Education has fallen so low as a health priority that it's barely noticed when the lack of it causes devastating consequences, including death. What are health insurance companies thinking when they cover the cost of life-saving health equipment and deny the cost of learning how to use it?
My friend, Pamela who has type 1 diabetes, got an insulin pump and a continuous glucose monitor several months ago. Finally, she hoped to be able to better control her blood sugar. Her health insurance company covered the several thousand dollar cost of these two devices.
Then they refused to cover the much smaller cost of having someone teach her how to use them.
Pamela has had diabetes for 35 years, since she was 20 years old. She also has hypoglycemic unawareness. That means she cannot feel when her blood sugar is dangerously low; she gets no symptoms. A dangerous low can lead Pamela to lose consciousness and possibly slip into a coma and die.
Pamela has managed her blood sugar all these years by testing it every few hours and using corrective doses of insulin to bring down a high blood sugar, and eating to bring up a low blood sugar. It's a very intensive form of management.
If you met Pamela you would have no idea what she has to do every day. Or that she seldom feels well because of the degree of fluctuation in her blood sugars. So while Pamela looks fit, is slim and eats healthy, she's not in good health. And, she has never been able to exercise--an important part of diabetes management.
Exercise drops her blood sugar like a stone, both while she's exercising--and up to 12 hours after. Since Pamela doesn't feel when her blood sugar is low, or any symptoms that her blood sugar is dropping, exercise puts her at risk.
Even a bit of light walking lowers Pamela's blood sugar. Once she ended up in the ER due to a very low blood sugar in the middle of the night. To make matters worse, and it's something she worries about constantly, Pamela lives alone; there is no one to help her if she can't dial 911.
Frightened to exercise, Pamela has been losing her stamina these last 15 years--she can't really even touch her toes--and she's growing anxious about her health.
Last fall, she decided she must find a way to exercise to maintain her health and improve her blood sugar control. You should know, without being able to control her blood sugar and be active she has a higher risk of diabetes complications--cardiovascular disease, blindness, kidney disease, amputation, neuropathy and circulatory, gastric and nervous system disorders.
Pamela's plan was to get an insulin pump and a continuous glucose monitor (CGM). An insulin pump delivers a steady flow of insulin into the body; it mimics how a normally functioning body works. Knowing how to program and use an insulin pump requires rigorous initial training and education.
A CGM tracks your blood sugar every few minutes so that you can see your blood sugar in the moment, and see if it's going up or down. It has a warning alarm that sounds when your blood sugar is too high or too low. Pamela, an educated, committed and responsible patient, decided that both devices would be the way to protect her from the potentially devastating result of her hypoglycemic unawareness, finally allow her to get activity and improve her blood sugar fluctuations.
"Great idea," I confirmed. Yet, this Spring, Pamela showed me how weak her muscles still are; she tried curling her toes and couldn't. Pamela already had her insulin pump and CGM five months then and still hadn't been exercising. Here's why.
To get her pump and CGM Pamela had to first prove to her insurance company that she really needed them. So last September she produced a portfolio of documents:
- A doctor's certificate of medical necessity
- A 14 day summary of blood sugar results
- A graph of glucose trends over an eight week period
- A log book of all blood sugar results for an eight week period
In total, 15 pages of data showing that her variations in blood sugar warranted the two devices.
Voila! Three months later, Pamela received her equipment.
But Pamela's insurance company, having spent $6,559.76 on a continuous glucose monitor and an insulin pump, and an additional $16,200 this year alone for the supplies for the two devices, will only pay $250/year for her to see a diabetes educator to teach Pamela how to use her life-saving equipment.
Pamela estimates that she will need about 15 visits with a diabetes educator. At most, that will cost her insurance company about $2,000.
To use an insulin pump, ratios need to be calculated for insulin dosing to match carbohydrates you eat. These ratios need to be calculated differently for different times of day as blood sugar fluctuates 24/7. Once the calculations have been made, there's an initial stage of gathering results, assessment, evaluation, setting programs, making adjustments and testing the adjustments.
Imagine you're a teenager and your father just handed you the key to the beautiful, new shiny car he just bought you. Yet, you don't have a driver's license, you've never had a driving lesson, and he's not going to let you get one. The car cost $32,000. Driving lessons would cost $300. Sure, you can get in the car and drive. And maybe you won't kill yourself or someone else.
Because Pamela needs the education to use her devices, she's been paying for it out of pocket the past two months while appealing her insurance company's decision that limits her to one and a half visits/year with an educator. At the insurance company's rate, it will take Pamela 10 years to learn how to use her life-saving equipment. Ten more years of difficult to manage blood sugars would almost ensure more diabetes complications, maybe even death.
Pamela is now up to her eighth visit with her educator and they have hit a milestone. They now know why her blood sugar hits dramatic lows and how to avoid it. This means Pamela now walks for exercise without putting herself in peril like before--and is improving her health.
A few more visits and Pamela will have the knowledge and the means to manage her blood sugar for presumably the rest of her life. She'll have a solid edge in preventing further complications and--save her health insurance company hundreds of thousands of dollars in retinal and foot and leg-removing surgeries that won't have to be performed, dialysis time that won't have to be booked, a bed in a nursing home that won't need to be reserved and possible prosthetics.
I know this story is one of many. I have another friend who had her request for a CGM denied. Her insurance company told her that her type 1 diabetes was cured because her A1C was in the range recommended for diabetics. Not the normal range, just the one meant for diabetics. Maybe our target audience for increased health literacy needs to include health insurance company executives too.
All of us pay the premiums insurance companies are drawing from when they decide to withhold education for preventable health tragedies, and choose instead to pay the enormous financial bill down the road. Whether it be for diabetes complications or other conditions' complications that can possibly be avoided now.
Many stories in the news lately question whether our dollars are first going toward insurance executives' pay and then getting doled out for our care. Isn't it time we insist life-saving education be given the same priority of dollars as life-saving devices--and insurance executives' bonuses?
Disclaimer: No one has asked me to write this article. I did not name the insurance company involved because this occurs among many insurers across the country.