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by: Theresa Flaherty - Thursday, April 3, 2014

“Hi, this is Theresa calling from HME News. How are you?”

“Oh, Theresa, I am living the dream,” was the reply.

It’s a refrain I am hearing more often these days from weary providers. I sympathize with them and, on more than a few occasions I’ve been told they feel like they are talking to a therapist as I gently probe for what’s troubling them.

Let me tell you, I feel like a therapist some days.

But despite it all, there are always providers trying new ideas, thinking outside of the box. Those stories always brighten my day.

At the start of this week, I was feeling decidedly pessimistic because, with a Friday deadline looming, I was having trouble tracking down people to talk to, as well as drum up fresh content for the May issue. And did I mention we woke to snow, sleet and freezing rain that day?

“Theresa, you have to be creative, think outside the box,” editor Liz told me.

We are wrapping up writing tomorrow and, looking through the stories that have already been filed, I think we have a nice variety of stories, from a group of CRT companies that have formed a strategic alliance, to an unusual partnership between a pharmacy and an HMEs. I’ll sleep better tonight thinking of the joy providers will experience upon getting their issue.

It doesn’t hurt that the sun has been shining for 3 whole days.

by: Theresa Flaherty - Monday, March 17, 2014

Well, I am sorry to say today’s the day I finally pulled the plug on my plans to get a Dexcom CGM (color: pink). The reason: I can’t afford it.

The problem is the cost of the sensors, which are good for about a week to 10 days (my personal experience says one week). A three-month supply runs $1,356 until I meet my deductible. So, rather than spend a lot of money (mine and the insurer's to just have the device sit around unused) I decided to wait for the time being.

I was explaining my dilemma (and shock and awe at the cost) to Lisa Feierstein of Active Healthcare. Turns out her company also offers Dexcom and she too, couldn’t believe the price (to be fair, she’s the boss so wasn’t as intricately familiar with the pricing as I’ll bet her staff is).

Although she was able to give me better pricing if I didn’t go through insurance, it was still quite high. The problem, as Lisa told me after doing some research, is that the sensors fall under the DME benefit rather than the prescription drug benefit.

“Welcome to our world,” she told me.

I suddenly have a lot more sympathy for all those seniors complaining about how they can’t afford their equipment. Well, except for the ones who can, they just don’t want to.

It’s probably for the best. I having been having a spectacularly bad run of luck with devices lately. In November, my cell phone finally gave up the ghost, followed in December by my laptop. Last week, on the heels of springing the clocks forward, my watch slowly ticked to a halt (between the two events, I may not be on time for work until we set the clocks back in the fall).

Fortunately, unlike the aforementioned, I am not yet giving up the ghost, or the hopes that perhaps next year, I can get the CGM.

Theresa Flaherty

by: Theresa Flaherty - Thursday, March 13, 2014

This blog headline caught the attention of my Google alerts: Why Medicare's Attitude Toward Diabetes Could Kill Senior Citizens.

The blogger has Type 1 diabetes and, judging by her picture, is nowhere near Medicare age. She is, however, concerned about the national mail-order program which she believes will reduce access to high-quality supplies.

To be sure, the blog, which I wound up skimming because it's rather legnthy, hits on some critical points, including the AADE survey of contract suppliers which I wrote about in February and problem with FDA standards for meters (which aren't reassuring).

That second item is relevant to the bidding problem, but also presents a much larger issue, which then circles back to potential problems with bidding. If a meter isn't accurate, what's the point? It's hard enought to keep those sugars steady without the meter throwing a monkey into the works. 

The blog includes a link to a recent US News and World Report article. Did you know that 98,000 (!) seniors over the age of 80 wind up in the ER every year because of insulin-related hypoglycemia? That sounds like a lot. If meters aren't providing accurate enough info to calculate an insulin dose, that's a serious issue, for both the FDA, which really needs to tighten its standards, and CMS which is paying, if not for the actual meters, for the related supplies and, when necessary, ER visits.

To get back to our weird little niche, if 98,000 people are having issues with just insulin, what are the long-term ramifications of less obvious problems associated with the bidding program? Here, I am not talking specifically about faulty meters, but bennies who become less compliant because they get a new meter they don't like, for example.

Slowly, insidiously, the blood sugars creep up, causing a host of very expensive complications (heart and kidney failure, anyone?). And we're not talking just the over-80 crowd. We're talking anyone of Medicare age, including those who are still working because they are, well, able. What's the cost to Medicare here?

It's heartening to note, at least, that the (sort of) broaders public is indeed, well aware of the problems and dangers of short-sighted cost-cutting measures like competitive bidding.

Theresa Flaherty



by: Theresa Flaherty - Friday, February 21, 2014

As winter drags on it may seem like efforts to repeal Medicare’s competitive bidding program move at a glacial pace, but they are moving.

“The conversation is alive and CMS is on the defensive,” Cara Bachenheimer told me yesterday.

As proof of that: On Feb. 12, Rep. Renee Ellmers, R-N.C., published an op-ed in The Hill, calling for a reform of the bidding process. On Feb. 5, CMS officials were called up to brief members of the House Ways & Means Committee.

“CMS said everything is great, but several members voiced opinions about problems,” said Bachenheimer.

Meanwhile, stakeholders’ eyes remain firmly fixed on the “doc fix,” a potential vehicle for key points of the market-pricing program. Alas, rumors persist that some lawmakers think bid rates should be applied to Medicaid to pay for the fix.

“It’s difficult to know what’s going to happen and everybody on the Hill denies there’s a list,” said Bachenheimer. “We are doing what we can to make sure we stay out of the pay-for package.”

Theresa Flaherty

by: Theresa Flaherty - Friday, February 14, 2014

Yesterday, while taking a snow afternoon, I finally managed to connect with Neighborhood Diabetes (who I have actually talked to in the past for stories—kind of cool) that I was referred to by the diabetes center to get the CGM.

The good

The insurer, as expected, gave the OK.

The bad

Also as expected, I would have to pay for the $1,100 device out of pocket because I have not yet met my deductible ($2,500). I never meet the deductible (see previous parentheses).

The OMG!

A three-month supply of the sensors (figuring 1 per week): A whopping $1,356! First, I thought I heard wrong. Then, I actually said, “Oh wait, is that the combined cost of the CGM and the sensors?” Nope. Just the sensors. That too would be applied to the deductible.

Hey, I’d finally meet the deductible. Too bad I'll wipe out my HSA for the year.

Needless to say, I told her to call me back on Tuesday so I could do some number crunching (and research and price shopping). She has to call me back because I couldn’t get through to them for three days (a whole different concern).

On a funny note, in order to get the prior authorization, I need to supply three weeks of logs to document that I am testing at least 6x per day. Which I do. Unfortunately, if I don’t remember to press save on my meter, it doesn’t record the test. Which means I am going to get delayed in the getting the device. It's not that I disagree with the need to supply the logs, but who the heck shells out this kind of money if they aren't serious about managing their diabetes??

I am still leaning toward the CGM, and a blood sugar of 48 this morning about 30 minutes after I got to work (well, I did have to dig out of nearly a foot of heavy, wet snow) is pushing me further down that road.

I am off to test and to make sure I log it. Stay tuned.

Theresa Flaherty

Type 1

by: Theresa Flaherty - Monday, February 10, 2014

When I saw this abbreviated headline, “This student is on death bed, but his family still has to prove…” I immediately jumped to the conclusion the family was trying to prove some sort of medical necessity or lack of mobility or some such nonsense that we hear about every day here in HME land.

What the family actually had to prove is that Ethan, an 11-year old born with cerebral palsy (who died mere days after this article was written) can’t take a standardized test. (Sample Q: What does a peach taste like? A: He was tube fed).

It’s all so different and yet so eerily (and frustratingly familiar). It brings to mind the instances where paraplegics (or, I guess, their wheelchair provider) need to prove medical necessity, or amputees need to prove they don’t…have a leg?

Yes, yes, yes, fraud needs to be prevented and I don’t know a single provider I talk to who would disagree.

But, it would appear that the education bureaucracy is as rigid and unflexible (and robotic) as any other. Policy is policy and there’s no coloring outside the lines.

Common sense be damned!

I would suggest that now that the child has died, perhaps these people can be left in peace.

Although, if this was an HME issue, the auditors would likely be bending over the tombstone with a clipboard in five years.

Theresa Flaherty

by: Theresa Flaherty - Friday, January 31, 2014

It’s official. The winter doldrums have set in. The anticipation of the holidays has been replaced by blackened snow and brown and tattered wreaths hanging neglected.

I can’t get out of my own way to do much of anything. Did I pack my motivation away with the Christmas decorations?

I can’t help but worry that a similar fatigue has set in for HME providers. That’s because the deadline to register for the Office of Medicare Hearings and Appeals forum got extended (it ends today). That made me wonder if they weren’t seeing the sign-ups they expected.

And, Carolyn Cole from VGM this afternoon emailed me a press release touting the importance of participating.

“The forum will be loaded with hospital and pharmacy representation. We want to make sure we’re there too, to represent DME as an important part of the audit discussions,” said John Gallagher in the release.

To be sure, VGM is doing its darndest to get people fired up to attend the forum and also hit the hill next day to talk to lawmakers. I am quite confident that a dedicated few will indeed, make the effort.

That’s not to say that the vast majority of providers don’t care, but simply don’t have the time, the inclination or the resources.

But with audits eclipsing competitive bidding as the issue du jour, I hope a few more people get out there and speak up.

The iron is hot.

by: Theresa Flaherty - Friday, January 24, 2014

I handed back the CGM yesterday and asked "where do I sign up?" to get one of my own. That's because, while I wouldn't want to be tethered to it constantly, the peace of mind—and the guts to more aggressively manage my diabetes—that little black device offers would be worth it. Totally. Turns out lots of people use it during certain times, such as when their numbers aren't making sense, overnight, or maybe during a long hike.

After going over the downloaded graphs, as well as my log book, Erica (the nurse, not our HR manager) and I made some changes to my dosing, as well as to my routine, to see if that fixed a few, shall we say, less than optimal patterns. I can report that after one day, I can already see major improvement in sugar trends.

I filled out the paperwork to get the process rolling and to see what my insurance will cover and what my out-of-pocket would be. Looking online, they seem to run about $1,200, not including the sensors. And it comes in pink or blue, in addition to black. I'll keep you posted. I can't wipe out my entire HSA on this but I think I can swing it.

Meanwhile, one technology trend I am not sure of: Google's blood sugar detecting contact lenses, which has received quite a bit of press in the last week or so. I know from social media that many patients say they'd only consider the lenses if they already needed contacts, which makes a certain sense, I guess. I just find it hard to believe technology is anywhere close to being able to track blood glucose levels without actually sampling blood.

Theresa Flaherty
Type 1

by: Theresa Flaherty - Monday, January 20, 2014

I woke up Sunday morning around 5 am thanks to the guys clearing the latest snowfall from the neighbors. At which point I wondered, why hasn't the CGM beeped at me all night?

Cause it needed to be charged, which doesn't take long, but since it has to stay within 5 feet of me, it was kind of a pain at that hour(old house, not a lot of conveniently placed outlets.) However, while killing the 20 minutes or so I needed to recharge, I found the logbook they gave me at the doc's office on Wednesday and which I had promptly misplaced. So, part of Sunday afternoon was spent backfilling it, with sugars, carb counts and insulin doses, as well as what I ate and when, and exercise, illness, stress and what color pajamas I wear.

Just kidding on that last one.

I can think of no greater nightmare of a patient population than those with diabetes for the HME suppliers. Cause let me tell you, I hate keeping logs (although I love having them when at an appt) and we all know what happens if Medicare wants to see those logs and they, frankly, don't exist for suppliers to collect. (I will try and be more diligent by the time I reach Medicare age, but I am making no promises, suppliers. Sorry!).

I've been talking to providers today and last week, and last month, about audits (otherwise known as "nightmare," "ridiculous" and "frickin' ridiculous") and it's clear, even without the infamous ALJ memo, that the problem is getting worse.

"I think she did that to raise a red flag," John Gallagher told me today, about the memo.

Here's hoping that, between the ALJs themselves complaining, and other provider groups up in arms, that there's strength in numbers.

Speaking of numbers, this morning's (4 am!) low of 43 only points to why I am using this CGM. Come to think of it, last Monday I also had an ungodly early low.


Theresa Flaherty

by: Theresa Flaherty - Friday, January 17, 2014

In diabetes we have a rule: the rule of 15. What this means is, if you have a low blood sugar, you should consume 15 grams of carb, wait 15 minutes then test again. It's a good rule and it can work pretty well if you can stick with it.

I woke up this morning around 4 and according to the CGM, my blood sugar was an excellent 98, which I confirmed with my meter. However, since I was planning to roll over and go back to sleep for another 3.5 hours I decided to have a swig of OJ in case my numbers were trending down. I have noticed in recent months (years??) that I do not need 15 grams of juice. This was never more clear than this morning. I had some juice (maybe an ounce—3 carbs—at the most). I'd like go on the record here as saying that even at that dark hour, I used a glass, no carton chugging for me.

Fast forward some time (maybe an hour? I was too groggy to care) and the CGM woke up me to tell me my sugar had soared to at least 240. Could be overnight hormones, could have had a rebound from a low after all (I really don't think so), could have been the juice. But it was interesting all the same, and will be something I ask Erica about when I see her. That's the whole point of the device, to track trends, but also anomolies.

I think the rule of 15 could apply to a lot in life. Take this morning when I discovered that someone had burnt toast badly enough to scorch my brand new stainless steel toaster. It's less than a month old and it has a big black mark. Did I immediately text the likely suspects? Leave a passive-aggressive note? Nope, I waited a few minutes and the urge passed. I'm still ticked, but I am sure the offender will do their best to clean it up. It wasn't intentional, after all.

Theresa Flaherty