October 18, 2018

Of Adam, Appendixes, CGM, then AID in Hospitals

My friend Adam Brown just went through the maze of navigating blood glucose and a hospital stay. You can read about it in his post titled: My Appendix Ruptured: Scary Lessons Learned About Diabetes in the Hospital

Years ago my son had his appendix out. Like Adam, we were not willing to let the hospital manage his diabetes. Institutionally, they didn't like that idea. After all, had white coats. We prevailed. In the end, they were impressed. I came away convinced that PWD and their caregivers are WAY BETTER at insulin management than hospitals.

So did Adam.

I am in no way suggesting that hospitals, nurses, anesthesiologists, or surgeons don't know their stuff. They certainly know their stuff. I'm just saying that nothing like your diabetes is their stuff.

I wrote about our appendicitis adventure a post called, Poke a Finger on the Invisible Hand. I learned some lessons. While back then I prattled on about meter accuracy. I was fighting the current battle not the next.

Adam came away with a deep conviction that CGM is desperately needed for inpatient care. I agree with Adam. That is a battle to be won.

I think we need to go one step further. Adam spoke of needing to turn loop off for surgery.

Our experience was clinicians at the hospital were loquacious about insulin and had no real plan to administer it other than assuring us they had a sliding scale. That they couldn't answer what rates were in that scale gave us no comfort.

CGM is critical to better care. Full stop.

That includes those hopefully few times PWD are inpatient and under the knife.

I have seen academic presentations on the importance of managing post-op BG for non-PWDs. In fact, I spent a day in lofty, scholarly presentations on the matter. (I have had such adventures - you wouldn't believe.) Seems surgery is a shock to the system and high BG are a risk for complications, particularly infection. Not the kinda highs PWDs routinely see, by the way.

Bugs like sugar. Who'da guessed?

CGM isn't enough. The staff does not have the time or experience to manage diabetes' insulin needs even with CGM data. 

I think Automated Insulin Delivery is desperately needed in hospitals. OK, You are right to say, "Hey! Wait there isn't really automated insulin delivery other than DIY solutions in the wild."


But as systems come online, somebody needs to look at them for use in hospitals for T1s. Then T2 and finally for everyone who has had surgery and is a glucose risk.

Adam pointed out the horrifically inflated cost of finger sticks in his stay. He reports his appendix burst creating the need for infection care. But imagine the savings in those cases where infection could be minimized with automated BG control. Automating insulin could be a cost-effective driver of better post-operative care for some, maybe many.

In the meantime, better is better. If Adam Brown, possibly the most empowered patient in T1 history (or at least second to Kelly) cannot keep his automated insulin delivery system on in the hospital the rest of us are destined for trouble.

September 28, 2018

Is Your Work Getting Rebate Bucks from Your Chronic Condition

I have ranted about PGM rebates a lot. One big question is who gets the money? It may be the company you work for.

Quick Rebate Refresher.
When people with insurance get a drug at the pharmacy there is a lot of money changing hands behind the scenes. Your insurance policy doesn't pay the retail price. They get a rebate. It can be a big chunk of the price. They often get that rebate even if you haven't met the deductible and you pay the full retail. Some of that flows back to your insurance to 'help hold down the cost of coverage." A recent article suggests that most of it flow back. 

So you may have a high deductible to hold down the cost of coverage, and they get huge chunks of what you paid for medicine before meeting that deductible to help hold down the cost of coverage too. Double whammy or reverse insurance.

As Drug Channels Explained
Put another way, the PBMI data demonstrate that employers operate their pharmacy benefits like reverse insurance. Employees and their dependents taking medicines for chronic, complex illnesses generate the majority of manufacturer rebate payments. These funds are used primarily to offset total plan costs for the employer, not to offset the costs incurred by the patients whose prescription activity generates those rebates. 
Paying rebates at the point of sale would put the rebate and the usage together so that patients benefit from the rebates paid on the drugs they use. Or the whole system could just be eliminated as the kickbacks they look like.

August 30, 2018

The Type 2 Medical Device that makes the Biggest Difference for Me - a Bicycle.

Two wheels, pedals, and spandex.  I know that the last thought is not a pretty image. - Sorry.

Biking helps with blood sugars (unless I have a massive Reese Cup craving after a long ride.) Time on the bike helps transfer weight from my gut to my leg muscles and maybe also shed a few pounds off.  I find a calm, meditative state when I ride. Particularly in a group ride where I don't need to think about navigation. Some folks get that in yoga, for me it kicks in around mile three of a long spin.

But even though I love biking, at times, I just don't want to go out. Last week I had 100 miles in five days. This week - zero. It is too hot, I told myself. The sofa is too comfy, whatever. It is super easy to swap being active for the shadow of being active.

I need some help keep at it. Peer pressure can be that nudge. I find knowing that my friends are out running or biking makes me feel I should 'keep up.' Strava.com, an activity tracking site helps me stay motivated.

I was invited to Stava years ago by a friend (thanks Adam) who is much younger, more fit than I am, and thinks about motivation more than I do (follow that link.) I was afraid Strava would put me in competition with him. That is something that I couldn't win. So it took me a while to join.

Turns out, we didn't complete we just gave each other 'attaboys. Who doesn't like a pat on the back?

Being part of a real-world group helps too. I don't socialize a lot on rides (see meditative above), but there is a comradery to groups, an implicit I'll show up and ride with you if you show up to ride with me. I have had rides where my ability/will to keep going broke. I hit the wall. Friends slowed down and helped me back. I have paid that forward for others.

Today Strava and real-world are colliding. I passed on riding on Tuesday. It was crazy hot. But there, on Strava, I see my friends showed up to ride anyway. That is enough to guilt me into a ride in the crazy hot tonight.

Thankfully, I have friends that help pull me back when I feel an excuse to not exercise. My type 2 device doesn't make a difference if I don't use it.

August 2, 2018

Call Lilly for Help with Insulin

The market for medicine in the United States is nuts. It is not always easy for patients to find the options that may help.

Navigating the process for Lilly insulin users is now easier with a newly opened helpline. They say:
Starting August 1, a new dedicated helpline called the Lilly Diabetes Solution Center will assist people who need help paying for their insulin – such as those with lower incomes, the uninsured, and people in the deductible phase of their high deductible insurance plans, Eli Lilly and Company (NYSE: LLY) announced today. A customized suite of solutions for all Lilly insulins, including for Humalog® (insulin lispro), will be used by helpline operators to find answers that best fit the personal circumstances of patients.*
Nothing in diabetes is perfect. Hopefully, this is one step towards better form many.  Better is Better.

*More at https://investor.lilly.com/news-releases/news-release-details/new-lilly-diabetes-helpline-assist-people-seeking-solutions

April 24, 2018

Drug Prices Should Piss People Off, Maybe Not For The Obvious Reason

Drugs are expensive. Like death and taxes, drug list price increases seem inevitable. There is lots of room for justifiable ire.

I think maybe that anger gets aimed at the wrong target. We all feel we understand prices. We go to the store, see an amount for a product on the shelf and choose to buy or not. If the price goes up, we pay more. Sometimes we fill out a form and get a rebate that limits that price increase. But rebates typically are a pain in the ass, and most folks don't factor them in.

But the list price of drugs on the shelf is misleading. In part because few see it. For most, we make a copay and don't know what the actual price our insurance policy paid for the meds.

HUGE rebates are happening, and nobody sees it. How huge? More than $150 billion. Yeah with a "B." So the drug prices keep going up but so do the rebates to the invisible parts of the drug payment system.

In some cases the rebates more than equal the price increases. What that means is that the drug company nets less income even while they raise the price. Where does the money go? Rebates.

Remember back when nobody bought a car without a rebate? It is like that - on steroids. Plans do not buy drugs without rebates.

Those rebates may get back to the insurance plan and in theory, reduce premiums. But that is not true in all cases, and there is no way to know.

So be pissed that $150 billion in drug rebates seems to sift through the cracks of insurance coverage and we the insured patients may or may not get the benefit of that sifting.

What can be done?

Maybe the first thing to do is to start to understand that rebates exist and be pissed that $150 billion is getting shuffled around with nothing approaching transparency. Our anger at drug prices should be focused on this rebate scheme.

What is a good policy solution? Applying rebates at the point of sale for all plan members, whether or not they have met their deductible.

For the uninsured require the average rebate that drug pays insurers to be applied to the uninsured too.

Want to learn more?
This post at Drug Channels.

July 7, 2017

Vote for FDA's AP Efforts as Excellent Public Service

FDA has given us, diabetes community, excellent efforts on artificial pancreas regulation. They have worked with innovators and patients to help the regulatory process work for people with diabetes. We should say thanks. Here is an easy way to do that.

Vote to recognize FDA's Artificial

Scroll down and click next to
"Courtney Lias, Stayce Beck and the FDA Artificial Pancreas Team"

Here are the details:
The FDA's Artificial Pancreas team was selected as a finalist for the Samuel J. Heyman Service for America Medal in the Management Excellence category for our contribution to the first-in-the-world approval of the 670G hybrid closed loop system last fall. These Medals are awarded by the Partnership for Public Service, a non-profit organization whose mission is to "help government serve the needs of all Americans by strengthening the civil service and the systems that support it." In part the nomination says:

Before Lias and Beck got involved, both the industry and patient advocacy groups publicly voiced concerns that FDA’s review process caused unnecessary roadblocks and was standing in the way of developing this technology and delivering it to those in need. 
Lias and Beck changed this dynamic by treating all those involved—the device companies doing the research, the doctors, the hospitals and the advocacy groups—as partners, not adversaries, as they worked to improve and speed up the process. 
“They used to see the FDA as a barrier and now I believe they see us as an ally,” Lias said.
Read the full details of the nomination.

More information about the award program can be found here https://servicetoamericamedals.org

June 27, 2017

Meter Accuracy Study - DTS

Diabetes self-care is driven by data from glucose meters. The accuracy of meters matters because it is the cornerstone living successfully with diabetes. The Diabetes Technology Society just published a blinded study of meters. Have a look: https://www.diabetestechnology.org/surveillance.shtml

February 9, 2017

Pills better than insulin for t2?

Physicians Briefing reports a Swedish study that shows a lower risk of mortality (I vote that is a better outcome) with oral type 2 medications than with insulin. Good to see the study considered hypos. Given that diabetes is underestimated as a cause of death, it is good to see research looking at the big picture of all-cause mortality.

WEDNESDAY, Feb. 8, 2017 (HealthDay News) -- For patients with type 2 diabetes, novel oral glucose lowering drugs (GLDs) are associated with reduced risks of all-cause mortality, cardiovascular disease (CVD), and hypoglycemia, compared with insulin use, according to a study published online Jan. 24 in Diabetes, Obesity and Metabolism. 

Still - YDMV. The best course of treatment is the one the patient and physician agree meets the individual needs.

I think this "all-cause" approach should be taken when considering access to care beyond medications. One size doesn't fit all. Disrupting access to diabetes tool from strips, to the appropriate pump should be considered on a similar basis. 

February 2, 2017

Diabetes is Underestimated

Sometimes I think diabetes it is the Rodney Dangerfield of health. Unfortunately, it isn't a joke.

A recent study highlighted in this piece at Medscape says diabetes is underestimated as a cause of death in the US. The study puts diabetes, "the third leading cause of death in the United States in 2010, after diseases of the heart and malignant neoplasms and ahead of chronic lower respiratory diseases and cerebrovascular diseases." 

People with diabetes can thrive. By engaging early, we minimize complications, costs, and deaths. We need the appropriate tools and medications to be successful. 

Join me in calling on Congress to maintain the prohibition on pre-existing conditions, like diabetes, being grounds to exclude people from health care coverage. 

It is easy. 
  • The Diabetes Patient Advocacy Coalition has an easy to send letter to Congress. I'm sending it often. You can too.  
  • I'm sending Tweets from their Twitter Scorecard. Join me.
  • Getting through to our Senator's by phone has been iffy recently. So I 'm sending snail mail. 
Not only do we need to work with our doctors to care for diabetes. We need to work with our elected officials to maintain access to coverage. We need respect.

January 25, 2017

My Diabetes May Vary

Variations are inevitable and frustrating. 

Following treatment for cancer, I started medications as part of recovery including an emotional health medication. They seem to help. But the emotional health drug has a side effect - it bumps up my glucose levels. This feeds a feeling of fasting glucose frustration.

My go-to response is to try "to eat better." But when I don't see immediate results, the myth that I can control the rat bastard with diet, makes me feel a temptation to just eat less, to produce less glucose. The risk (and some days the reality) then becomes to eat less AND worse.

I aggravate everything doing that. It is a losing proposition.

So type 2 diabetes becomes more front of mind. I am checking glucose more. (Boy, I would love a sensor that filled in the gaps in my glucose profile. Come on Libre)

I think on balance the numbers are OK-ish. But they show that type 2 diabetes doesn't play well with others health issues, including emotional health.

As it changes, it demands additional adjustments. I know that is the deal. Knowing it doesn't make it less frustrating.

Type 2 is inevitably frustrating.