January 31, 2013

ADA Changes Blood Glucose Monitoring

If the American Diabetes Association believes they have undone the damage that their 2003 Guideline set in motion; they may have another thing to consider. What happened in the 2003 Guidelines was a recommendation for people with type 1 or type 2 diabetes who use insulin in multiple daily injections or with an insulin pump should self-monitor blood glucose “three or more times daily.” Most payers interpreted this to mean that three tests per day was sufficient for all patients on insulin.

To find out if the new 2013 guidelines had changed any minds, I have decided to correspond with my insurance company, Medicare, and inquire from a few other medical insurance companies that cover part D. I now have a response from the medical insurance companies and a brief statement of “no anticipated changes” from Medicare. Even the Veterans Administration stated that there are no anticipated changes. One medical insurance company said they are taking a wait and see stance about what other companies are thinking. My medical insurance company stated that since I don't use them for my test strips, they are not responding further. I talked with my agent and he asked. He was told there would be no changes at present. The last medical insurance company said they are still asking questions, but anticipate only minor changes if accompanied by an order from the doctor.

This made me contact another company and I was told in a phone conversation that there would be no changes until the ADA decided that a certain number was needed. This raised my hackles, and I said they did. We discussed the section and I was told the key words were “many patients” and that until ADA clearly stated for “most” patients, they would continue the current limit. Then I was asked about the Joslin blog of January 16. I stated I had read this. I was told that this also confirmed the current position of no change. This is about as big a slap in the face as you can get. This insurance company said the the Joslin blog is also the reason they will be limiting type 2 diabetes patients not on sulfonylureas to one test strip per day. It had been two per day.

I can also envision insurance companies requiring doctors to forward meter downloads to prove that the patients need as many test strips as requested. I know that this is on the mind of one of the companies I have corresponded with as they asked if I would be willing to do this. I know many diabetes clinics and a few doctors do have the software to do this, but most primary care physicians do not. Think of the cost and if you think they are not going to pass this on to the patient, you are in for a surprise. Another statement one insurance company clearly made is, “if this was that important, why did they (ADA) wait ten years to make a statement like this?”

I personally think that until ADA includes more people from the medical insurance industry and a few patients (type 1 and type 2), they will continue to be laughed at and not believed to be setting recommendations and guidelines for the patient, but in their interests only. In recent years, this seems to be the trend. Even we, as patients, have to wonder what they are doing for the patient. They are great at wording that means and says very little. This has to be what the medical insurance industry thinks about their wording and their reasoning for no anticipated changes. Even though ADA is saying they made some changes, in the real world, there may not be changes.

One section says the following, “The frequency and timing of SMBG should be dictated by the particular needs and goals of the patient. SMBG is especially important for patients treated with insulin to monitor for and prevent asymptomatic hypoglycemia and hyperglycemia. Most patients with type 1 diabetes and others on intensive insulin regimens (MDI or insulin pump therapy) should do SMBG at least prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. For many patients, this will require testing 6–8 times daily, although individual needs may be greater.” The bold words is my emphasis and is the wording used by two companies below.

The above is the section quoted back to me by two of the insurance companies, one that will make no changes, and the one that will use a doctor's order and consider the need.

Another area that was also used is, “Because the accuracy of SMBG is instrument and user dependent, it is important to evaluate each patient’s monitoring technique, both initially and at regular intervals thereafter. Optimal use of SMBG requires proper review and interpretation of the data, both by the patient and provider.”

In reading the section, type 1 is specifically mentioned, but other areas only use the term MDI (multiple daily injections) and self-monitoring of blood glucose (SMBG). This leaves those of us with type 2 on insulin wondering if we will be excluded from obtaining support for intensive testing.

Again, the ADA has played down the importance for people with type 2 diabetes on oral medications and on no medications of the need for testing and also the need for being tested more than two times per year by the A1c. This statement is typical of the ADA's attitude, “The evidence base for SMBG for patients with type 2 diabetes on noninsulin therapy is somewhat mixed. Several randomized trials have called into question the clinical utility and cost-effectiveness of routine SMBG in non–insulin-treated patients. A recent meta-analysis suggested that SMBG reduced A1C by 0.25% at 6 months, while a Cochrane review concluded that the overall effect of SMBG in such patients is small up to 6 months after initiation and subsides after 12 months.”

For me this is almost criminal in both the attitude and actions they have about not educating these people with type 2 diabetes and then preventing those that know the importance from obtaining the necessary testing supplies.

And if you doubt what I am saying, why then would the Joslin Diabetes Center post the blog they did on January 16, 2013 (mentioned above), in which they ask the question, “When Should I Check My Blood Sugar?” “The answer depends on the medications you are taking, your current level of control and what information you are looking for. For example, people with type 1 diabetes who take insulin four times a day need to check at least as many times. People with type 2 who control their glucose levels with lifestyle or lifestyle and metformin may check only once, or perhaps twice, a day.”

Patients at Joslin need to be concerned about the side Joslin is on, as it clearly is not for the patient. This blog seems a clear rebuttal of the 2013 ADA Guidelines. Don't think the medical insurance companies won't see it this way (two companies have). This is just one more reason they have for not making changes. When a well known and prestigious diabetes clinic publishes information like this for patients, they are not doing us any favors.

The two companies (mentioned above), did have me call them and talk to an office that make the determination. They admitted that there will be controversy over this, but that with a leading diabetes clinic saying only four times in difference to the ADA of six to eight times, the decision will remain no change until everyone is in agreement. When I asked about meter downloads for proof that a person was testing more frequently, the answer was that this was under consideration, but that not all physicians would be capable of submitting this information. They did say that to force this issue now could be considered discriminatory, but that it is under consideration for future years. They said with a doctors order for the testing and the meter downloads being submitted, this could be a factor when everyone is in agreement as to the number of testing requirements for both type1 and type 2 on insulin.

In the phone conversations I also asked about those type 2 people on oral medications. Both companies stressed that they will be allowing two test strips for those on sulfonylureas and will be allowing more if there is a doctors order because of repeated episodes of hypoglycemia. Others, to include those on no medications will remain on one test strip per day without a doctors order proving the need for more test strips. They would not discuss what the doctors orders needed to state.

Then to read another article also questioning ADA's attempt to change the minds of insurance companies, read this from Diabetes in Control. Dr. Richard Grant, incoming chair of the ADA Professional Practice Committee says, "We're trying to say it's very situation-dependent …. both by the patient and the patient's context." This really says nothing even if they are claiming otherwise.

This statement really drives home the point that ADA has not succeeded, “With regard to the removal of the three-times-daily number, Dr. Yehuda Handelsman (Metabolic Institute of America, Tarzana, CA) expressed concern that insurers might actually interpret that as endorsing less frequent testing for patients who use insulin. How messages are conveyed matters, he said. "It's about how you define the goals and where you put the emphasis."

According to Grant, the new document was the ADA's best attempt to balance the evidence from the literature with the needs of the individual patient. "Evidence-based guidelines apply to populations of patients with diabetes, but we really need to tailor these population-level recommendations to the individual in front of us."In other words, this is why insurance companies are saying loud and clear, “no anticipated changes” So forget what ADA claims.

For other perspectives and more hope in others areas of the country, read this blog from Diabetes Mine and this blog from Diabetes Self-Management.

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