Medicare Putting More Diabetics at Risk

A new survey from the American Association of Diabetes Educators (AADE) found that Medicare’s Competitive Bidding Program (CBP) significantly reduced beneficiary choice and access to commonly used diabetes testing supplies. The lack of choice forces beneficiaries to switch to unfamiliar or unsuitable testing systems, and can have dire health consequences.

AADE’s survey is the latest in a continuous round of reports by AADE and others pointing out the inherent problems with the CBP. Last year, a National Minority Quality Forum report showed a direct link to increases in mortality and complications, inpatient admission and supplier costs. The unintended consequences from switching testing supplies results in diminished or ceasing altogether of blood sugar testing, leading to an increased risk for complications such as blindness, kidney damage, cardiovascular disease and lower-limb amputations.

The new survey reinforces AADE secret shopper surveys done in 2011 and 2013 showing the same downward trend in availability and access.

“Evidence continues to show that the competitive bidding process is failing people with diabetes and putting them at unnecessary risk,” said Kellie Antinori-Lent, a diabetes clinical nurse specialist at the University of Pittsburgh Medical Center. “Patient safety and choice must come first.”

Key findings from the survey include:

• The number of manufacturers making diabetes testing supplies (DTS) available under National Mail Order (NMO) has fallen 50 percent since the start of the Competitive Bidding Program (CPB)
• The number of diabetes testing systems available under NMO is less than half the number available in 2009 before the CPB started
• Many suppliers do not offer models covering 50 percent of the market share of the DTS
• Suppliers do not provide consistent information about inventory to customers

The Centers for Medicare and Medicaid Services (CMS) established the competitive bidding program for mail-order suppliers of diabetes testing equipment in January 2011. Soon after, widespread anecdotal reports suggested that the suppliers were denying access to the specific brands and types of equipment promised to be available on Medicare.gov. The most recent study showed some improvements, finding fewer discrepancies between the information provided on Medicare.gov and what is available to consumers.

To ensure beneficiary safety and well-being, a complete review of the program is necessary. AADE applauds the recent announcement by CMS to delay Round 2019 of the Competitive Bidding Program in hopes that the process can be overhauled to reflect evidence based data and best practices. Beneficiaries should have access to their preferred testing supplies, directed by their healthcare team.

AACE Urges Congress to Act

When I first read about this a couple of weeks ago, I was not happy with the American Association of Clinical Endocrinologists. My first thoughts were that the AACE would undo some of the good that the group Strip Safety had accomplished. But the more I thought about it, I soon realized that Alan J. Garber, M.D. of nefarious fame of the AACE was not calling the shots. I also realized that the more help for diabetes and the tools for diabetes, the better off we all could be.

The letter, signed by AACE president Mack Harrell, MD, and president-elect George Grunberger, MD, called for the passage of two bills: the Medicare CGM Access Act (HR5644/S2689), and the National Diabetes Clinical Care Commission Act (HR1074/S539). The latter would establish a public/private commission to coordinate activities that currently span 35 federal departments, agencies, and offices, according to the statement.

The letter also asks Congress to conduct follow-up hearings to examine FDA's pre- and postmarketing surveillance and enforcement activities for medical devices, along with a call for a review of Medicare's competitive bidding practices. With regard to the FDA, the AACE is asking for more rigorous pre- and postmarket surveillance of glucose testing supplies and the prohibition of devices that don't meet current quality standards.

The above are all needed and if accomplished, could be a big help for all people with diabetes. The Medicare CGM Access Act promotes Medicare coverage of continuous glucose monitors. Currently, Medicare does not reimburse for CGM, which means that well-controlled patients with type 1 diabetes lose an important means of monitoring once they hit the eligibility age of 65. Grunburger said it is unclear why Medicare does not cover the devices, despite the evidence of benefit and cost savings. The device has been associated with a reduction in hospitalizations for hypoglycemia.

CMS Stranglehold on Medical Testing and Diagnostics

The Centers for Medicare and Medicaid Services (CMS) is up to its dirty tricks continually. CMS may become the laughing stock of the medical care world if they continue to restrict what health care providers can do. The rules are becoming so restrictive that even the CMS employees cannot keep up with the changes. With this, is it any surprise, that Medicare is projected to be insolvent by 2026, only twelve years from now?

More from the bad news side: Medicare will not pay for more than one test a year that is not directly related to the illness currently being treated by the doctor. In addition, Medicare rules forbid your doctor to treat (and therefore to test for) more than one ailment per office visit. What is the patient to do? Many people using Medicare have more that one medical problem and often three or more.

In theory, the patient could pay for the additional testing, but if those tests are deemed “medically unnecessary,” your doctor could go to jail for writing that prescription if he or she bills Medicare for the test. And if she or he wants to discuss the results of the test and prescribe a course of treatment, all discussion and treatment must be about that original ailment, even if you’re now sick with bronchitis instead. I am only guessing, but this sounds like if you have more than one illness, then you will need to see a different doctor for each disease or illness. How ridiculous CMS is becoming!

If a product or diagnostic test is new, getting Medicare to create a new billing code for it can take a long time and cost doctors a significant amount of money in lost reimbursements. And if a billing code exists, Medicare must agree to pay for the service. Medicare has not been willing to pay for genetic testing, except in screening for compatibility for kidney and bone marrow transplants. And with genetic testing to help individualize and personalized medicine, Medicare is unwilling to cover the level of genetic testing need for this to become a reality.

Medicare won't pay for physicians to consult with patients by email or over the phone, even if the patient is old, disabled, or too ill to come to the doctor's office. Medicare will not pay for doctors to teach diabetics how to monitor their glucose levels or manage their diabetes in other ways. The same goes for other chronic illnesses.

Read about Medicare and their restrictions and follow the many links in this article.

Medicare – Give Us Back Our Test Strips

Where this will go, I don't know, but those of us with type 2 diabetes need to be able to test our blood glucose and not feel restricted by when and how often we are able to test. Yes, people do need the education about testing. They also need to be taught how this will help them be better able to manage diabetes. While I do not want to vent, I have had conversations with several doctors that agree with me and wonder how we are best able to turn this around and get more people to test on a regular basis. Yes, Medicare, give us back our test strips!

Read carefully as I don't plan on pulling back in some areas and I honestly feel that there is some truth as I am getting emails that agree and some medical professionals that agree in part. Some do very carefully state some ideas, as they are not sure they can rely on me not to use their names and quote them. So continue reading about self-monitoring of blood glucose and related educational ideas.

First, I must point out that much of the research for self-monitoring of blood glucose (SMBG) is suspect. Not only are the participants carefully selected, but also most studies seem to exclude people with type 2 that have an interest in or knowledge of SMBG. Many of the studies are observational in nature or rely in participant-completed surveys, which are not reliable for scientific accuracy. In the USA, many of the studies are funded by the National Institutes of Health (NIH) or the Centers for Medicare and Medicaid Services (CMS). Then on the unscientific information, Medicare takes more test strips away from us.

I have made this accusation before and I will again. This is based on my research and in no way is it scientific. There is a conspiracy happening in the USA between government agencies and medical organizations to keep many people with type 2 diabetes unaware of the damage being caused by our grain industry and low fat mantra, which is promoted by the US Department of Agriculture (USDA). In turn, the NIH and CMS have cooperated by funding non-scientific studies giving Medicare the incentive to reduce our testing supplies.

Then the America Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE) promote the USDA line of thinking – whole grains, low fat, and people with diabetes that do not know better listen to them. Then the American Association of Diabetes Educators (AADE) and the Academy of Nutrition and Dietetics (AND) which follow the ADA and AACE do little do encourage people to think for themselves. They are pushing mantras and mandates and expect people with type 2 diabetes to accept the dogma blindly.

The AADE does nothing to promote and teach diabetes self-management education (DSME). They give mandates and mantras that patients are learning is bad for their diabetes health. Most CDEs will not teach patients about self-monitoring of blood glucose (SMBG) for fear that patients will discover the truth about whole grains and low fat. The monopolistic workers for the AND mandate that we consume a minimum number of carbohydrates per day and go ballistic when we do not and literally call us noncompliant and often refuse to work further with us. This refusal is the one good thing for us as patients.

Now some will say that the AADE does promote DSME, which in a small way they do, in some sources and pamphlets, but very little of the information ever reaches the patients. A few conscientious CDEs do teach DSME and even fewer teach SMBG until they are confronted by older CDEs and encouraged to stop. So please Medicare give us our test strips back and find us doctors willing to teach us the truth. We know there are doctors that are breaking ranks with the ADA and AACE because of the lack of diabetes education being taught.

I am also aware of doctors attempting to use peer mentors to dispense some diabetes education when CDEs are not available or have taken positions in conflict with the doctors. This may become more common as the increasing numbers of patients diagnosed with diabetes come into existence and the numbers of CDEs entering the field continues at a snails pace. With this gap widening almost daily, is it not surprising that doctors are exploring other avenues to assist in diabetes education. Even more doctors are investigating shared medical appointments to expand education by presenting it to groups of patients when there is not time to do it individually.

The controversy about the registered dietitians will need to play out in the court system before we will know whether their numbers will decline. Nutritionists that are joining other organizations to continue being able to dispense nutrition information may be able to step in and fill the widening gap. This should be great for those of us with diabetes as my experience with these nutritionists has been positive. They are interested in balancing nutrition and not issuing mantras and mandates for us to follow. They will suggest ideas that some of us may disagree with, but will work with us to help us balance our nutrition whether we follow a low carbohydrate, medium fat diet, a paleolithic diet, or even other diet plans. They are not locked into telling us we must eat a required number of carbohydrates.

Patients around the globe need education about diabetes and how to apply this to their daily lives. In the USA, we need Medicare to give us back our testing supplies in sufficient quantity that newly diagnosed patients can determine how the different foods and food combinations affect our blood glucose levels. Then allow enough test strips for people to use on a daily basis and to do random checks when adding new to them foods.

Okay, why do I use Medicare as the scapegoat? Because the medical insurance industry generally follows the lead of Medicare in lock-step. If NIH and CMS are going to do studies, let’s have them do studies for three to five years and give continuous education during the studies. Have the education reinforce the principals set out at the beginning and ask the participants what they need in more information to help them. And, have the studies be scientific studies with the proper scientific methods applied and not the observational and survey format from the past. Do not exclude study participants that are interested or have knowledge of SMBG, Teach the study participants SMBG or DSME. Medicare, give us back our test strips!

I might also suggest that if doctors are going to be paid incentives, they must provide education on a continuous basis to be eligible. This should be audited for verification.

If insufficient CDEs are available, make use of peer mentors and even retired doctors if this is needed. The only way to put a halt to the increase in the diabetes epidemic is to educate the current patients and make sure they have the testing supplies to make it happen. Educated patients will not be afraid to spread the education.

What Is A Medicare Patient To Do?

With the mounting deficit and calls to curtail government spending, what is in store for Medicare and Medicaid patients? Will we see more healthcare rationing, more hospital supervised euthanasia, or will these patients be left where they are to suffer an undignified death? As a retired person on Medicare, I can believe all of this and more as our government forces euthanasia on the less fortunate.

Inhumane is a word that comes to mind. Just how far will all this be taken remains to be seen; however, I foresee some of our worst nightmares coming true as the medical community lobbies for higher and higher profit margins. I do not like raising these alarms, but as the saying goes, I do not want to be the only one left speaking out when they come for me.

Will the votes of the “baby-boom generation” and earlier generations be nullified by legislators that refuse to listen to their constituents? Judging by what the trend has been for the last few years, this seems likely to happen. Just because our federal legislators are insulated with extremely good medical care, they can look past those that have a need for medical care.

This article in Medscape points out how our medical community thinks. It points out how our physicians are willing to protect their profits. While I can believe a little of their needs, they seem most unwilling to consider any compromise and will stop seeing Medicare patients if congress does not give them what they want. They are laying out their intentions with a boldness unheard of before.

When 82% of the physicians say they will stop seeing new Medicare patients or severely limit access to existing Medicare patients, this cannot be a good thing for the patients.

While the Medscape article says nothing about the stance of hospitals, many of the physicians are employed by hospitals. It seems likely that the hospitals are in this as well

This is a warning to current and future Medicare patients about the future access to medical care – it is not going to be there for us, unless you are independently wealthy enough to pay your way.

Investigation Uncovers Disturbing Doctor Discrimination

Even if this was only researched in Illinois, you can depend on this happening across the USA. I know that this happens, but I did not realize the magnitude and numbers of children affected. Can this be corrected for the benefit of the children involved – a lot of actions will be needed by all concerned to begin to make this happen.

There was to have been a survey of doctors using at technique employed by stores called mystery shoppers, but titled stealth patients. It was to have been conducted by the Department of Health and Human Services (HHS) and was published in the Federal Register.

As of June 28, 2011, this survey has been put on hold when the American Medical Association (AMA) publicly complained and got the support of Rep. Tom Price, MD (R-GA). This survey was to discover how patients on Medicaid and Medicare are treated when attempting to obtain appointments when compared to those with regular medical insurance.

For doctors, it does reveal that it is all about the money. I say that if they have a standard of living that is so high there is no room for tightening of the financial purse strings, let them go out of business and live like many people are living that can't find jobs in today's economy. Except they will end up employed by hospitals.

The first investigation shows how the medical profession treats the children that have public insurance in the state of Illinois. The second investigation with stealth patients is about adults and what the medical community is not doing for those on Medicaid and Medicare. Hopefully this can be resolved and the survey can go forward, but much of the information is already out and the survey may be a waste now.

Until many issues are resolved for children on public insurance and Medicaid and Medicare reimbursement issues are resolved, the problems will continue to exist and these patients will continue to avail themselves of the Emergency Departments of hospitals where they cannot be refused treatment, but the taxpayers are saddled with the costs.

Read about the Illinois investigation here. The first article about the HHS survey is here, and the article stating the survey is on hold.

Other Problems in Diabetes Management

These problems in diabetes management can be completely out of your control. The medical insurance industry which follows very closely the actions of Medicare can really hamper the management of diabetes.

First, even though Medicare has small programs when they reimburse doctors for screening elderly patients for diabetes, the medical insurance industry will not. In addition, the medical insurance industry and Medicare will not reimburse for expenses that do not diagnose diabetes. If the HbA1c is less than 6.1 or less than 126 mg/dl, blood sugar reading, insurance will not pay for prescriptions and anything relating to the potential advice that could help you prevent or delay the onset of full diabetes. This is the sad part of our insurance industry.

Then in the area of testing strips, most insurance companies are limiting them to just two per day that they will reimburse for. A few are even getting bolder and limiting the number to 50 test strips per month for people on oral medications. This makes learning what different foods do to your blood glucose levels very expensive after diagnosis and until you have gained confidence in the foods that you may consume.

This also is true when you add new foods or have unusual times like eating out a lot when it would be wise to know what the foods are doing to your blood glucose levels. This is why I can understand people that have a creep up in A1c's. We are being forced by our insurance to not manage our diabetes and maintain daily controls.

This in turn encourages doctors to discourage testing and doing what is necessary to manage our diabetes. The doctors then say that the A1c give us a quarterly reading to tell us how we are managing. I say this is not good enough. By being able to test as needed, we can more readily see how a food is affecting our blood glucose so that we can change the serving size or eliminate the food from our menu.

If a person is on insulin, there are a few more strips, but sometimes not enough. For those that are on oral medications, make sure that you know whether the medication can cause hypoglycemia. For oral medications alone, the amount of test strips should be allowed an increase, and medical insurance should cover them.

To me, Medicare and the medical insurance industry actions are counter intuitive and more harmful for patients than practicing a little preventive medicine. Granted there are always those individuals that will never manage diabetes and give the rest of us headaches because they have participated in the surveys that the medical insurance companies send out showing that there is little or no need for larger numbers of test strips. The medical insurance companies also find them for the studies to back their cutback of testing supplies.

This is making it harder and more difficult for those that wish to tightly manage their diabetes to accomplish this unless they are able to afford the additional test strips out of their own pocket.