Posts Tagged diabetes
June 3rd 2015 Kaiser Health News reported the ACA seemed to cause more provider visits for management of diabetes “More Patients, Not Fewer, Turn To Health Clinics After Obamacare”. This is both good and bad.
The “good”: more attention to a patient’s condition is likely to result in better diabetic management, fewer complications, fewer hospitalizations and longer life.
The “bad”: since clinic visits can be billed to insurance, clinics make appointments and make money for each visit. The payment for visits rather than outcome is expensive and a known problem in US healthcare (fee for service). Diabetes can be managed over the phone in many, if not most cases — but there is no money for the provider in that approach. Phone care has a much higher value for the healthcare system and the patient; but, low-cost high-quality (high value) care is not getting the incentive.
The care of diabetics is further compromised by the pharmacy. A key piece of equipment for a diabetic is a glucose meter. The manufacturer almost gives away the meter so they can make huge profits by selling the disposable test sticks. The sticks are not interchangeable, not generic, sold in small lots, each lot sold with a co-pay, each lot requiring a visit to the pharmacy, and the use of gasoline to make the trip. If you don’t have much money the speed-bump turns into a mountain.
The solution: every few years mandate a generic test stick that manufacturers of glucose meters must support. “Uncouple” the meter maker form the test stick maker. And, sell the sticks in lots that last for at least 90 days, and that are sent to the patient by mail. Adjust the payment to providers so that they must contact diabetics by phone to adjust medications at least 2 times per month in order to bill for a medium or high level clinic visit. Also, each provider must obtain patient satisfaction data to prove the adequacy of service.
Addendum: Here is a link to an interesting court case about glucose meters
Too much treatment is dangerous just like too little treatment. Treating blood pressure too early or too aggressively increases the risk of death. Treating elderly patients with diabetes with too much medicine increases episodes of low blood sugar that damage the brain and leads to broken bones from falling.
In 2014 the national guidelines for blood pressure treatment were changed to allow a higher blood pressure. Similarly, a recent study found increased mortality for elderly patients treated too strongly for diabetes.
This is not rocket science. Imagine a blood pressure medication that could lower the blood pressure to any level. Knowing that zero blood pressure means you are dead, it stands to reason there is a point where treating blood pressure goes from helpful to dangerous. Same for blood sugar.
Sometimes this problem is called “treating the test“. In essence prescribers just look at the numbers and write a prescription, but ignore symptoms of weakness or spells of altered consciousness. Hypertension and diabetes are good examples but this happens with lots of other conditions.
Examples of over-treatment include treating a sore throat with antibiotics, treating mild asthma with oral steroids, or treating an elevated lyme serology test with antibiotics. It takes time to make a correct diagnosis and time to explain treatment to patients — some health care providers simply don’t take the time to do either.
Most drugs have a “therapeutic window“. As long as the window is open the patient gets benefit. But, the window closes due to side effects and advanced age.
If a person is over 80 or in poor health excessive medical treatment is a substantial risk. In this group even the thought of a low cholesterol diet is foolhardy. It’s all about risks and benefits.
Doctors have long complained they don’t get paid to solve problems over the phone. Now primary care providers (not specialists) can charge $40 per month for something called “Chronic Care Management.” (CCM)
If you have several long term and serious conditions like diabetes, congestive heart failure and chronic obstructive pulmonary disease then Medicare will pay $32 per month and you or your supplemental insurance will pay the rest for this service. Many supplemental insurance plans have deductibles and co-payments — so many, if not most patients will be paying an extra $8 per month.
Who actually does all the work? The office nurse. The doctor supervises the decision making.
You will have to sign a consent for CCM in order for the doctor to bill you each month, so it is important to know what to expect. Some doctor’s offices will make the service helpful but in other offices you may never know where the money is going.
If you can’t tell you are getting CCM then simply stop the service — revoke the consent with a letter “Dear Doctor, effective at the end of this month please stop “Chronic Care Management”. I will continue visits as usual.”
In general, CCM is a good thing. Here are some of the problems it solves: Without CCM many doctors just don’t take the time to coordinate services except as part of an office visit — if you go to the emergency room the primary care provider would not act on recommendations until you actually go for an office visit. If your visiting nurse suggests some course of action then you go for an office visit. If you want to see a specialist you first go for an office visit. If you get discharged from the hospital and need physical therapy you go for an office visit before it will be ordered. With CCM the doctor gets $40 per month to coordinate care without always going for a face-to-face visit.
The minimum requirement for the provider is to spend at least 20 minutes per month working on your case without seeing you in person. Here is a list of things providers of CCM are required to do (at no extra charge) and thus things you should expect:
- Transitional care management: meaning admission or discharge from some medical service or facility (like giving orders for physical therapy after hospital discharge or providing full medical records to a rehab facility)
- Supervision of home healthcare. The provider gives orders for home care with lists of medications, duration of treatment and goals of treatment.
- Hospice care supervision.
- Provide a limited number of end-stage renal disease services.
The provider must have 5 capabilities and use those capabilities as needed:
- Keep your records in a computer
- Create a care-plan — an outline of goals and actions the provider will follow to meet those goals. Like “keep blood sugars in control — by weekly phone contact”. The provider should give you a copy of the plan — it should be specific to you and not a standard form applicable to anyone.
- Provide phone access to talk to a someone associated with the office 24 hours per day (they should be able to look at your computer record). Provide office visits as needed (presumably same day for urgent problems and within a week for non-urgent problems)
- Facilitate transitions in care. Like provide prescriptions and orders for therapy after discharge from a hospital or providing medical information to specialists for each visit. Or, keeping orders for home oxygen up to date. Or, immediately sending outpatient medical records to the hospital where you are admitted.
- Coordinate care. This does not mean providing all care, it is not a wall around you. If you need to see a specialist the provider makes sure all your medical data is transmitted to that specialist and makes appointments for you. And, follows the instructions of the specialist (as medically reasonable). Engages therapy such as home visits by nurses, physical therapy, occupational therapy or social service. And, makes efforts to meet the care needs outlined by those therapy services (as medically reasonable).
CCM does not eliminate office visits but it makes sure loose ends are dealt with and it obligates the provider charging CCM fees to provide access to someone that can look at your chart 24 hours per day. It also means the ER can call the primary care provider office and get up-to-date medical information about you in an urgent situation.
Disclaimer: the rules and fees for this program are in a state of flux. What is true today may not be accurate tomorrow. So, discuss the meaning of CCM with your primary care provider. Give them a copy of this article as a place to start a discussion. Here are some additional helpful links:
Elisabeth Rosenthal of the New York Times published her article “Even Small Medical Advances Can Mean Big Jumps in Bills” on April 6, 2014. Type 1 diabetes is a rapidly fatal illness without insulin treatment. The discovery of insulin in the 1920’s changed the disease from fatal to treatable and with improved insulin and improved devices to deliver the drug people with the disease now can look forward to a long life.
The article by Ms. Rosenthal points up the cost of current insulin pump therapy. She lists the yearly cost of insulin treatment for one woman as $26,470 (a large part paid by the woman’s insurance).
Surely, big pharma would not take advantage patients with life threatening illness like diabetes. Surely, they would not pad the bill with unnecessary equipment or lock-in patients to their brand of insulin with a device linked to that brand. Surely, US big pharma would not disadvantage US citizens and favor drug plans in other countries. WRONG, WRONG AND WRONG AGAIN. It’s the modus operaindi of such organizations and a lack of regulation that allows it to happen.
- Ms. Rosenthal comments on the fluff added to the bill: talking pumps with multiple colors and new models every year.
- The linking of insulin pumps to only one type of insulin (made by the insulin maker).
- The withdrawal of less expensive insulin from the market.
- The 70% profit on insulin.
- The limited number of companies that now make insulin.
- The sweet deals for countries that drive hard bargains (acquisition cost for a bottle of insulin in the UK $30 but in the US $200).
It seems there is a line to be drawn. On one side is the unquestionable benefit of research and development that brings fantastic life saving benefit to many patients. On another side is a business formula for fantastic profit to a few people. Fortunately, one need not choose either extreme — it is possible to have adequate research and reasonable profit as demonstrated in other parts of the world.
So, what can and should be done?
- Break up drug companies to separate the manufacture of insulin and the manufacture of insulin pumps. The competition in the pump market should not be limited by the drug maker.
- Limit drug patents with a strict end point and encourage smaller companies to make generics that may not be an exact copy but simply be similar (bio-similar).
- Set prices for drugs and devices based on realistic economic considerations (like limiting profit to 5%).
- Allow government sponsored research to compare various types of similar therapy to allow a reasonable choice by patients and providers.
- And, allow the government to negotiate prices since the government now pays a big part of health care costs.