Playing Hardball

Playing Hardball

Look at this post we found on Facebook;

“I am not sure what to think anymore. I have been awaiting the 670G through priority access since September. I was informed by my minimed rep today that within the last week Anthem has declared the 670G experimental and will not pay for any supplies, including reservoirs, infusion sets, or sensors. She states this is across the country and not just in Virginia. All Anthem orders are on hold until this gets worked out.”

Now first we won’t post this person’s name even though it is disclosed on Facebook. To be honest we aren’t quite sure what the protocol is when it comes to using a Facebook post so we have decided to err on the side of caution and keep this person’s name private. The name isn’t really that important but the statement is very important as it shows the games being played between payers and Medtronic (NYSE: MDT).

Here is a portion of the Anthem decision;

“Medically Necessary:

Use of an open-loop automated insulin delivery device with a low glucose suspend feature is considered medically necessary for individuals who meet the following criteria:

  1. Age 7 or older; and
  2. Type 1 diabetes mellitus; and
  3. HbA1c value of 5.8% to 10%.

Replacement of an open-loop automated insulin delivery device with a low glucose suspend feature is considered medically necessary when the medically necessary criteria above have previously been met and all of the criteria below have been met:

  1. The device is out of warranty, and
  2. The device is malfunctioning, and
  3. The device cannot be refurbished. 

Not Medically Necessary: 

Replacement of an open-loop automated insulin delivery device with a low glucose suspend feature is considered not medically necessary when the criteria above have not been met. 

Investigational and Not Medically Necessary: 

Use of an automated insulin delivery device with a low glucose suspend feature is considered investigational and not medically necessary for individuals who have not met the criteria above.

Use of other types of automated insulin delivery devices (for example, control-to-range, control-to-target, closed-loop, or hybrid closed-loop devices) is considered investigational and not medically necessary under all circumstances.”

The full position can be found at https://www.anthem.com/medicalpolicies/policies/mp_pw_c193646.htm

Now we know everyone is going to hate when we say this but this decision was made to save Anthem money, this is all about money. To be clear we have no idea what the deal is between Medtronic and Anthem but we suspect Anthem wants a lower price and Medtronic has said no. Therefore, Anthem needed to find a way to bring Medtronic back to the negotiating table and hence this “medical” decision.

Listen how any insurer can call an FDA approved device investigational is beyond us. This is even wackier when one looks at the amount of data available on the 670G. As we have said before the 670G may not be an artificial pancreas but it is an advancement in insulin pump technology. What it isn’t is investigational and we don’t care how Anthem justifies their position. The fact is Anthem couldn’t come out and state the system is too expensive and they want a better deal from Medtronic.

Anthem is aware that Medtronic has made deals in the past and they knew they only way they could extort, excuse us, negotiate better terms was to do something like this. Simply put Anthem is playing hardball with Medtronic and is swinging a heavy bat.

So, while these games get played who gets hurt? The patient as per usual. It’s not like patients can change from Anthem and there is no other system like the 670G. They could we suppose pay out of pocket for the 670G, not exactly an alluring option. Or they could go through the additional burden of proving to Anthem that the 670G is medically necessary. An option which is not just time consuming but also quite frankly an insult to the patient.

This is not the first, nor will it be the last time a patient gets screwed because a payer wants a better deal which to us is just sad. These patients have enough to deal with already and fighting with their insurance provider just adds to this burden. Enough with games already.