Tuesday, April 12, 2011

Realistic Limits of Glycemic Management?

There's a lot of talk these days within medical profession, and among healthcare providers, lawmakers and public policy wonks about chronic diseases and diabetes (mostly, they seem to talk $#!t about diabetes -- and much of what they say is either wrong or only partially correct, but the belief among some self-appointed diabetes advocacy organizations comprised exclusively of doctors or nurse educators) seems to be the old saying "there is no such thing as bad publicity except your own obituary".

To be sure, this conversation is not without reason: according to the U.S. Centers for Disease Control and Prevention (CDC), chronic disease now accounts for about 75% of the nation's aggregate health care spending -- or somewhere around $5,300 per person in the U.S. each year, and it's growing more expensive each year (see HERE for more). But "medicine" (a collective term I use to describe the medical profession, the drug/biotech industry and various other related professions and industries) has only actually CURED a handful diseases overall. Increasingly, the modus operandi (M.O.) for everything in medicine, whether it's cancer, AIDS, Lyme disease, or heart disease seems to be to transform once fatal-conditions into permanently chronic ailments. From a business perspective, this makes perfect sense.

But at the same time, the medical profession has managed to deflect much of the blame away from their own failures to patients instead, often with condescending comments to the effect that "his or her failure to adequately manage their condition(s) was responsible" with the very expensive (without much regard for cost) and too often, less-than-adequate tools which are overpriced to begin with. We are living in an age when so many people seem to have chronic ailments, and increasingly, more and more will have multiple chronic ailments, all of which will require multiple, ongoing treatments until they die. At least a few cash-strapped states are, in effect, hoping people with chronic ailments will die because their deaths would cost taxpayers less than keeping them alive (see HERE for an example). Supposedly, the U.S. is more advanced than other countries, yet when it comes to healthcare, U.S. taxpayers might receive better care with our dollars in Mexico than we would in the U.S. -- go figure that one out (if you don't believe me, visit PatientsBeyondBorders.com for more quantifiable details, and for more behind this trend, see HERE).

The basic arguement when it comes to public policy is that unless chronic disease spending is controlled, then there's simply no way to reign in runaway healthcare spending. That is a seemingly rational conclusion -- but vastly over-simplifies the situation to a short tagline, and the situation is far more complex than that. Indeed, organizations such as the Partnership to Fight Chronic Disease (PFCD), which calls itself a "coalition" committed to raising public awareness of the issues related to chronic diseases has made that a cornerstone of it's strategy.

However, truth be told, PFCD consists largely of business interests such as insurance companies that have a vested financial interest to be gained from reigning in spending on chronic disease care arguably has done little (if anything at all) to try and address the ballooning expense burden for those who already have one or more a chronic diseases. So much for the mission of raising public awareness to all issues related to chronic diseases. Yet in spite of it's legitimate-sounding name, the only money the organization is interested in saving belongs to it's members.

Not surprisingly, diabetes is one of the 5 chronic diseases (the others are heart disease, cancer, stroke, and chronic obstructive pulmonary disease) that fall into the organization's dialogue, even though heart disease and stroke are every bit as preventable as many cases of type 2 diabetes are, yet those speaking about diabetes seem to give diabetes its own special category because it's widely portrayed by the mainstream media as more of a character flaw than a "legitimate" disease. Shame on them!!

While it's true that chronic diseases contribute to contribute a disproportionate share of healthcare spending, what PFCD fails to acknowledge is that historically, no society has ever been able to PREVENT its way out of an epidemic already underway! At best, we can try to contain the losses and take corrective steps to prevent it from happening again in the future, but that requires action -- something the organization has been remarkably short on. So far, their efforts seem to have done more to fight patients with chronic disease, rather than address the root cause behind the problem. On the prevention score, perhaps their efforts on this front can prevent another epidemic from occurring, but as for the diabetes epidemic already underway, they seem blissfully igorant of the fact that treating diabetes itself is nowhere near as expensive as paying for the health complications of uncontrolled blood sugars, and that our healthcare "system" (a term I use very loosely) does a remarkably poor job of coordinating care for people who already have diabetes, and statistics back me up on this.

A November 17, 2008 editorial in The New York Times summarized it all in less than a sentence: the U.S. is "The Wrong Place to Be Chronically Ill" which cited a study I also mentioned a previous posting a while back. According to at least one international comparison, the U.S. ranks well below virtually every other developed nation on it's care for chronic diseases, hardly something the U.S. can brag about when trying to call itself a "world-class" healthcare system.

It's sad and ironic that insurance companies will readily pay for surgery for, say, amputations necessitated by unmanaged blood glucose levels -- often without as much as a preauthorization requirement, or even a co-payment -- yet will place numerous, challenging restrictions on patients trying to get coverage for their basic treatment needs -- all done in an effort to save the insurance companies money. For example, testing supplies often are limited, and/or restrictions are placed what will be covered, and payments with high co-payments and supplier restrictions and/or brand requirements, resulting in patients having to jump through hoops to get such basic tenets of self-care even covered. Consequently, many patients simply give up rather than deal with numerous appeals for coverage they are often rightfully entitled to. Unfortunately, U.S. Healthcare "reform" does not seem to be reforming any of those not-so-little cost issues, but we should acknowledge that it IS a work in progress, and refinements will no doubt be required over time anyway.

Fact: Private Insurance Has Little (If Any) Genuine Financial Incentive to Ensure Good Long-Term Patient Outcomes

While some might be shocked to read this, part of the challenge is that long-term health outcomes are really a non-issue for the average healthcare insurance company. As a result, it makes more financial sense to place such limits on a costly component of routine self-care becuase it impacts the bottom line immediately.

Why are long-term outcomes a non-issue for heath insurance companies?

Because, as their actuaries will tell you, odds are, the average person will switch carriers 5 or more times before they're ultimately covered by Medicare, at which point, they effectively become healthcare wards of the State with government-funded healthcare. (Some in Congress want to gut that, too). As an insurance company, their job is to keep the person healthy enough to avoid any costly catastrophic expenses, all while limiting the expenses incurred to do that. Anyone who believes the insurance industry has a vested financial interest in keeping people with diabetes healthy is likely suffering from a condition known as wishful thinking -- it just isn't so!

Odds Are Great Complications Won't Set In Until Patients Are Covered By Someone Else, or Even Better ... Medicare!

As a result of this peculiar system, there is every incentive to minimize the line items on expenses for these basic care/supplies, because odds are pretty small that this person will be with this same insurance company for life. Any complications will likely be incurred by someone else (such as Medicare). People regularly change jobs, they move, their companies switch healthcare providers, etc. Its more about managing the odds that those big expenses for treating complications will occur under their coverage, and that's a risk that insurance companies can manage. Of course, increasing industry consolidation increases those odds, which is one reason costs have continued to outpace the rate of inflation, but flipside of that equation, meaning the benefit of maximizing the risk pool with a larger base of customers, is as you might expect, not exactly shared with patients.

Public Misinformation About Diabetes Adds to the Challenges To Effectively Address the Problem

The mainstream media have played a huge role in helping to make things this way, and the Oprah Winfrey Show debacle in 2010 (see Sheri Colberg's well-written commentary from a medical perspective at Diabetes in Control on that, or Riva Greenberg's eloquant commentary on the Huffington Post from a patient perspective HERE for more on that) did very little to clear things up, and probably added to the existing misconceptions, making them harder to resolve. Instead, the "Big O" tried to do what 75+ years of the same scare tactics have completely FAILED to do: translate treatment recommendations into actionable recommendations that can be widely-utilized by patients, and in the process, she also continued to perpetuate misinformation in the process.

In many respects, type 1 diabetes is unique among diseases in that it was really the first disease transformed from a fatal disease into the world's first chronic disease. But while insulin, hailed in 1921 as a "cure" for the disease, was later redefined as only a partial victory against the disease (it falls short of restoring patients to the health they had before the disease struck, and too often ends up with so-called disease complications many years later). While patients can and do live long reasonably healthy lives with the disease, fixation on glycemic control is seen by critics as a misplaced priority that has many practical limitations that the medical profession does not seem to want to recognize. In fact, the medical profession didn't even agree on the merits of glycemic control until the DCCT concluded in the late 1980's, followed several years later by the UK Perspective study on type 2 diabetes. But with those two studies, most of the medical profession shifted its focus and efforts away from disease eradication to glycemic control, and the manner that healthcare delivers care in a HMO/PPO dominated landscape has only recently been looked at, and the news so far so isn't so pretty.

Funding Disease Management at the Expense of Disease Prevention

Glycemic control, along with improvements in treatment (not only for the symptoms of diabetes itself, but also treatments for a number of different complications) has helped to solidify the public fixation on glycemic control. But that same fixation on glycemic control has simultaneously occurred at the expense of preventative measures that might have helped prevent (or at least help minimize) the diabetes landslide that now faces not only the U.S., but most of the world (including such places previously better known for starvation as India and China).

That disconnect needs to be reconciled, and I hate to say it, but we're really a day late and a dollar short for that. Those investments should have been made decades ago, but they weren't, and while they need to be made now to prevent many future cases, it's really too late to prevent our way out of the epidemic already underway. We now have to reap what those lack of investments decades ago have sowed. That's where there's a really big disconnect.

To be sure, glycemic control has reduced (and will continue to save) billions in medical expenditures, but glycemic control comes at a price, too -- its definitely not free as many naïvely seem to believe -- and cost-sharing has been disproportionately been placed on the patients, rather than the healthcare providers, although as I reported (see HERE for more), at least one provider (United Healthcare) seems to be rethinking that strategy, albiet with only with a handful of it's biggest clients, right now. But their findings could pave the way for some real, necessary changes if they turn out positive. And in the U.S., our healthcare "system" (a term I use very loosely) was really built to treat acute illnesses, not chronic illnesses -- which incidentally, are growing very rapidly, as medicine has transformed many once-fatal ailments such as cancer and HIV into chronic diseases without actually curing them.

Limitations of Glycemic Control Seldom Acknowledged

Consider one of my all-time favorite posts, by Scott K. Johnson entitled "14 Chips?" (see HERE for the practical implications). Over the last 24 years, I have met with many nutritionists who boldly claim it can be done, yet relatively few have themselves lived with their own recommendations, which is a problem -- but I've also had several who had type 1 themselves and they admitted their recommendations are far from scientific. Those who do seem to acknowledge that much of the recommendations are just that, but face practical challenges that really don't work well in our busy, increasingly mobile society. In the days when every meal was eaten at home, it was somewhat easier to deal with, although in an effort to address the nation's obesity epidemic (which, BTW, is a different challenge from it's diabetes epidemic, as many obese individuals do not have any form of diabetes, and the two often do not go hand-in-hand, in fact, obesity is now seen as the body's innate protection from a nutrient-dense diet without corresponding energy expenditure), disclosure for nutrition facts, and regulators walk a tightrope in trying to weigh how to properly disclose those facts with how they are delivered, while not suggesting that Americans consume MORE calories. This year, the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) jointly issued and updated Dietary Guidelines for Americans (DGA), which are updated every 5 years. Theis year, those guidelines provided advice about consuming fewer calories, making informed food choices, and being physically active to attain and maintain a healthy weight, reduce risk of chronic disease, and promote overall health -- for the first time EVER.

But many believe the recommendations have continually been weakened by the food processing industries. In fact, in February, I REPORTED that a doctors group sued the USDA for conflicts-of-interest over the new DGA. Although it was a somewhat radical group (doctors seeking to promote a vegan diet) who filed the suit, most other doctors pretty much disregard the new U.S. DGA altogether, in spite of the guidelines' major influence on everything from school lunches to the kinds of foods carried by large U.S. supermarket chains.

Practical Challenges to Glycemic Management

We need a more realistic examination on the limitations of glycemic control (I prefer the term "management" because patients only control a few of the many variables that can influence blood glucose levels), especially in the context of how healthcare is actually delivered in our society. If and when that is done, the conclusion might be that many patients are likely doing what can be done with, and so far glycemic control, but those limitations, if they haven't already, could reach a point of no further improvement, and it's not as far as the over-optimistic proponents seem to believe. The treatment protocol is demanding and relentless, and success and the rewards for this effort can't even be guaranteed. You may improve your odds, but counting carbs, errrrr, counting carDs, is not allowed at the casino of real-life!

Conclusion: We Need to Reprioritize Our Collective Diabetes Agenda Because "More Talking" About It Just Isn't Working

I promised to keep this editorial positive, and I think the conclusion is remarkably obvious. Rather than piss away another $200 bajillion bucks on another stupid study proving the benefits of glycemic control, and then giving it a cutesy name like ADVANCE, my advice to these researchers is to try leaving your home-schooled social environment and observing how life with this disease really plays out in real life.

Patients with chronic diseases are nickel-and-dimed for everyday expenses, while catastrophic expenses are paid without question, precertifications or any hassles whatsoever. This is reality, yet the U.S. medical profession has been sooooo slow to acknowledge this reality. At least one big U.S. company (in this case GE) is testing a new tactic: reducing or even eliminating co-pays for people with diabetes with the idea that by removing some of the many self-care barriers, they might actually reduce healthcare expenditures in the short-term (see HERE for more). Instead of doing yet another study on how to incrementally improve glycemic control by a few basis points, try instead to remove practical barriers to achiving this lofty goal. Get rid of excessive paperwork, approvals, precertifications, co-pays, etc. that stand as obstacles in chronic care delivery, and we might discover a shockingly simple truth: the easier we make it for patients with chronic conditions to care for themselves properly (within reason), the better the results will be and the lower costs will be for the healthcare system.

Just don't expect a payoff on it immediately!


Pearlsa said...


This post is very insightful. I especially am getting tired with the headlines that seem to pop up every so often “Diabetes to cost tax payer billions” or “Diabetes to bankrupt Medicare”

Steve said...

This is great information, Scott. As we are still relatively new to treating diabetes (daughter, 9, dx'd 12/09), we struggle daily with not only trying to keep her within a target range (with very little help of a dietician, i.e. none), but in fear of the possibilities that exists that by not keeping her in range we may be causing her body more problems as she gets older. It is the worse predicament for any parent, not knowing how our actions today will affect her well-being tomorrow.

Both my wife and I are shocked by the varying studies, writings, and messaging we come across that contradicts one another. Often, it seems, we are left to figure out what works best for her on our own, despite what appears to be a wealth of knowledge out there. It is a shame that things have to get bad before any one of those brains will take notice.

Thank you for your insightful and in depth reporting.

Unknown said...

In response to Steve's comment: The vest you can do is get up in the morning and start each day a new. Especially with a preteen - once the hormones start chugging away the control will become more unpredictable - regardless how hard you try. ON e suggestion is to send her to your local diabetes summer camp. Invaluable information for her and you and your wife. Not only will you get a new set of support you will see that you are not alone in your struggle. Bottom line - keep the hypos to a minimum, manage the hypers best you can and let your daughter be a kid - she only has one chance at it.
Registered Nurse, Type 1 x30+year
Former CDE, Camper and Camp Nurse at Camp Glyndon (ADA).