Living with chronic illness isn't just about the illness itself. Everyone's experience is different, but for me, I consider there to be three large components of my life with type 1 diabetes: the physical management of the disease, the psychological aspect, and then the piece of the puzzle that is often over-looked: the financial obligations attached to the medicine and equipment necessary for survival.
Insulin ain't cheap...and it isn't even close to being the only thing you need to survive post-diagnosis. For starters, there's the delivery of the insulin. Since insulin must be delivered subcutaneously (under the skin, in fatty tissue), it means choosing one of the following: injections (syringes or pens) or an insulin pump. While many people choose injections because injections are the best management option for them, many people choose insulin pumps (often in tandem with a continuous glucose monitoring system) because of the increased potential for optimum blood glucose control. Both pumps and CGMs have durable components that are used over and over, as well as consumable materials that necessitate site changes on a frequent basis. Paying out of pocket for these items is a burdensome financial obligation, but many people do so in order to get access to these life-giving items.
For individuals and families with health insurance, the burden is still heavy. In many cases, monthly out-of-pocket costs for an individual can reach several hundred dollars, even with what might be considered a decent healthcare policy. Patients rely on their doctors, pharmacy/supply companies, and insurance company to get what they need in order to live. Doctors write the prescription, pharmacies/supply companies provide the product, and the insurance company is expected to provide the agreed-upon coverage for which the patient and/or employer pays for via the policy premium.
If you've stuck with me to this point, you may be thinking: why are you telling me this? None of this is news. You are correct. Nothing I have said so far is new information. Here's where things get...interesting.
In the May 2016 edition of the UnitedHealthcare Network Bulletin (billed as "important updates from UnitedHealthcare to health care professionals and facilities"), there is an announcement pertaining to diabetes patients (see below for full text/click image to view the document in its entirety).
Medtronic to Become UnitedHealthcare's Preferred DME Provider of Insulin Pumps for Diabetes, Effective July 1, 2016
What does it all mean? Great question. When I first read the announcement, I remained calm. I approached the situation intellectually. I knew I needed more information. Today, I spoke with an UHC representative. She initially had no idea what I was talking about, which led me to direct her to the Network Bulletin online. She put me on hold several times in order to look into my question, which was "what does this mean for me, an UHC member and user of a non-Medtronic pump?"
The rep was patient and kind, for which I must give her credit. The one thing she was not was knowledgeable. After just about an hour of phone time, she left me with the advice to wait and see what announcement comes in the mail, as when the new policy is close to becoming effective, UHC will be obligated to inform me. I thanked her for her help, and hung up, with no further knowledge than I had an hour earlier. As I went about the rest of my day, the issues with this announcement (as it appears currently, without any further explanation available from UHC at this time) began to develop into more reasoned arguments.
At this time my concerns are many, but here are what I consider to be the most pressing:
1. Patients need to have the freedom to choose whichever medical device will offer them the ability to achieve optimum blood glucose control and quality of life.
Everybody is different. Every body is different. Features of one insulin pump can be a huge benefit to one user, while causing major issues to another. What works for one person today may not work for that same person in six months, one year, or ten years from now. The good thing is that we have options. Medtronic, Animas, Tandem, Insulet, and Roche each offer unique products that allow patients to find a tool that works best for him/her.
When I began researching pumps, I asked my endocrinologist what she recommended. To her credit, she was very open, despite the fact that the practice she is in is heavily committed to one specific manufacturer. She told me that the devices all do the same thing (deliver insulin), so it was up to me to determine which one worked the best for my needs, fitting into my life the best. I did thorough research and landed on the Insulet OmniPod Insulin Delivery System. I am happy. It works for me and fits well into my active lifestyle. Perhaps one day, I will need to look at other options, but for now, I am very pleased with my choice and know that the other options on the market would not work for me or my diabetes currently.
To allow an insurance company to dictate that I must use whichever one product they choose for me (due to financial arrangements that benefit both the insurer and the manufacturer, but not the patient) is unethical, irresponsible, and smacks of the style of a single-payer style healthcare system, such as Denmark's, where the government decides which company to work with and that is the single option you receive. No freedom to choose. Fortunately, that is not the way our healthcare system works (free enterprise=freedom of choice), so the idea of a private insurance company coming up with such a policy is both ludicrous and unsettling.
2. Potential antitrust issues, which lead to the stifling of innovation and development for the benefit of the patient.
I am not a lawyer. That being said, from what I gleaned from my history and government classes in high school, this agreement between UHC and Medtronic strikes me as having elements that could violate antitrust laws, which are in place in order to promote fair competition for the benefit of consumers. Fair competition between pump companies means that consumers have options and may choose the best option for their unique situation. As companies compete for market share, they are driven to invest in research and development, clinical trials, and other markers of innovation. If one company completely dominates the market (which is bound to happen if Medtronic, already a largely successful company due to longevity in the marketplace, ample marketing budgets and a proliferation of area reps in doctors' offices, is made a sole or "preferred" provider for UHC, one of the largest private insurance companies at 84 million policyholders), smaller companies who offer products that are unique from the Medtronic product may not be able to compete.
The inability to compete in the marketplace would not be an indicator that their product is inferior, but rather that consumers are simply unable to choose a non-preferred pump due to prohibitive cost and would be forced to use whichever product UHC tells them is their sole option. Research dollars won't seem like a good investment to companies as they fight to stay afloat, and the preferred provider won't have an incentive to continue to improve their product, as the consumer is held hostage. Without competition, the "preferred" provider has the ability drive up prices. Innovation is not just a hallmark of American culture and success, but also an imperative catalyst for moving forward in patient care best practices and the equipment that allows us to follow suit.
3. The realization that an exclusive or "preferred" relationship with Medtronic for insulin pumps may easily become the same for continuous glucose monitoring.
There are two current CGM products on the market. The Medtronic Enlite sensor and the Dexcom G5 (Dexcom G4/G4 with Share still available as well). The Dexcom G4 sensor has been clinically proven to be significantly more accurate than the Enlite, with greater overall accuracy and a more positive user experience. That being said, plenty of patients choose the Enlite sensor. It works for them, and they should have the ability to choose that option if they wish. There are also individuals who choose to use the Minimed 530G Pump + Enlite Sensor (one integrated system). Then there are individuals who choose to use Dexcom in combination with a Medtronic pump, or any other pump as they see fit.
My question is this: once Medtronic is the "preferred" DME (durable medical equipment) provider of insulin pumps, will there be a natural evolution of UHC suspending coverage of the Dexcom CGM, as the Medtronic pump and CGM are combined in a single device? Right now, we all just want to know more about what this new policy pertaining to insulin pumps means for ourselves and our loved ones, but I can't help but look down the road a bit to see what the next battle might be. As a diabetic (or person with diabetes, if you prefer), I don't have the luxury of living life unprepared, in the physical management of my blood glucose levels or in the financial management of procuring the life-giving supplies that allow me to take control of my diabetes and overall well-being.
As it stands, there simply is not enough information available to the public regarding the UHC announcement to have a complete understanding of its implications upon non-Medtronic insulin pump users. This is about patient rights, advocacy, diabetes self-management, autonomy, and self-efficacy, but it is also about healthcare ethics, the evolution of our healthcare system, innovation, and economic competition. I would implore all people touched by diabetes to pay close attention to what happens next. Maybe you're like me, on a non-Medtronic pump, waiting to find out how you will be affected by this policy. Even if you are under warranty and able to get coverage on your non-Medtronic supplies for now, there will be a time when that warranty runs out and your choice will be limited. Maybe you are on a Medtronic pump already--you also should take notice of this arrangement. There may come a day when there is another product that will work more seamlessly with your management and lifestyle, and you will want the ability to choose what is best for your health.
Maybe you don't have diabetes at all, but the precedent set by this relationship could affect policy decisions at other insurance companies in the coverage of other supplies or medications. We each have to be our own advocates. The people making these decisions for us are not our doctors. Many of them have a limited or nonexistent understanding of diabetes, type 1 or type 2. Their loyalty is not to the consumer or patient, and you can be rest-assured that they are not taking your best interests to heart when making the decision to limit your choice in managing your diabetes in favor of a sweet deal. Don't let that decision be made for you. Stay tuned as this story continues to develop and make your voice heard in this conversation.
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