Diabetes Self-Management Blog

I’ve never liked Michael Moore’s movies much, but Sicko is way better than anything he’s done before. He really exposes the madness of our medical system. He does this partly with some horror stories about people who couldn’t get help. But, more importantly, he shows how they do it better in England, Canada, and France.

All these countries spend far less on health care than the U.S. does (40% to 70% as much), but they cover everybody and have much better health. Even Cuba, a very poor country that spends 4 cents on health per person for every $1 we spend, has similar life expectancy and health outcomes.

Other countries’ health-care systems are better because they a) cover everyone for basic care, and b) focus more on prevention and basic care and less on expensive treatments of advanced disease. This has the effect of helping people stay healthier, which saves a lot of money and improves quality of life. The U.S. system, in contrast, doesn’t pay much for prevention or wellness, but spends billions treating advanced complications and keeping very sick people barely alive.

I write about the failings of American medicine in my book Diabetes: Sugar-coated Crisis—who gets it, who profits, and how to stop it (New Society, 2006). I explain how our $2,000,000,000,000 medical system may actually do more harm than good. One example relevant to Diabetes Self-Management readers: In the 1990’s, four diabetes treatment centers operated in Manhattan, teaching and supporting self-management. All had excellent results in controlling blood glucose and preventing complications. Their patients were living good lives. Clinically, they were a great success.

They all closed within ten years. Why? Because insurance paid so little for these prevention services that the clinics all lost money. The only time they could get paid was when they failed. When someone needed an amputation or laser eye surgery, they made money, but when people stayed well, they operated at a loss. So they had to stop.

Meanwhile, in this same time period, nearly 50 dialysis centers opened in New York. Almost all of their patients were people with one of the worst complications of diabetes: kidney failure. Many had very low qualities of life, but they were kept alive. Insurers paid for the service, and the dialysis companies made nice profits.

Who Pays for Self-Management?
This is what happens when you have a medical system based on profit. Drug companies and other profitable, high-tech ventures take over more and more of the system. Low-tech interventions like self-management support struggle to stay alive.

For example, Medicare pays for 10 hours of diabetes self-management training (DSMT) in the first year after diagnosis and two hours per year after that, and they don’t pay much. (Most private insurers have similar or even less generous benefits.) As a result, says American Association of Diabetes Educators past president Virginia Zamudio, most people with diabetes don’t have access to DSMT at all.

You would think that insurers would be happy to help people manage diabetes, since the cost of complications is so high. But instead, according to health economics expert Thomas Bodenheimer, M.D., insurers often provide minimal services for people with diabetes, because they want to encourage you to take your business elsewhere. Some insurers are more blunt about it—they won’t sign people with diabetes up at all, or they raise the rates impossibly high. An American Diabetes Association study found that some insurers raised premiums 37.5% for an eight-person business if just one worker had diabetes.

The medical system can hurt people with diabetes in other ways, too, as I’ll discuss in my next blog entry. I’ll also talk about what we can do to protect ourselves and change the system. One group that is working to make the system better is New Health Partnerships. NHP brings providers and patients together to develop better ways to support self-management and to figure out how to make it work economically for everyone.

Please tell me: What have been your experiences with the medical system? How has it helped you and hurt you? What ideas do you have for changing it? And if you haven’t seen Sicko, I encourage you to see it. It’s actually about a lot more than health care. Let me know what you think of it.

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Comments
  1. It would be interesting to know if diabetes is managed differently in the UK than it is in the US, and if so, is it better?

    Posted by jb |
  2. Here in Ohio, it is even worse than in most of the U.S. Ohio is one of only 4 states that does not require private insurance to cover diabetes education and supplies. I know of one insurance company that says diabetes education has been completed adequately if the patient has received a printed handout on diabetes care!

    Every legislative session since 1994, Ohio has introduced legislation to require the same coverage the other 46 states now have. This year, the bills are SB 99 and HB 137. All Ohioans who read this — please go to the “Advocacy” section of the American Diabetes Association web site to find out more, and to receive updates when we need support for this bill.

    Posted by Ann |
  3. I am an American living in Germany and am insured by Germany’s public health insurance program. During my fist visit to my endocrinologist here, the doctor registered me for a special “tight control” program for diabetics. I visit him every three months and have blood drawn for a HbA1C. This result is reported to my insurance company, but it is an anonymous report (they don’t know it’s my HbA1c).

    In exchange, the insurance company gets a large chunk of money from the government and I get all of my prescriptions either free or deeply discounted. My new insulin pump was also 100% covered by insurance. I can see my endocrinologist at any time and there is no charge for the visit.

    The German insurance program is not perfect; in fact some things cost more here than in the US (dental care, for example, and I pay a lot more taxes). They are also moving more and more toward private insurance, which is disappointing, but I am happy to be here while this program is available.

    Posted by anonymous |
  4. I live in London, Ontario, Canada and my son was diagnosed with Type 1 Diabetes 3 years ago at the age of 7.

    I will tell you here that the major focus is on management.

    When he was first diagnosed we sent three days at the clinic learning about diabtes, testing his sugar, understanding his diet, giving insulin and discussing the social impact. This entailed meeting with the doctor, nurses, dietitian and social worker.

    He now goes every three month to test what his average sugar has been, his growth and weight, his diet and social issues. Adjustments are made to his diet, insulin if required.

    I think they have a great system setup to assist in the management of type 1 diabetes.

    brian

    Posted by briviere |
  5. Not every system is perfect - I do know that when my daughter was injured in London, UK. The physicians there told me to seek medical care back home - care was better in the US. She was covered by the health system in the UK as she was employed by a UK company. The physicians knew I was a nurse - as I wanted them to be honest,factual, and precise when describing what she needed. I trusted thier opinion and brought her home for treatment.
    Granted one incident - I also have close friends in Canada who have waited a long period of time to see a specialist - 6 months now. Our system may not be perfect - none of them are - but I am not convinced UK, Canada, France or even Cuba are better.

    Posted by cde1953 |
  6. In my case, even though insurance would have paid for an education course, my Dr didn’t think I needed one. (The Dr was assigned by the insurance company, not chosen by me)

    After i was able to change Drs, the 2nd Dr also didn’t think I needed education.
    (Of course she didn’t believe in doing an HbA1c but once a year either!)

    I’ve now changed insurances and have another new Dr. I’m asking her for education on my next visit. But since I’ve been diagnosed for 2 years now, I don’t even know if the new insurance will cover it.

    At least i’ve had the internet and since diagnosis i’ve kept my HbA1c at 6% or below.

    Posted by Ephrenia |
  7. JB asks about diabetes care in England. Apparently, it’s not that good. The Health Commission there recentlyfound that 90% of practices are not doing enough to promote self-management.

    Still, their outcomes are better than Americans’. I think this goes to show that medical care is not the most important factor in people’s health. People in UK and most other developed countries have more social support in many areas of life. This reduces stress and makes it easier to manage diabetes and other chronic illnesses.

    Posted by David Spero RN |
  8. Sicko is definitely propaganda. It uses dramatic license to exaggerate the real situations. Socialistic and communistic medicine has value, but it also has it’s drawbacks. Ask anyone in the countries mentioned and they can give a huge list of problems with their system vs. ours. They have very little access to follow-up care. They wait months (8-15 months in some cases) to get surgery on aggravating problems that we have access to in days. Michael Moore has a history of distortion of the facts and in this case, his one-sided reporting makes communism look like the closest thing to heaven as for medical concerns. I can’t buy it. I hope others look at that film with skeptitism. I really disagree with your promotion of his film and now will look with skeptitism at your work. Sorry… you just sent me a big red flag when you recommended that film.

    Posted by lagower |
  9. Hi Lagower,
    Sorry that my liking a film prejudices you against my health information. But please check the data on health outcomes of other countries and the United States at the World Health Organziation site . You’ll see how much better other countries do.

    This difference is not entirely due to health care, of course. Our society is unhealthy in many other ways—that’s what my new book is about. It has very little to do with socialism.

    Keep reading, see what you think, and please write again.
    David

    Posted by David Spero RN |
  10. Another reason why I love being Canadian. Also, I notice that whenever I am in the US, fast food establishments are in abundance. These places contribute to a very overweight society, which in turn promotes laziness, and subsequently in a lot of instances, Type 2 Diabetes. Consequently, it makes one wonder if there really is a genetic factor in Type 2 - if Mom sits down to a bag of Fritos every day, I can assure you little Bobby will too. It’s not genetics - just another case of monkey see, monkey do. Type 2 Diabetes needs to be renamed Commercial Onset Diabetes. These drug companies and fast food places are thriving on Type 2 Diabetes; without Type 2 Diabetes, there’s huge profit losses.

    Posted by Carmen |
  11. Lagower, I’m not sure you’ve studied other countries other than your own, but Canada (your neighbor to the north) is not communist, never has been and never will be. Most of our hospital waits are for elective, non life treatening surgeries. Due to some very bad retinopathy, I went blind after giving birth to my son - the next week I was booked for my vitrectomy. I also chose not to have anymore pregnancies because of my Diabetes and the possible life threatening risks and had my tubal ligation done that week. Both surgeries were done in hospitals and were free. Our medical system takes Diabetes very seriously…oh and its also a democratic society and we vote for our parliament, and it’s not a dictator, he or she is called a Prime Minister.

    Posted by Carmen |

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