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In the first three months following the acquisition of his continuous glucose meter Dexcom, Ric Peralta said he had reduced his average blood sugar by 3 percentage points.
"I went from a very poorly managed blood sugar level to an incredibly well-managed thing," said Peralta, a 46-year-old optician from Whittier, California, who was diagnosed with type 1 diabetes in 2008.
Peralta was so excited that he became a "Dexcom Warrior", a kind of local product spokesperson. It was hard to imagine life without her new monitor, a device that allowed her to track trends in her blood glucose level 24 hours a day on her smartphone. And yet, he has spent several weeks without a device in the last year due to insurance restrictions. Physician groups and patients consider these rules to be heavy, but insurers defend them if necessary.
Diabetes activists and lawmakers have begun to draw attention to the rising price of insulin, which has resulted in legislative pressure, lawsuits and congressional hearings. But insulin is not the only thing that people with type 1 diabetes have difficulty getting. The management of the disease requires other essential medical supplies, which often save life. And patients often have difficulty accessing these supplies – barriers put in place by insurance companies.
A device that changes lives
Peralta has been informed of the latest version of the Dexcom continuous blood glucose meter by the mother of one of his patients. He visited the company's website and, after two weeks, the device was sent home.
"I still have not fully appreciated how it would change my life," said Peralta. "It was amazing."
Typically, people with type 1 diabetes check their blood glucose by taking a drop of blood on a finger and placing it on a disposable test strip read by a blood glucose meter. Doctors suggest checking this blood glucose between four and ten times a day. These readings are essential to help people with diabetes manage their blood sugar – prevent it from falling too low, which can cause sudden seizures and loss of consciousness, as well as becoming too high, which can cause vision loss and nerve damage. even, over time, lead to amputations.
Instead, the Peralta continuous glucose meter gave accurate blood glucose readings every five minutes. That's 288 readings a day, about 278 readings more than even the most conscientious patients do not have the oldest method.
"When I had to do the old-fashioned prick test, I did it just before eating, so I could see how much [insulin] I had to take, "said Peralta. (People with type 1 diabetes must take multiple daily doses of insulin to keep their blood sugar levels within normal limits because their body stops producing the natural hormone.)
"I did not realize that I had serious problems [blood sugar] peaks and valleys between my meals, "said Peralta.
Tighter control of blood glucose can reduce the risk of heart disease, kidney failure and nerve damage. For Peralta, it also offered peace of mind.
The monitor sounds an alarm when its blood sugar becomes dangerously low. Peralta said his colleagues had started to bring him sweet snacks when they had heard the alarm, so help him restore his blood sugar to normal. When he takes his family on an excursion – his favorite activity – he does not have to worry about losing consciousness while driving.
"It even syncs with my car so I can just say," Siri, what is my blood sugar? "I'm safe for my family."
Conditions of prior authorization
When common chronic diseases such as diabetes are well controlled, it prevents the disease from getting worse and saves money for the health system and the patient.
But Peralta said his problems using this new tool to manage his diabetes were thwarted by insurance problems that began about a year ago.
The latest Dexcom continuous blood glucose meter has three parts: a sensor that measures the glucose level, a transmitter that sends the wireless sensor readings, and a receiver that displays these readings on a screen.
For each of these pieces, Peralta needs a "prior authorization", namely that his doctor obtains the authorization of his insurance company before prescribing the device.
Dexcom sensors last about 10 days each and Peralta's insurance allows it to purchase a supply of three months at a time. But he must also obtain prior authorization for each supply, which means that every three months, his doctor must reconfirm with his insurance company that the sensors are medically necessary. The same goes for the device emitters, which last about six months each.
"I have to overcome obstacles and get information from my insurance to get an authorization," said Peralta, frustrated, adding that "for the past year, almost every time something went wrong".
"Prior authorizations are in place to protect patients, improve safety and ensure that the care they receive is as safe as possible and as affordable as possible," said Kate Berry of the American group America Health Insurance Programs.
But for Ric Peralta, this requirement is a burden.
The most recent snafu took place in March. Peralta ordered a new supply of sensors directly to Dexcom, but said the company had also requested the approval of a new issuer. And since its insurance approves the sensors and transmitters according to different authorization deadlines, the refund request was rejected. Peralta estimates that he spent four hours on the phone with Dexcom and his insurer over the next month and a half to fix the problem. During that time, he had to pass finger tests.
"It's infuriating," said Peralta. "If I do not control this disease properly, I will die. And they make the task as difficult as possible. "
A burden too for doctors
Prior approval has become a major concern for physicians in the US health care system, as shown by a survey conducted in December by the American Medical Association.
Of the 1,000 physicians surveyed, 91% said prior approvals "have a negative impact on patients' clinical outcomes"; 75% stated that the requirements "may at least sometimes cause patients to discontinue the recommended treatment"; and 28% said the prior authorization process had "led to serious or life-threatening events" for their patients.
"In my practice, we have five individual doctors and we have hired five full-time employees whose primary task is to obtain prior authorization and deal with insurance companies," said Dr. Bruce Scott, Otolaryngologist. -Laryngologist and AMA Speaker House of Delegates.
"Prior authorization is a burden on suppliers and diverts valuable resources," Scott said. "It's a problem."
WADA has even created a website that lists the stories of patients and providers claiming to have difficulty accessing access to important medical products and procedures due to problems with obtaining prior approval from patients. Insurers – pain medications for a patient with cancer at X. rays in the emergency. Scott said that WADA did not expect insurers to completely eliminate the requirements for prior authorization, "but we think it should be targeted and better planned."
The American Association of Clinical Endocrinologists, an organization of physicians whose specialty is often associated with the treatment of diabetes, goes further.
"We believe that endocrine physicians should not be required to complete prior authorizations for endocrine therapy," said Dr. Scott Isaacs, an endocrinologist in Atlanta and a member of the AACE Board of Directors. .
"It's a big burden for patients trying to solve this problem. Sometimes it's the paperwork; sometimes it's a real denial, "said Isaacs. "It's also a heavy burden for doctors and they want it."
Berry, of America's Health Insurance Programs, acknowledges that the prior authorization process is likely to be improved. In fact, in January 2018, WADA and AHIP signed a consensus statement identifying five areas for improvement. It has been co-sponsored by the American Hospital Association, the American Pharmacists Association, the Blue Cross Blue Shield Association and the Medical Group Management Association.
Who carries the heaviest burden?
For Ric Peralta, the ultimate burden of fulfilling all these prescriptions rests with him and other patients like him.
After his last confusion with the sensors in March, he discovered that the battery of his transmitter was dead.
Peralta has made another frustrated call to Dexcom and has recently obtained an additional issuer to bring it back to the system while its official order is subject to the approval process.
"I am very worried about what will happen in two months when I will have to recall orders," said Peralta.
"Am I going to have to do this again?"
This story is part of the reporting partnership between NPR and Kaiser Health News.
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