Monday, September 17, 2007

Pennsylvania's new chronic care group to focus on diabetes first

Back in April, I wrote about how Pennsylvania Governor (who was the mayor of Philly when I lived there) Ed Rendell planned to focus on caring for chronic diseases, including diabetes, as a cornerstone of his "Prescription for Pennsylvania" healthcare reform plan. When the governor announced the chronic care commission earlier this year, he reported about 78% of health care costs can be traced to about 20% of patients with chronic diseases.

This morning's Pittsburgh Post-Gazette has a story with more details on how the plan will impact diabetes care. A commission is expected to focus first on diabetes, then move on to other chronic conditions including depression, asthma and heart disease. As the paper notes, many experts have expressed concerns that the current U.S. health care system, which focuses almost exclusively on acute care, is not optimally organized to care for people with chronic diseases like diabetes. Payment systems, for example, generally do not provide incentives for health professionals to spend time with patients to help them manage their chronic conditions.

"We cannot reduce the occurrence and cost of chronic diseases without aggressively addressing prevention, detection and treatment in a comprehensive, pro-active way," he said. "Setting that up will be the job of this commission."

The commission is expected to deliver a plan by Dec. 31 recommending changes needed to implement a model for improving chronic care statewide. If the governor approves the plan, some changes could begin to be implemented next year. The 43-member panel includes officials from leading healthcare insurers, hospitals, unions and other groups, as well as six ex officio members who lead various Pennsylvania state agencies.

While prevention of those forms of diabetes that can actually be prevented is certainly an element that deserves attention, the reality is that type 1 diabetes (an autoimmune disease) cannot be prevented, yet many foolish public health approaches assume that everyone with diabetes has type 2, is obese and also suffers from co-morbidities including hypertension, and that simply taking a few extra steps each day will work wonders for everyone suffering from diabetes.

For example, New York City's plan makes these over-simplified assumptions, and has effectively alienated a potentially powerful ally in their effort, namely patients with type 1 and/or their caregivers (notably parents of children with type 1). For example, in their communications to all patients whose hemoglobin A1C is greater than 9 (including children with type 1 diabetes) talks almost exclusively about weight-loss and blood pressure control, in spite of no evidence that either is an issue in children with type 1 diabetes.

As a New York Times article from last year revealed that in 2006, California officials learned the hard way what parents of children who have type 1 think about such campaigns. The Times article explained:

To address the epidemic of obesity, the state ran a series of hard-hitting television advertisements that ridiculed junk food and showed sweet-faced preschoolers asking questions like "Can I have some fat?" or "Dad, can you buy me some diabetes?"

The advertisements were aimed at parents of children in danger of developing Type 2. But there was little response from that audience. Instead, parents of children with Type 1 barraged the state with e-mail messages and phone calls, furious that the ads had referred to diabetes without mentioning Type 2. The ads lumped all diabetics together, the parents said, implying that Type 1 diabetics were somehow to blame for their disease.

"We never anticipated this intensity of feeling about making the distinction," said Kris Perry, executive director of the state agency that produced the ads. "The responses were very emotional, coming from a place of people feeling really hurt."

Its still very early, and the Pennsylvania Commission has yet to formalize their plans. The good news is that Governor Rendell has stated very clearly that while prevention is important, it is only 1 piece of the puzzle, but that more needs to be done in order to manage care for patients who have the condition. Let's hope Pennsylvania learns from the mistakes California made in 2006. In the case of New York City's plan, its ironic that no status report has yet been issued on their plan, in spite of implementation over 1 year ago. The New York City Department of Health and Mental Hygiene stated publicly that their goal was to reducing hemoglobin A1C levels among already-diagnosed patients by 20%, but since no updates have been published, its seems fair to conclude that those lofty ambitions have not yet been met.


Anonymous said...

When I visit my endocrinologist every three months, my “examination” always begins with a BP reading, and a bG test. Generally, before I actually go into the office, I perform a test myself, and have a very good estimate of my bG level. (Of course, when my wait time extends for 45 minutes or more, I am sure that the bG level as determined in the office is different from what I read before entering the office.) Nevertheless, the test is performed—ALWAYS—and my insurance company is billed $23 for this test (of which, of course, I pay a portion with my co-pay). I once challenged the P.A., telling her I had just done a test before coming in, and felt no need for another. She told me (1) I could use HER number to validate the accuracy of my meter (a specious ‘reason’ when you consider that ALL meters have such a varying +/- error margin), and (2) the office depended on the income generated by performing this test “to keep the lights on.”

Since a bG reading only gives us a measurement at a particular moment in time, and only rarely does the doctor use this “moment in time” measurement to TREAT us, I question the cumulative expense (and profit) generated by this single, simple test. Suppose that I (and the office staff) determined my bG was 190 . . . my doctor certainly isn’t going to whip out a syringe and give me an injection of insulin. He MAY use that number to harangue, intimidate, belittle me . . . but in essence, it merely provides an introductory “talking point” if it is used at all.

Consider that I paid $1 for the strip to test my bG immediately before entering; the office staff paid $1 (more or less) to perform the identical MEANINGLESS test; and the insurance company reimbursed $18.40 (to help keep the lights on!?!?!?!) Do you see what kind of services could be paid for with the dollars currently, cumulatively spent to perform this test.

I think this is another case of doctor-insurance-system fraud . . . and we all whip out our wallet or our insurance card, and pay and pay and pay. Why does diabetes cost so much? Can you extrapolate this, considering all the Medicare/Medicaid patients who “get the test done” and yet the results of this “moment in time” reading does not result in immediate treatment intervention, and only rarely in change of overall treatment protocols?


Unknown said...

It should be interesting to see what happens in PA, especially since I will be moving there in less than a month now (gulp!). Any word on who might be on this committee? I'd love to write them all a letter, reminding them that yes, there are 2 kinds of diabetes, and they should avoid New York's mistakes.

BetterCell said...

It would be so much less confusing and so much correct to just have the Nomenclature changed from Diabetes(Type 2) to Insulin Resistant Disease.

Is it any wonder why it is so difficult to find Physicians(even in NYC) that:
1. Want to
2. Know how to
3. Have the Intelligence to