Change

Change can be hard.

It can also be also be a chance to reflect on what is important.

This sweeping statement sounds somewhat romantic until you learn that I am talking about health insurance.

Up until recently, M was covered on her father's PPO coverage at his place of employment. This worked out pretty well on the day she was diagnosed. We paid about $38 each time we visited a specialist, and about $84 per month on insulin, and $87 per month on test strips. Also, we paid about $50 every six months for lancers, since M only changes them about once per day. Infusion sets cost us about $240 every quarter, so about $800-$1,000 per year.

All of this totals roughly $3100 per year in maintenance.

All very interesting, I'm sure.

But then Daddy got a new job. And insurance doesn't kick in for 90 days.

Okay then, let's get on Mommy's insurance plan: an HMO.

The insurance itself costs less, for sure. And prescriptions are a lot cheaper: $15 for test strips and insulin. Doctor's visits are $10. But M's current endocrinologist is not on the plan. In HMO speak, this means that the insurance will not pay anything toward M's care if we see her current doctor. At least on the PPO, if M's specialist was not on the plan, we would still get some coverage, but not as much as those "participating" in the plan.

So now what?

We have to change doctors.

We have been thinking about this for a while, anyhow.

After all, M's diabetes nurse educator would frequently give us conflicting advice, and although we asked repeatedly to be part of trials, we were never even told if any were going on. I assume that we were put toward the bottom of the list due to the fact that we live over one and a half hours from the hospital.

Fortunately, we have heard many great things about the hospital just 40 minutes away.

Searching the web, I learn which doctors are on our plan, which is somewhat helpful, but I can't find any information about the doctors themselves. So I turn to my new resource: the STAR parents.

I send an e-mail to the group explaining our situation, and within two days I have the names of the two favorite pediatric endocrinologists in the Dartmouth area, as well as the name of a favorite Diabetes Nurse Educator.

I contact our PCP (Primary Care Physician) and request that we be referred to the new doctor. (For all of you Russians out there who are mysteriously reading my blog, we in the States cannot refer ourselves to our own specialists: another doctor must "officially" make the request in order for our insurance to approve and pay for the visits.)

Service was excellent, and within a week I received a phone call from the new hospital confirming an appointment with our new DNE. The copay for the visit was $10.

So an HMO doesn't sound too bad, does it? Lower prescription prices (even if they do give us 100 fewer test strips per month), lower copay prices, a specialist nearby....

Except that if the diabetic stuff hits the fan, and we need to see someone "outside of the plan", the expenses may very well not be covered.

Which is why, after 90 days, we will be switching back to a PPO through Bill's new job. I will continue to remind myself: change can be good. But hopefully after the 90 days, we won't have to make another one for a while.

Ups, Downs, and Opinions

Shortly after M switched to Novolog, she also began lacrosse season, which usually requires a couple of weeks of adjustment.

I am pretty sure that the timing could not have been worse.

Having two major changes in lifestyle make the diabetic body, let's just say, unpredictable.

Her blood sugar was a mess. 32! 595! 31! 536! AHHHHHH!

This change and unpredictability sparked a lot of debate and discussion among those of us who were responsible for M's care.

First it was the DNE, who told me that "insulin is insulin", and that any change that was occurring must have to do with her renewed exercise levels. I disagreed, knowing that we have made this change before, and it was never quite this erratic. I did wonder if maybe M was eating food that I didn't know about, but she assured me that she was not.

Then the school nurse decided to chime in. "You need to get that insulin changed back! Ask the insurance company to change it! They will make an exception if there is a reaction that is detrimental to her health!"

The athletic trainer agreed. "It was not this bad before! It must be the insulin!"

I found these forceful declarations unfair.

I was exhausted. I was checking M's bg levels every two hours around the clock. I was stressed. I was tired. I actually became weepy a work. My coworker suggested that I take a mental health day after she asked me how M was doing, and I welled up at the thought of my daughter and her unpredictable results. I wondered daily which child I would be coming home to: the pasty gray-faced child, or the insane cranky child who felt defensive about her test results.

My diabetic students told me to hang in there; that I was doing the right thing. Monitoring bg levels regularly would give me the information that I needed.

M and I decided to give it a month. After two weeks of bi-hourly monitoring, we adjusted her basal rate rather aggressively, up in some places, down in others.

Happily, after about 4 weeks, we are back within our "normal" range.

But let me tell you, having everyone give me, a strung out parent, different advice just about sent me over the edge. I understood each point of view, and they all reflected my own guesses as to what was going on. I felt defensive any time someone felt that they could give me an absolute answer.

There are no absolute answers, no matter who thinks that just one thing will make a person's body go from insane to normal.

I knew in my gut that it had to be a combination of factors.

And while that reasoning and very careful monitoring paid off, I still feel that it would be inappropriate to tell people that they were only partially right.

Saying, "I am smarter than you are," just seems a little rude.

I may even be smarter than this car!

No choice

So a few weeks ago I receive a letter from our insurance company.

It states that my daughter is on a medication that is "no longer a preferred medication".  And I think to myself, "Really. The only medication that she uses is insulin. Did you have an alternative for insulin you HMO bastard pieces of shit?" (We actually have a PPO, but I just love that quote.)

Upon further investigation, it seems that Caremark has decided that it no longer wants to work with Humalog (from the Eli Lily company in Indiana), and prefers to work with Novolog (from Novo Nordisk, a company in Denmark). They stated in their letter that failure to switch to the preferred medication may result in loss of coverage for the current medication.

This makes me nervous.

Why? Because the one student I know for sure uses this stuff has very wild swings in blood sugar during the day. His mother and I spoke about different kinds of insulins at a school event. She was touting Novolog as better because it works faster, more like natural insulin.

I thought that maybe we would try it, eventually. Maybe it would work more effectively with M's lifestyle, but we would wait to do it over the summer, if we did try it, so that we could monitor the effects of the change on her system without too much life getting in the way.

But the insurance company threw off my time line.

I asked another diabetic student about which insulin she used. She said that she uses Humalog, and that she had tried Novolog, but after trying it, her doctor wrote her a letter stating that she needed to switch back for medical reasons.

What were the medical reasons?

She wears her pump very discreetly, snaking the tubing from a pocket in her jeans to the infusion set on her thigh. While using Novolog, she said that she was developing divots on her thighs at the infusion site. Her doctor noticed that her muscles were withering where the Novolog entered her system, and successfully appealed the insurance company mandate.

I was a little alarmed.

I brought my concerns to our DNE, who immediately poo-pooed the idea. She had never heard of any of the problems to which I was referring. She told us that "There is no difference between the insulins, and anyone who tells you otherwise is blowing smoke."

After careful consideration, we chose to give Novolog a try without appealing the decisions of the insurance company. We hope that all will go well, and that we won't have to fight for an appeal in the future.

With lacrosse season starting up, I am hopeful that this new medication will interact with M and her lifestyle smoothly.

But I know better.

No adjustment is simple in D-world.

I will be sharpening my swords for battle, just in case.

Please don't make me use this.

Flexible Spending

I think I have written before about the glories of the Flexible Spending Account.

I love having one. The Flexible Spending Account, or FSA, is not the same as a Health Savings Account, or HSA.

The FSA was first introduced in the 1970s, but being that I was under 12 at that time, I was not aware of it or its benefits. It seems to have increased in popularity lately, because health care costs have been increasing. Or maybe now that I know what it is, I hear a lot more about it. I remember hearing about FSAs for the first time during the Clinton administration on Good Morning America, but at the time my husband was a student, and I worked in a private school, neither of which offered any kind of benefit package.

Basically, an FSA is a benefit that employers can offer employees, along with 401(k)s, disability, and life insurance. You agree to have a preset amount removed from your paycheck, before taxes. This money is then set aside for pre-approved purposes, like health spending or dependent care. You could use this money for any health care items that are not covered by your insurance. Your deductibles, your prescriptions, chiropractor visits, and medical equipment could all be purchased with the money in your account. Since the account is pre-tax dollars, you will not pay taxes on the medical expenses paid out from your account.

What I like best, however, is that for those of us living somewhat close to the bone, when an unexpected expense comes up, you know that you can pay for it, because the money is already set aside.

There are two disadvantages, however.

One is that you must pay your expense out of your own pocket first, then be reimbursed by the company who manages your account. This can be tough when you are, for example, buying durable medical equipment like an insulin pump. Maybe you can't come up with the $1600 up front. In these situations, many people put the equipment on their credit card, then pay off the expense when their reimbursement check arrives. I have heard that some plans offer debit cards with a preset amount on them, but I have yet to meet anyone with one of those. I would LOVE one. It sure would be more convenient.

The second, which infuriates a lot of people, is that you must use all of the money that is set aside in your account by the end of the year. Actually, there is a two month grace period, as long as the EXPENSES occur during the year during which the funds are set aside. If you do no use all of your money, it goes away. In other words, it is forfeited back to your insurance company. Which makes sense, since we know how broke all of our insurance companies are, poor babies. I remember hearing on that Good Morning America episode about how it is important to set aside only the money you know that you will use. In other words, low-ball it.

My first real encounter with the FSA was quite by accident. My husband was working at a company that did offer the plan, but I didn't pay attention to it. Then one year, my husband's paycheck seemed suddenly much larger. When I looked at the previous year's pay stubs, I saw that we were having about $150 per pay period taken out for something I couldn't identify. When I called HR, they explained that we had signed up for the FSA, and that these deductions were going into our account.

Well, no we hadn't. The HR department at his employer made the Keystone Cops look like the Navy Seals. I am sure some incompetent boob put our money aside and left the next person in the alphabet alone, wondering why he had no FSA.

I know when not to pick a fight, however. Instead of railing against incompetence, I asked the nice lady on the phone if there was any way to get our money from last year back. The woman sighed loudly in anticipation of actual work. Then she explained, through what sounded like gritted teeth, that we couldn't, unless we could a) find receipts for $3600 worth of medical expenses that we paid AND b) that those expenses had occurred during the previous year. If, and ONLY if, we could do that, could we c) submit the expenses, using the proper forms, before March 1st.

$3600 is a great motivator. And besides, Older Brother had recently gotten braces. I needed only to ask the orthodontist to print out a receipt to get my money back. Which I did. So HA! In your face HR people!

After that, we began actively using FSAs whenever they were offered. Back then eyeglasses were covered (they are not now, thanks to the new health care legislation), so we set aside about $1000 per year.

The year M was diagnosed, we had set aside $3500 for braces. We were a little bummed when the orthodontist told us that she wouldn't be ready for braces for another 18 months. We thought we wouldn't be able to use up all of our money and would lose it.

But she was diagnosed. And we used it, and thousands of dollars beyond. Her second year of diagnosis, we set aside $4000. We used it easily. Now we are setting aside the limit that is allowed starting in 2013, $2500.

So paying for M's pump will be a little easier than it would be otherwise. Which means that she can have a pump sooner. And she can control her bg even better. And she can be healthier.

Which is why, even though it is not perfect, I love my FSA.

That's the name of the game!