Expert Shares Tips on How to Get an Insulin Pump for Type 2 Diabetes
Joy Cornthwaite, MS, RD, LD, CDCES, a Registered Dietician Manager with McGovern Medical School at UT Health Houston, joins Beyond Type 2 to discuss insulin pumps for people with Type 2 diabetes. In this discussion, we cover misconceptions about pump use to manage T2D, the benefits of using an insulin pump, insurance terms to know, and how to talk to your provider about obtaining one. This interview was condensed and edited for clarity. For the full discussion, watch the video below.
BT2: Can you briefly explain what an insulin pump does?
Joy: It’s a device that holds and continuously dispenses insulin and is placed on your body. Some devices are tubed and others are tubeless. You can program that pump to dose your insulin for you without doing multiple daily injections. The insulin pump can be worn for two to three days. You can also tell it how much insulin to give you at mealtime, as well as other features to help you get the right amount of insulin you need.
Why is an insulin pump would be beneficial for people with Type 2 diabetes? Would you mind kind of going into some of the misconceptions that people with Type 2 have about insulin pumps?
A lot of times, people living with Type 2 don’t they will have coverage for an insulin pump and assume it’s only for people with Type 1. It’s better to ask, instead, if they have a trusted care professional who can help them figure out how to obtain one. People with diabetes are super resourceful, so they’re willing to start doing the work themselves. You can just call your insurance and see if it’s covered as durable medical equipment (DME) or as a pharmacy benefit.
Can you explain the difference between the medical side which is durable medical equipment versus pharmacy benefits?
On your medical side, it’s your primary insurance card. So, the big insurance companies that you think about are the ones that would cover it on the medical side. There are different amounts and deductibles, what they cover, and you would use your insurance at a DME company. Think of this as a warehouse for diabetes supplies that has a contract with your insurance company to provide you with pumps or supplies for your health care at a discounted rate because they’re in-network together. So, if it’s on your medical side, you want to make sure that you know who the durable medical equipment provider is that would fulfill your order.
If it is on the pharmacy benefit side, then the insurers have a better relationship with the PBMs are third-party intermediaries who negotiate prices between pharmaceutical companies and insurance companies. Examples of PBMs are CVS Caremark, Cigna Express Scripts, and OptumRx.pharmacy benefits manager (PBM). So, they’ve managed to negotiate a certain rate to provide you the pump on the pharmacy benefits side. Some people may have different deductibles for their medical and different deductibles for their pharmacy, and some insurance plans have those two things combined. You want to ask these questions: Is this something that’s covered under my medical? Is it covered under my pharmacy? Do I have a separate medical deductible that has to be met and the separate benefits on the medical side? Or do I have separate benefits on my pharmacy side and what are those benefits?
What are the reactions your Type 2 patients have had to get on an insulin pump? Do they feel more confident making decisions surrounding food?
It starts with building trust and our care plan around all the things to protect and keep someone safe. So, it’s not usually the very first thing we talk about when someone comes in, especially if they’re a new patient, but it might be something we end up discussing. There’s a long continuum of what’s happening in a person’s diabetes journey. I may have a patient who comes in that says they’re considering an insulin pump, and my job is to help them explore the pros, cons, and which pump fits their personal goals. There’s a lot of consideration that goes into deciding the right time to go on an insulin pump.
After that, we have insurance verifiers and trained diabetes care and education team members who help people figure out the insurance part of obtaining a pump. We determine if [DME or pharmacy benefit] will cover the pump, what the payment is, and which is the better option. Then we focus on the education and how to shift from multiple daily injections (MDI) to pump therapy. A lot of the questions for someone with diabetes on MDI can be addressed with pump therapy. I get questions about needing to feed their insulin, meaning someone takes their insulin but doesn’t feel like eating. They eat anyway to avoid going low. With an insulin pump, you can adjust your basal rate, which gives you a steady dose of insulin throughout the day, or extend a bolus (mealtime insulin). That’s part of the beauty of transitioning someone from MDI to a pump.
Can you talk about what an extended bolus is and why it’s a great feature?
The extended Bolus insulin, also called mealtime insulin, is taken before meals and can be used to correct high blood glucose.bolus feature is one of my patients’ absolute favorites. Imagine that you are eating something that processes glucose very quickly. You’ve eaten a food item and it’s a little bit higher glycemic index or transitions from the food in your mouth to cause your blood glucose values to rise faster. Well, you can extend the bolus. You would tell the pump that you’re taking a certain amount of carbohydrates, and then you would ask it to dispense your insulin over time. So, if the peak of your glucose is going to happen quickly, you would ask it to dispense more insulin up front and the rest of it later. What the extended bolus is doing is matching the insulin to the peak of the food.
So, if you eat something that’s maybe a little bit more high fat, like a pizza, that’s going to delay your stomach emptying. Most people will see a rise in blood glucose after something high fat three or four hours after. But instead of injecting all your mealtime insulin at once, you can tell your pump “I’ve eaten this amount of carbs and I want just 10% of my insulin up front, and the remainder later on when my glucose levels would be higher.” Now, you’ve taken the peak of the insulin and moved it to match the food, which is going to cause your glucose to rise later.
I think the extended bolus gives people a sense of a lifting of the stigmas around diabetes, like not being able to eat this or that. With a pump, you can choose your activities, you can choose your meal planning, and you can help shift the insulin so that it matches with what’s happening in your body. It’s just nice to have that level of control over your own decisions. If you’re exercising and your glucose values rise related to the exercise (such as resistance training), you can extend a bolus or a temporary basal change, so you can adjust the amount of insulin that you need. You can also use your pump to customize Small, background doses of fast-acting insulin administered by the insulin pump. basal rates throughout the day. That can mean getting a higher steady dose of insulin in the morning but lower in the afternoon, or whatever fits your lifestyle.
What are some burdens of wearing an insulin pump you’ve heard and how have you eased those concerns?
We make sure they make the best decision after learning all the information. That includes allowing people with diabetes to decide which cons are worth living with and which fears to push through if it means getting the benefits of pump therapy. We look at all the benefits that someone wants from a pump, which pump will provide those benefits, and look at the other pumps and see which burdens are too much to handle. Some people may say they don’t want to be tubed because it reminds them of their condition and would cause stress. Some may want a pump that’s fully integrated with a continuous glucose monitor (CGM). It’s helpful for me to know that I’ve gained my patient’s trust and can answer their questions to fit their individual situation.
What questions can people with Type 2 ask their healthcare providers to get them to advocate on their behalf for an insulin pump?
Make sure that there’s an infrastructure at your clinic that can support you. Because of resource management or staffing in certain clinics, there may not be someone who understands how to download or interpret data from your insulin pump. Next, do research to see if your pump would be covered and how, or you can ask someone at your clinic to find out for you. Then, you’ll want to ask your provider if they’ll be able to help you with your pump. If not, ask if they know [a specialist] who can. Don’t take no for an answer; always ask yourself what the next step is. A lot of patients I’ve met have primary care providers who’ve directed them to someone who can help with their pump journey. Also, if you’re in a rural area and an endocrine specialist is far from you, you can do a remote visit to get started on pump therapy and the diabetes care and education that follows.
This content was made possible with support from Insulet, a Founding Partner of Beyond Type 2.