Abstract
“Never angrily rant into your web cam. While smashing a keyboard in half over a game of ‘World of Warcraft’ may seem totally justified in your head, to the rest of the known universe you look like a raging psychopath.”—Ray William Johnson
The good news is I generally do not rant into my webcam and certainly never about a game of “World of Warcraft.” But as we end 2021 and enter 2022, I am already asked in this ninth iteration what could be a novel topic for me to discuss. After all, over the years I have tried to tackle all of the dysfunctionality about our medical system, diabetes management, and world politics, but not necessarily in that order.
“I have never made but one prayer to God, a very short one: ‘O Lord make my enemies ridiculous.’ And God granted it.”—Voltaire
I did not really appreciate I have professional enemies, but we all do: insurance formularies. I have never prayed that these wise men and women who police the medications we are allowed to use for our patients are our adversaries, but it is difficult not to come to that conclusion when we recount that our time is spent in ridiculous ways.
Take, for example, my 60-year-old male patient with type 1 diabetes and a previous myocardial infarction who needed a glucagon prescription. It had been many years since he had one refilled, and both he and his wife acknowledged what they had at home was long expired. I reviewed the new choices available, but at the time of the visit, we did not know which of the various glucagon preparations would be available. Ideally, my electronic medical record would provide that information to me, but in my world, which is rarely the case.
A few days after our visit, I received a fax that the one I picked was not on formulary. I warned the couple that might be the result, and we would have to use another. But as it turns out, no glucagon preparations were on this patient's formulary. Instead, I was asked to substitute glucose tablets, honey, karo syrup, or sweetened orange juice. I was surprised Sugar Frosted Flakes did not make the list. I thought about these options, and if a “peer-to-peer” discussion was appropriate given how glucagon therapy has been part of every guideline for type 1 diabetes for decades, I declined this idea. I felt it would be more productive and efficient to have an old-fashioned temper-tantrum with a letter to the medical director of the insurance company that did not use words with three syllables and could be understood by a 4th grader (with no disrespect intended to 4th graders).
In my letter, I pointed out how this patient with 40 years of type 1 diabetes has impaired hypoglycemia awareness, and that it was nonsensical that we prescribe a Krispy Crème donut when the insurance was already paying for an insulin pump, a continuous glucose monitor, and a PSCK-9 inhibitor. After sending my 2021 rant 1 (which in a nonsubtle way exploited my venue to the world) and offering the medical director a deal he could not refuse (not related to Vito Corleone but rather the First Amendment) the couple received its glucagon.
To be clear, I generally will not spend this amount of time fighting for a drug that hopefully will never be used as long as one preparation is part of the formulary. But how can a payer, 100 years after the discovery of insulin, have no glucagon on their formulary? When I asked, I did not receive an appropriate answer. Even Aaron Rodgers would have had a better explanation.
“People say that the most expensive piece of medical equipment is the doctor's pen. It's not that we make all of the money. It's that we order all of the money.”—Atul Gawande
Dr. Gawande's point is poignant for the Durable Medical Equipment (DME) companies. The background for the institution of DME companies has been recently explained and is well understood by U.S. clinicians. 1 I had assumed that much of our world in diabetes moving to a pharmacy benefit where patients could pick up their glucose test strips, continuous glucose monitoring (CGM) supplies, or even pumps from a DME supplier would be a win for the patient and a win for the prescribing clinician. Still, our world (or mine anyway) is worse due to the large number of seniors I see where pharmacy benefits for pump and sensor supplies do not exist, as the world is dependent on DME companies. I want to make it clear it is a total pleasure, honor, and privilege to see so many patients with >50 years of diabetes. Some >60 and 70! These people are my heroes. The problem is the DME companies do not treat them as such.
Let us start with how they function with my staff. I have known for years (decades) they send us a fax for signature, and that same day a signed copy can be sent back to them. Despite that, and despite sending it to the correct fax number, we are told it was never received. We play this game often for weeks, with me signing off for the same patient multiple times. This is one of many reasons the patient does not receive their sensors or pump supplies on time.
As an example, just before the Christmas break, a clinic manager was covering for one of the front-desk patient care coordinators. A patient called concerned her diabetes supplies had not reached her, even though everything had recently been faxed in a timely manner. The clinic manager called the DME company, and after many minutes on “hold,” reaching a human on the other line, and reviewing everything that had happened, the clinic manager was told that the signed DME forms were faxed to the wrong number. This is despite the fact that the clinic information was faxed to the number on the form we were asked to fax to.
The form and the clinic notes (and CGM tracings) were then faxed to the correct number. A clinic medical assistant, when asked, told the clinic manager this happened daily and that in a few days, it is likely the information would need to be faxed to yet another number. This is simply routine standard diabetes therapy for DME companies, yet I have never seen this topic addressed as “standard” in the American Diabetes Association or American Association of Clinical Endocrinology standards of care.
It gets worse. First, the DME company told the clinical manager it is our fault, like with every clinic. We are faxing to the wrong number. My response: why don't you give us the correct number at the beginning of this frustrating process, which is as painful as a daily root canal to my staff? The bigger issue: time after time, it is the patient who suffers, with days, weeks, or months of time without their sensors, strips, or pump supplies. These seniors often are not able to navigate the complex system, especially for those who are not computer savvy. Although I am by no means a technology “geek,” I also find many of these websites nonintuitive, and for someone in their 70s or 80s who did not grow up with the internet, it is no wonder there are so many interruptions in patients receiving their supplies.
One would think these DME companies would be ashamed of themselves. But that is not the case. Customer service has never been known as their strength, and the reason is that their concerns of patient satisfaction seem minimal or nonexistent, whereas their primary incentive is to pass assessments from independent auditors, as noted last year. 1 I was copied on an e-mail to one DME company from an angry patient, a retired physician, who did not receive his CGM supplies. His comment after not receiving responses to his e-mails or phone calls: “Would you people wake up and respond to me? Your job is to provide a service to people with diabetes! You are not doing your job!” Indeed, that is the point.
Although the pharmacy benefit managers (PBMs) mostly for pharmaceuticals, and the DME companies have different infrastructures, histories as part of our medical system, profit margins, and certainly legal challenges, the one point we can all agree is that they have added frustration and expense to patients, and irritation, anger, apathy, discontent, depression, and work dissatisfaction with physicians.
Although the COVID-19 pandemic has added to physician burnout, even before 2020 American medicine was challenged. A 2018 survey of 600 primary care physicians reported that 48% were considering leaving medicine due to insurance bureaucracy. 2 When physicians were asked how they felt about insurance, the most common response was frustration, followed by stress, anger, defeat, and hate. Could one imagine how these same physicians would rate their local politicians?
“Insanity: doing the same thing over and over again and expecting different results.”—Albert Einstein
I have wondered for many years if Dr. Einstein was referring to the management of type 1 diabetes in the hospital. As a medical student, a resident, and then as an endocrine fellow, what I saw from wise, seasoned, and respected physicians has not changed today. Although hospitalists are a new phenomenon, I would argue the culture of type 1 diabetes in the hospital has not changed.
One of my junior colleagues came to me with her patient's story. The patient is in her 70s, type 1 diabetes for >40 years, and is now living in an assisted living facility, which allows her to receive fixed doses of prandial insulin with correction doses. For readers who are pediatricians, this is unusual, as many of these facilities only allow two fixed doses of insulin daily.
Nevertheless, in the fall of 2021 she was admitted to her community hospital for diabetic ketoacidosis (DKA) twice. Her first episode was “iatrogenic,” and although she was in the hospital, the insulin drip was stopped two times, and as many interns in July have noted, the anion gap rose to high levels, twice. She was discharged after receiving one morning dose of glargine, yet her outpatient basal insulin was degludec, which she started the following evening, which is her usual time. The savvy reader (and University of Washington endocrine fellows) knows where this story is going. She had a second episode of DKA 2 days later. Her glucose level was >700 mg/dL, and at the assisted living facility she was found to have a wide complex bradycardia, which despite appropriate treatment resulted in a cardiac arrest. After cardiopulmonary resuscitation, intubation, and pressors, it was found her potassium was 8.6. In the community hospital this second time, she was transferred from an intravenous insulin drip to subcutaneous glargine, but this time with the assistance of the endocrinologist in our clinic. She was bridged to degludec as recommended due to the prolonged kinetics of the latter insulin. 3 It should also be noted that while in the hospital, her glargine dose was twice the amount of her outpatient degludec, and she developed hypoglycemia to 45 mg/dL before discharge.
This abridged version of this sad case addresses many gaps in our system for type 1 diabetes, especially the elderly: assisted living facilities, poor understanding of the various insulin preparations by hospitalists, but most importantly, the poor communication with the outpatient specialist for the admitted patient with type 1 diabetes. We have seen fundamental mistakes for decades (such as turning off an insulin drip without any subcutaneous insulin “on board”), and with new medications and technology, are we naive enough to consider this will change? I am still speechless about a patient several years ago, admitted with euglycemic DKA, who at the time was diagnosed with type 2 diabetes (later found to have type 1 diabetes), receiving an SGLT2 inhibitor, and the drug was not discontinued, even while he was an inpatient! Suffice to say, we have a long way to go with our Continuing Medical Education programs.
“Laughter is the best medicine, unless you're diabetic, then insulin comes pretty high on the list.”—Jasper Carrott
Of course, there are many other topics that could have been included. In this 100th anniversary since its discovery, insulin is still not accessible for everyone, especially in low- and mid-income countries. Misinformation is not only prevalent with vaccines—we see it with diabetes daily. I will need to wait until next year to talk about the use of the word “obese”—who would have ever thought that was something naughty?
“Science is the most durable and non-divisive way of thinking about the human circumstance. It transcends cultural, national, and political boundaries. You don't have American science versus Canadian science versus Japanese science.”—Sam Harris
It is the science and human victories that should keep us all focused. Although these rants are just one person's frustrations, at the end it will always be research, published in a peer-review journal and repeated by others, which will give us the most benefit. The problem will always remain how to pay for the fruits of these discoveries, and what systems are in place to provide these benefits to the most people. That is our greatest challenge, and to date we have failed.