Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
Glucose Monitors Can Benefit All Types
I disagree with the negative tone of a recent KHN article about whether continuous glucose monitoring (CGM) helps non-insulin-using people with Type 2 diabetes (Type 2s) (“‘Painless’ Glucose Monitors Pushed Despite Little Evidence They Help Most Diabetes Patients,” March 16).
As a board-certified endocrinologist, I have seen firsthand significant benefits of CGM for people with diabetes, including Type 2s not using insulin. This technology provides useful real-time information about the effects of various foods and activities on glucose levels. CGM also shows how to avoid dangerous hypoglycemia, which can be a side effect of sulfonylurea drugs, frequently prescribed for non-insulin-using Type 2s. Much international research in this population, not mentioned in the article, shows benefits of CGM, including improved A1C levels and decreased hospitalizations and emergency room visits.
While no tool is right for everyone, Type 2s who want to learn about what affects their glucose levels and are willing to use information to change their behavior will often benefit significantly from CGM.
— Dr. David Klonoff, University of California-San Francisco
— Dr. Christopher Chen, Miami
Medicare and most other health insurers will be happy to learn about “multiple finger sticks, which cost less than $1 per day …” Not even close to being true!
As a 75-year-old with Type 1 diabetes (for 14 years, the last three using CGM), I would agree with your basic premise but for the convenience. CGM is another step closer to the artificial pancreas that will hopefully save costs and lives.
My CGM system does not alert (sleeping or awake) for low blood sugar. It has also left my A1C unchanged (but it was already acceptably low). The monthly cost of CGM vs. an average of eight finger sticks a day, necessary for my severely reactive Type 1, is comparatively low.
It would be far better for reporters and diabetes patients if diabetes weren’t the endlessly complicated disease that it is.
— Phil Murray, Elk River, Minnesota
— Dr. Aaron Neinstein, San Francisco
You put something in your story about CGMs that is misleading. While a Dexcom CGM does not test a specific A1C, it does keep records that are shared with your endocrinologist that outline an average A1C, which for me has been off by 0.5 points, higher or lower. I am a Type 1 diabetic; but I can tell you that Type 2 diabetics can benefit from this if they watch and respond to the numbers they’re getting. They can have a clear glimpse into all that causes their glucose to rise and fall: Stress releases a hormone called cortisol that raises glucose, while anxiety burns energy and can drop it rapidly. Even coffee with no cream and sugar raises glucose.
My A1C before my CGM was always in the high 6s. My last one and the one before that? 5.6 and 5.7, which is basically a normal A1C. The CGM isn’t doing this for me … but because of the CGM, I am able to outline what exactly causes my glucose to rise and fall and how to respond to it.
Checking glucose three times a day is not an effective way to manage diabetes at all. It is far more expensive to follow sugars the way that they’ve traditionally been followed. We need to equip diabetics with better tools to monitor where their numbers are going so that they can become empowered to manage this disease effectively.
— Rhonda Ronsman, Milwaukee, Wisconsin
— Dr. MeiLan Han, Ann Arbor, Michigan
A Short Course on Treating Long Covid
Here’s some advice for those who treat people with lingering problems caused by the coronavirus (“Children’s Hospitals Grapple With Young Covid ‘Long Haulers,’” March 3). Primary care physicians and pediatricians seeing patients with symptoms subsequent to covid-19 infections, generically called “long haul” covid, should attempt to distinguish between those symptoms that are the same as those of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and those that are unique to Long Covid. For those similar to ME/CFS, the health care provider should avail themselves of the symptom management developed for ME/CFS, at least as a first approach. Symptoms lasting beyond six months of the acute infection may satisfy the criteria of ME/CFS and that diagnosis should be considered. Adult and pediatric ME/CFS primers are available both online and in hard copy for both health care provider and patient.
— Dr. Kenneth Friedman, Plantation, Florida
— Myra Batchelder, Brooklyn, New York
A Revealing Narrative
Thank you for bringing Paloma Marin-Nevarez’s story to us on Reveal (“‘Into the Covid ICU’: A New Doctor Bears Witness to the Isolation, Inequities of Pandemic,” March 1). I was most struck by her insightful response to your question regarding what she thinks about health care workers being regarded as heroes. I am a physician, too, and have never felt comfortable with this hero meme, but couldn’t put my finger on why. The idea that designating someone else a hero excuses the designator from doing something themselves, like wearing a mask or not eating in a restaurant, is spot-on. As Paloma said, “What the f*** are you doing?” It’s the same with our forced hero worship on those in the military. Sure, many in the military do remarkably heroic things in their line of work and risk their health, but so do miners and fishermen and oil rig workers and loggers. But what if we were more willing to sacrifice by not using as much fossil fuel or giving more of our money to international aid? Could that avert some of the necessary sacrifice of those in the military? It’s easier just to say they are heroes and move along with our lives. Thanks for making me think.
— Dr. Gerald Gollin, San Diego
— Brynn Bowman, New York City
Deciphering Billing Codes
Isn’t part of the issue the Medicare Advantage Plan and their coverage (“Her Doctor’s Office Moved One Floor Up. Her Bill Was 10 Times Higher,” March 26)? I find the code J10140 is for 80 milligrams of Depo-Medrol, which has an N status indicator on the Centers for Medicare & Medicaid’s Addendum B (meaning no separate payment and no copay). The CPT code for the injection is 20610, with a T status indicator, which shows a national copay of $52.25. When I do a lookup on the original Medicare site, it shows an average out-of-pocket payment of $61. So, if the patient was paying for a Medicare Part B plan under Medicare fee-for-service, the out-of-pocket would have been $61, not $354.68. People often think that Medicare Advantage plans are “free,” but the plan’s coverage is very different from original Medicare. The standard monthly premium for enrollees is $148.50, so there is a trade-off, but it should be noted that if the patient had Medicare FFS, the hospital would have received only $61 from the patient.
— Agatha Nolen, Ph.D., FASHP, CRCR (a Healthcare Financial Management Association certified revenue cycle representative), Nashville, Tennessee
— Mark Miller, Washington, D.C.
I’m a senior. Even with a Medicare Advantage or supplemental plan with zero premiums, copays are unaffordable. Medical clinics often lie about charges. I ask beforehand every time, and I get everything in writing. Insurance companies give incorrect advice or flat-out lie about coverages, and the surprise can be bankrupting. I have some serious health issues but will not seek medical treatment for any of them. My family and friends are all instructed to never ever take me to a hospital because, if I live through whatever (covid, heart attack, stroke), I would never be able to pay the bill. The medical system in the USA is insanely predatory on the elderly. I no longer wish to be the victim of predators and feel that I am in a better place, even if ill, by simply avoiding it. There is no such thing in this country as honest, affordable health care. People think “Medicare-for-All” is the answer but people are wrong, based on my experience with Medicare, including a scarcity of doctors willing to accept Medicare even with so-called “good” supplemental insurance. I am choosing zero-premium Advantage and, if by some remote chance I end up sick or injured and against my will am taken for treatment to some predatory medical facility, I will choose bankruptcy to eliminate the bill. A friend was recently diagnosed with cancer — she had “good” insurance. She chose to forgo treatment, ended up in hospice, and died — by choice — there was no way she could pay for everything.
— Rox Sitterley, Corvallis, Oregon
— Vic Vaughan, Fairfield, Connecticut
— Deborah Daly-Case, Fullerton, California
Cut Through the Surgery Confusion
Besides getting a blood oath of admission, why not provide some guidance as to what one should do to avoid bankruptcy (“Under New Cost-Cutting Medicare Rule, Same Surgery, Same Place, Different Bill,” March 23)?! Going to the local abattoir isn’t exactly a time for one to have presence of mind.
— Jack Shaw, Littleton, Colorado
— James Gerald Floyd, Orlando, Florida
Vaccine Hesitant? Consult History
This is an open letter to anyone who hesitates or chooses not to immunize themselves or their children. Teach the history of immunization. History — have you ever seen pictures of someone with smallpox? Look on the internet. Millions took the risk to be immunized, now smallpox has been eradicated in the world population. My great aunt and cousin had the opportunity to be immunized against diphtheria and were not — whatever the reason — and they both died of diphtheria, leaving a husband and small children.
Among my experiences as a student nurse was working at the pediatric hospital in Indianapolis in 1960 watching a 10-year-old with tetanus lying on his side with his body and head severely arched, a tube in his throat for breathing. Also at the hospital were large, metal, tube-like machines. Inside each machine was a child with Bulbar polio who could not breathe on their own. Their head stuck out one end of the machine, the rest of their body lay limp inside the tube, and nurses cared for them through “portholes.” They were in “iron lungs.” I also cared for children recovering from polio. I worked nights and would apply warm flannel “Kenny packs” to ease the pain in their arms and legs so they could sleep. These children were amazingly courageous.
When I had children of my own, how incredibly grateful I was that most parents had accepted the risk of an immunization for polio. Because of this, polio is almost eliminated in the United States. It causes me great emotional pain to hear of people refusing to take their part in preventing these and other illnesses.
— Donna Fellinger, Burlington, Vermont
— John Feal, Smithtown, New York
The War Behind Tax Dollars and Politics
Dr. Elisabeth Rosenthal’s article “How the US Invested in the War on Terrorism at the Cost of Public Health” (March 29) is balderdash. Criticizing the war on terror for the failure of the public health bureaucracy to protect the nation against covid is shameful and outrageous. And denouncing Donald Trump for it is like blaming Franklin Delano Roosevelt for Pearl Harbor. The progressive politics that inform the worldview of institutional health care have damaged (perhaps destroyed) the independence and reputation of medicine, and that’s something that can’t be quantified nor easily recovered.
— Stephen Power, Vacaville, California
— Jordan Reese, Philadelphia
Keeping the Fact Checkers Honest
Your “fact checking” is way too kind to the Trump administration (“Biden’s Criticism of Trump Team’s Vaccine Contracts Is a Stretch,” March 8). Yes, Operation Warp Speed did trigger the enormous expenditure of research dollars that produced three U.S.-backed vaccines in record time. However, the Trump administration devoted no resources to making them available to the American population in an organized fashion, and one could speculate that the entire project was designed primarily to inflate the value of the American Big Pharma companies tasked with developing the vaccines (I’m not disparaging the companies, just the Trump administration’s motives for stoking their financial fires). And, just to show that left-leaning politics can also be gilded with conspiracy theories, I’ll offer another. Early in the fall, many of us watched a “60 Minutes” episode during which we learned that our “glorious military” would be tasked with managing vaccine delivery. That certainly was not apparent once the vaccines became available and most “connected” Americans began obsessing over obtaining their own doses via their computers and mobile devices. When the history of the pandemic is written, I would not be surprised to learn that the Trump administration was mounting a shadow plan to deliver an entirely different type of resource throughout the country — soldiers to impose and enforce martial law once he lost the election he knew he would lose unless he could hijack it.
Anyone without a flat-line cerebral cortex could have seen that vaccinating 300 million-plus Americans in just a few months would be an information technology nightmare, actually made worse by the HIPAA limitations on health information data-sharing, but Trump’s administration “wasted” no time on that project, while replacing top-level administration staffers at the Pentagon with secretive sycophants. One wonders what they were hiding from the Joe Biden transition team in a totally unprecedented rejection of the safety of our democracy between Election Day and Inauguration Day.
— Dr. James Robertson, Hamilton, Montana
— Matt Deitchle, Indianapolis