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    Thursday, January 26, 2006

    Social Illness: Arnold Kling takes on the New York Times diabetes series, which blamed the insurance-medical-industrial complex for diabetes complications:

    Diabetes differs in many important respects from, say, a broken arm. First, the adverse impact on health from diabetes is long-term. Second, there are many potential complications. Both of these characteristics admittedly pose challenges for conventional health insurance.

    However, the biggest challenge for everyone involved in diabetes treatment is that patient skill is a major factor in treating the disease. Urbina's article brings this out. Diet and weight control are important. The appropriate level of medication depends on blood sugar levels, which must be tested frequently. A patient who is knowledgeable, well-organized, and possesses strong willpower can manage the disease far more effectively than a patient lacking those qualities. Much of the focus of the Beth Israel treatment center appeared to be on raising the skill levels of diabetics.

    The challenge in providing insurance to a diabetic population is taking patient skill levels into account. In theory, a health insurance company could offer skill-based health insurance premiums. Diabetics with the highest skill levels would pay low premiums. Diabetics with the lowest skill levels would pay high premiums. I do not know whether it is practical for health insurers to differentiate this way, or whether regulators would allow it.

    It seems that we want diabetics to increase their skill levels. Skill-based insurance premiums would get their attention. However, there are no doubt other obstacles.

    Poverty is one obvious factor in the low skill level of some diabetics. One would hope that Medicaid would work to alleviate this. However, Urbina's article points out that the Beth Israel Center lost money on Medicaid patients because of Medicaid reimbursement rules. To me, this suggests either that the government was not convinced of the value of Beth Israel's treatment system or that single-payer health insurance is not the panacea for disease management that liberals take it to be.

    I confess, I stopped reading the New York Times series at the first article when I realized its underlying premise was that poor diabetics are victims of a callous healthcare system. Kling is correct about skill level and motivation being critical in diabetes control. Let me give you brief run-down of the diabetics in my practice. First, the poorly controlled. Among them are a lawyer and a business executive who feel they are too important,too busy, or too smart (I haven't quite figured out which) to be bothered with going to diabetes education classes, to test their blood sugar with any sort of regularity, or to watch their diet and exercise. Even when they land in the hospital with complications, they fail to change their ways. Then, there are a handful of blue-collar, middle class people, some of who feel the same as the high-powered duo, but many of whom just won't accept the fact that they have diabetes. They won't check their blood sugar or go to diabetes education because to do so would be to admit they have a problem. Sometimes it takes awhile, but eventually they may come around. Then there are a couple of poverty stricken patients both of whom have ample medical coverage through Medicaid and who are eligible for free transportation to doctor's appointments. They are, alas, learning disabled and have trouble grasping the gravity of their disease and the importance of controlling it. (Those special ed kids from high school do eventually become adults, you know.)

    Now, let me introduce you to my well-controlled patients. They are business executives, lawyers, teachers, blue-collar factory workers, secrataries, housewives, mechanics, policemen and a couple of mentally disabled people who survive on disability. In the case of those who can care for themselves, they all share a strong obsessive-compulsive streak. These are the patients who keep a daily record of their blood sugar and bring it in at their appointments. They can tell me exactly what went wrong when they have a high reading - piece of birthday cake, an ice cream cone, didn't go to the gym that week - and they call me if their readings are high with no apparent good reason. They manage their disease more than I do. In the case of the mentally disabled patients on disability, they have caretakers who look out for them - managing their meals,helping them check their blood sugars, making sure they keep their doctor's appointments, and calling if a problem arises. In one case, it's a very committed social worker; in another, it's the supervisors at a group home. Personal committment makes a world of difference.

    The centers that the New York Times article mentions tried to instill that kind of obsessive-compulsive behavior in their clients. They were centers devoted to diabetes alone - with endocrinologists and ophthalmologists and nurses and nutritionists and podiatrists to watch out for their patients. By this description, it was a very intensive effort:

    Two hours a day, twice a week for five weeks, Ms. Hammond learned how to manage her disease. How the pancreas works to create insulin, a hormone needed to process sugar. Why it is important to leave four hours between meals so insulin can finish breaking down the sugar. She counted the grams of carbohydrates in a bag of Ruffles salt and vinegar potato chips, her favorite, and traded vegetarian recipes.

    After ignoring her condition for 20 years, Ms. Hammond, 63, began to ride a bicycle twice a week and mastered a special sauce, "more garlic than butter," that made asparagus palatable.

    She also learned how to decipher the reading on her A1c test, a periodic blood-sugar measurement that is a crucial yardstick of whether a person's diabetes is under control.

    "I was just happy to finally know what that number really meant," she said.

    ....... Instead of having rushed conversations with harried primary care physicians, patients would discuss their weights and habits for months with a team of diabetes educators, and have their conditions tracked by a panel of endocrinologists, ophthalmologists and podiatrists.

    "The entire country was watching," said Dr. Bernstein, director of the Beth Israel center, who was then president of the American Diabetes Association.

    By all apparent measures, the aggressive strategy worked. Five months into the program, more than 60 percent of the center's patients who were tested had their blood sugar under control. Close to half the patients who were measured had already lost weight. Competing hospitals directed patients to the program.

    "For the first time in my 23 years of diabetes work I felt like we had momentum," said Jane Seley, the center's nurse practitioner. "And it wasn't backwards momentum."

    Two hours a day, twice a week for five weeks. My patients go to one two hour class at one of the local hospitals and I dare say they come away with just as much knowledge. But the Times article says that primary care doctors like me drop the ball when it comes to diabetics:

    Too tall, many doctors say. When office visits typically last as little as eight minutes, doctors say there is no time to retool patients so they can adopt an entirely new approach to food and life.

    "Think of it this way," said Dr. Berger. "An average person spends less than .03 percent of their entire life meeting with a clinician. The rest of the time they're being bombarded with all the societal influences that make this disease so common."

    As a result, primary care doctors often have a fatalistic attitude about controlling the disease. They monitor patients less closely than specialists, studies show.

    And those high-priced specialists aren't much better:

    For those under specialty care, there is often little coordination of treatment, and patients end up Ping-Ponging between their appointments with little sense of their prognosis or of how to take control of their condition.

    As a primary care doctor I, of course, take exception to that characterization. It's true that I don't have the time to sit down and teach my patients about the minute details of a diabetic diet (I rely on the diabetic educator at the hospital to do that), but I do reinforce the importance of blood sugar monitoring, of the A1C level, of foot care, blood pressure control, and regular eye exams. I do that at every visit which can be from every 2-3 months for the poorly controlled to every six months for the well controlled. And from what I've seen of other doctors' charts that come into my office with new patients - the overwhelming majority of them do the same thing. Maybe one of the reasons those New York centers failed financially is that they were too focused on specialists. Perhaps the real problem is that there aren't enough primary care physicians, or even nurse practitioners, in the city to provide the kind of cheap, consistent care that diabetics need.

    Perhaps, instead of having classes for two hours a day, a 30 minute visit with a nurse practitioner at periodic intervals, depending on how well controlled the patient was, would suffice. If someone was well controlled and had no complications - labs all normal, exam normal, they could see her once every couple of months. If they were poorly controlled, more frequently with referral to a nutritionist for reinforcement of diet or whatever. And if physical complications were noted - then referral to the specialist. That would certainly be less expensive than spending all day with an educator - and the centers would get paid for it.

    This is the way diabetic care works in my community, except that most of the care rather than nurse practitioners. (I chose nurse practitioners because they seem to be a good fit with an affordable hospital center model for intensive outpatient management and follow-up.) The primary care doctors monitor patients for complications and refer them out when they arise. Diabetics see the podiatrist if they have trouble clipping their own nails or they develop callouses or foot deformities that put them at risk for future ulcers. Diabetics with ulcers get referred to the wound center. I have never had a problem with insurance companies refusing to pay for preventive care from an ophthalmologist or podiatrist for a diabetic. They even pay to have the podiatrist clip their nails.

    But then, my patients are covered by Ohio Medicaid, not New York Medicaid:

    ...Ms. Slavin said the center often scheduled patients for multiple visits with doctors and educators on the same day because it needed to take advantage of the limited time it had with its patients. But every time a Medicaid patient went to a diabetes education class, and then saw a specialist, the center lost money, she said. Medicaid, the government insurance program for the poor, will pay for only one service a day under its rules.

    The center also lost money, its former staff members said, every time a nurse called a patient at home to check on his diet or contacted a physician to relate a patient's progress. Both calls are considered essential to getting people to change their habits. But medical professionals, unlike lawyers and accountants, cannot bill for phone time, so more money was lost.

    And the insurance reimbursement for an hourlong diabetes class did not come close to covering the cost. Most insurers paid less than $25 for a class, said Denise Rivera, the secretary for the center.

    "That wasn't even enough to pay for what it cost to have me to do the paperwork to get the reimbursement," she said.

    Having once practiced in New York, I can attest that the Medicaid reimbursement there is lower than it is in Ohio. However, the same constraints mentioned above apply to all insurers - they don't pay for multiple visits to multiple providers on the same day for the same problem. That's why the nurse practioner/primary care model would be a better one for these centers.

    And finally, there's this priceless quote from a patient who found it frustrating that his insurance company put limits on the number of glucose monitor test strips they would cover each month:

    "I was a businessman for more than 40 years," said Mr. Schonfeld, a former food importer. "What I just don't understand is how these insurance companies can operate the way they do and keep their customers."

    That's easy. The patient isn't their customer. The patient's employer is.

    posted by Sydney on 1/26/2006 08:05:00 AM 3 comments


    I worked for the Indian Health service before my retirement...
    Native Americans have the highest rate of Diabetes of any ethnic group...and their care is free...
    We got community health workers to help people control their diabetes and help with diet, and a nurse educator...and as you observed, some did well, others did lousy...and it was not related to education or poverty.
    But if you want to blame "poverty" then maybe the answer is not a fancy hospital program at the big university (which is scary to many people), but locally known nurses working in the local institutions...

    You don't need the IHS and a closed population to do such things...
    Many churches have blood sugar and BP screening and classes.....most of these people probably went to other docs, but public health funds could be used to supplement education...and in Black culture, the church is more trusted than a sometimes hostile big white hospital...

    By Blogger boinky, at 5:50 PM  

    I'm Native American & a IHS vet also. Just want to point out a great number of Natives like me can't get free care, as they live outside of tribal catchment areas.

    By Anonymous Anonymous, at 6:10 PM  

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