July 23, 2009
Daily Care, Insurance/Costs
Question from Kent, Washington, USA:
My son was notified last week that Medicaid will limit his diabetes blood test strips to 100 per month starting August 1, 2009. He currently tests before each meal and snack (about five a day); before and after strenuous activity – tennis, swimming, dancing – each day (two each day); before bed and once during the night (two each day) and retests after an hour when he has insulin for high blood sugar, and after half an hour if he has low blood sugar (one to eight times per week, so about once daily); and every hour or so when he is ill. He is sensitive to hot weather so he tests more often during summer.
Born with a developmental disability, my son understands the importance of testing to control his blood sugar numbers and to avoid lows that cause him great anxiety; he has experienced seizures with unexpected lows but also is just troubled by the physical and emotional symptoms of lows. Sometimes, when he is away from home, he has a drink or snack when his blood sugar is at an okay level because he is afraid he will go low, but it is so important that he does treat a low when he feels it. We do not limit his access to snacks and he does carry breakfast bars and little cans of apple juice with him wherever he goes. Since he tests his blood sugar so often, we are able to maintain an average of 110 mg/dl [6.1 mmol/L] to 170 mg/dl [9.5 mmol/L] a fair amount of the time. He tends to panic when his blood sugar is under 100 mg/dl [5.6 mmol/L], so, recently, I have been telling him when it is between 80 mg/dl [4.5 mmol/L] and 100 [5.6 mmol/L], he should feel good and that we will test sooner when it is within that range so he does not go lower, just in case he likes the feeling of that range.
I asked that his doctor request an exemption to the Medicaid limit as soon as the forms are available at Washington State Department of Social & Health Services web site, but had a call back that they would request an exception that would allow him to test only four times per day.
It was my understanding that individuals with type 1 diabetes are encouraged to test more frequently, to maintain a target A1c between 7 and 7.5 to avoid or delay long term problems, as well as to avoid emergency events and hospitalization. Also, I believe that keeping physically active is in the best interests of people with diabetes. For my son, who does not often notice symptoms of lows or high blood sugar, and has communication challenges that make it difficult for him to let us know when he does feel unwell, especially when he does have unusual lows or high readings, we need to check him carefully when he is active. The main reason we test so often is to avoid Emergency Room (ER) visits and hospitalization that are much more costly than his test strips.
I am worried that when the limits take effect, I will test him as usual and run out of strips in the second week or I will have to ration strips by eliminating the activities that keep him strong and involved in the mainstream of our community. I am also uncertain about my son’s doctor accepting such a curtailment of testing, because my son has Medicaid and also because he has a developmental disability. My trust in that doctor fell from 10 out of 10 to 1 out of 10.
This year, as a result of the dismal economy, we have already cut every expense that is possible and we are still facing rising expenses in housing and food. I don’t know what we could eliminate in order to buy test strips for my son, but I do know that he can’t live the very ordinary life he has without them.
If more frequent testing is recommended, I would appreciate knowing what studies and articles are available to submit with his doctors request for an exemption. I would also appreciate any medical advice you have on how to figure out how to manage my son’s diabetes using 100 test strips per month. Are four tests per day the recommended number for people with type 1 diabetes? The limit for people with type 2 diabetes on Medicaid will be 30 per month. I believe that they are sold in bottles of 25 so that is a puzzle in itself.
Answer:
It sounds like you have been very helpful to your son in the treatment of his diabetes. This is not an easy thing to do. Unfortunately, insurance companies all have their lines in the sand. For Medicaid, the number of four glucose tests per day is a line in the sand. The number four does not necessarily stand for what is in your child’s best interest. It is what they think is reasonable and gets them off the hook for paying for additional strips and testing. This kind of glucose testing limit is found in other insurance companies. What the insurance companies want you do is pick up the responsibility for the difference in cost.
In order to make do safely with less, I would talk with your physician about what they would recommend. It might be helpful to write down numbers for a week and see where the trends are. If he were almost always normal at any of the time points, this might be a time point you can test less frequently. I do not think there are any substitutes for checking when you think he is low. If you have to make do with less, and the frequency of lows increases, I would use this as evidence for the insurance company that more is needed. Can you imagine? All that has to happen is one serious low and all the potential savings the insurance companies thing they will be saving will be lost if he requires an ER visit or ambulance response.
You might want to check with your local diabetes education staff to see if sample glucose strips are available. Additionally, you might look into how much the extra strips might cost.
JTL
[Editor’s comment: You may also want to see if the Partnership for Prescription Assistance can help you.
BH]
