a spectrum of manifestations; what works for me, may not work for you, and vice versa.  If you want to dose according to Dexcom and you are comfortable doing so, by all means, that is your prerogative, and I truly wish you all the success in the world.

Although I no longer use an insulin pump due to a freaky product defect hullabaloo that I encountered, I am happy for all of those who still have access and great results from insulin pump technology.  That same mindset goes for those who experience phenomenal Dexcom CGM accuracy and ease of dosing insulin accordingly.

Every great innovation in society has come by those who are brave enough to take risks.  Think no further than the Open APS and #wearenotwaiting folks in our own community.  Their courage, creativity, and selflessness are beyond measure.

My #DoseWithCGM worry, though, begins with this being a rushed decision.  CGM technology is not quite there yet in my opinion, and to have a trusted federal agency say that it is- under pressure from one side of the equation, rather than all sides- is a slippery slope.  

Dexcom is- again, in my own opinion- the most innovative diabetes company in the market right now; I am absolutely confident that their technology will only go up from here; but we should not compromise safety and swap out access to other products in the interim.  Generally-speaking, the government can curtail efficiency in health tech, but this is one rare occasion where it serves as a proper check and balance.  As far as CGM dosing, don’t ask, don’t tell; do whatever you want (as an informed, experienced, safety-focused patient), but leave the government out of it.

There are the obvious physical dangers to insulin dosing, at any time and using any product as a baseline judge of BG; diabetes can be a conniving JerkFace.

Sure, I have 25 years of T1D under my belt and have a good sense of the disparities between my CGM’s interstitial fluid reading, and the blood sugar reading of my meter.  But what about a newly-diagnosed family?  What if Mom boluses 7-year-old Jenny based off of the CGM’s 300, when she is really 180?  What if she is advised that this is an appropriate treatment approach by a federal agency set in place to keep her safe?

Sadly, insulin can be as life-taking as it can be life-preserving, and the reality is that it can sway from either extreme quickly and easily- through no fault of the patient’s or caregiver’s.  This disease has a mind of its own, and even technology can never truly replace a fully-functioning pancreas.  Again, #weneedacure.  A real cure.

“I guess if you ate low carb and had a steady line at 100 all day, dosing off of CGM wouldn’t be that bad considering the tiny boluses,” I said, shrugging my shoulders.

“Actually, I think that could be more dangerous.  There’s less of a BG cushion if something goes wrong,” a doctor replied.

Very true.  That, or what about the T1Ds (myself very much included), who are not always smooth sailing at 100 mg/dL all day.  Sometimes you wake up with a 55, rebound up to 224 when your liver releases sugar as the juice kicks in, correct and go back down to 78, eat lunch and sit at 162 for awhile, and  then somehow see a 340 by dinner because your menstrual cycle begins and unleashes hormonal hell on your body.  How in the heck can we ever expect a machine to keep up with that?!!

While I have seen the argument about meter reliability, I find it a weak one.  Let’s attack the issue at the root cause: meters need to improve.  But, they are still a better, more immediate guide than interstitial fluid ever will be.  Together, the two are a wonderful pair, showing us real-time data, trends, alarms, and so on.  I am not knocking either option, but I want to ensure that I have proper access to both in the long-term.

When I was normal person sick (NPS) last week, my CGM could not keep up.  Neither could I, but I used all of the tools in my toolbox, to include my own diabetes intuition, to get out of the murky waters.  Thankfully, I manually checked my blood sugar before dosing insulin at bedtime:

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I in no way want to stifle innovation by expressing this opinion.  I admire (and consider as friends) many of the advocates who are fully in support of this CGM dosing proposal.  I also respect the major diabetes organizations which are onboard.  Despite not agreeing wholeheartedly with their rationale in this case, I have no doubts that they want to see a better world for all diabetics.  We all do, in our own ways.

My experience in healthcare leads me to believe that this decision will ultimately restrict our access to test strips, as insurance agencies will look to cut costs.  And heck, as business leaders, they should; the ACA rewards and encourages cost reduction, and many consumers supported these measures vocally and at the polls.  Regardless, this is beyond anxiety-provoking for so many of us.  Test strips are ludicrously expensive already, and to imagine that we may be limited to a few checks a day to calibrate an imperfect CGM apparatus is maddening and disheartening, to say the least.  Pass the coffee.

Imagine the current healthcare loop-de-loop.  Imagine the Medtronic/UHC debacle.  Actually, do not imagine- because we are already living it.  And we know how unpleasant it is.  Now pretend that your insurance has restricted your test strip supply, and you do not feel comfortable dosing via CGM.  You have to get a letter from your endocrinologist, or perhaps a mental health care provider, indicating that you need more test strips to manage your chronic, lifelong condition which will never go away until there is a real cure.  Nonetheless, you have to jump through this paperwork hoop every 3 months, missing time from work to argue with suppliers about why you need life-sustaining medical supplies.  And maybe insurance will grant you 7 test strips per day instead of 2 when all is said and done…  While this example is (hopefully) extreme, it is still possible.  And it’s scary as heck for many of us.

“But Medicare won’t cover CGM.  Or how will this affect the Libre?”

Again, I think we are attacking the wrong sources- deflecting one issue onto many others.  By potentially limiting a test-strip-saavy demographic in the name of providing wider access to all is a total cop out.  Instead, hold our government more accountable.  CGM is a reliable tool, illustrated to be life-saving and absolutely quality of life-improving.  For these reasons, Medicare folks (or swap in folks who want Libre access), deserve to have better technology on hand.  But to substitute one option for another is silly, given that both CGMs and blood sugar meters have plenty of room for improvement in the current market.

Online polls and petitions do not represent the whole.  From a science and data standpoint, they illustrate a sample demographic from which we can make some educated-inferences:

1.) Most of these people have computer/smart phone/internet access.

2.) This enlightens us as to their ballpark socioeconomic status.

3.) That gives us some idea of their access to and quality of healthcare.

Convenience samples are fine as long as biases are disclosed.  We must say upfront that this is one side of the very large diabetes equation, and that this sample is not representative of The Whole.  While we cannot all leave our fulltime jobs or school courses to lobby in front of Congress or the FDA, those representing us should be enlightened as to how we all feel, and should act accordingly.

As Erin Gilmer has respectfully pointed out on numerous occasions, there are marginalized demographics who cannot obtain the most basic of diabetes care: dental visits, for example.  Yet we are up in arms over insulin pump collusion.  Or, in this case, CGM dosing.  The marginalized folks are not likely to be invested in this discussion because they do not have access to what is at stake; heck, they do not have access to the bare minimum.  While we raise our voices, we must take caution not to further drown theirs out.

In many of the presentations of the CGM dosing issue on social media, I saw big fish in the diabetes pond introducing the topic as, “Here, this is good, hop aboard and get involved!”.  This mindset is positive, for sure.  But we are not whole if one of us is not heard, if different viewpoints are not given adequate opportunity to be discussed.

What about the school nurse who wrote into the debate on a Facebook status post?  Did we listen when she said she would be uncomfortable dosing a child in her care at school based off of a CGM reading?  Do we care?

On the flip side, if someone has great CGM accuracy and wants to lessen the finger pricks his type 1 toddler endures, am I hearing him out?

 

Que será, será.  Whatever will be, will be.  Ultimately, a decision will be made regarding the FDA and dosing with CGM.  But we should all have a voice in it.

This is a long post and I surely will go to bed and realize I left out a few other big points.  But this is food for thought for now.  Although I am a little fish in the diabetes pond, it is my moral responsibility to use whatever platform I do have to improve life for diabetics.  In my personal judgment, voicing this opinion has merit towards that cause.

I also promise to be upfront about my own diabetes biases.  In the past, I have gotten on my soapbox and pledged up and down the river that we need a cure.  But perhaps I have not listened to the other advocate on the soapbox next to me, who may be more focused on an artificial pancreas and who may feel that it is too painful to believe in a cure after years of disappointment.  I have to respect that voice, too, because that person is part of The Whole.

So, here are my disclaimers:

1.) I can only represent my own opinions, but I hope that I can connect with others and help them by writing authentically and openly- whether we agree or disagree on various points.

2.) I will always hold out hope for a diabetes cure.  Even if it does not benefit me in time, I want future generations to live in a better world.  My blog focuses on this concept often, but please know that I respect everyone who strives for a better world for people with diabetes, however that world may be achieved.

3.) I will do my part to be more inclusive of The Whole.  Firstly, I will feature more about cystic fibrosis-related diabetes (CFRD) on my blog.  The CF community has so much to offer, and they have a valid seat at our diabetes table given CFRD/the risk of CFRD.  Let’s learn more together.  More to follow.

 

Too much skim or 2% milk leaves out a talented, diverse sample of people with diabetes.  For the time-being, instead of taking my coffee very light (with cream), no sugar, I pledge to focus more on The Whole.  

Thank you

 

 

 

 

 

 

Health Tech, Brains, and Bodies

Many thanks to my Stanford MedX friend, Mark Freeman, as well as Matt and Daniela, for having me on the Everybody Has A Brain podcast to chat about wearable health technology.

These awesome folks are responsible for one of my favorite healthcare takeaways: Everybody has a brain.  If you have a brain, then you have mental health.  Let’s normalize the conversation, then.

Mark and I discussed the pros and cons of my Dexcom continuous glucose monitor (CGM) experience, to include physical and mental components of using health technology.  I even sent along a not-so-perfect CGM photo to illustrate the sometimes-wonky T1D reality of Dexcom alerts.  Matt and Daniela then continued the chat on wearables.

Please take a listen (link below), and check out everybodyhasabrain.com to see other cool content.

Everybody Has A Brain podcast