Diabetes Economics

I wanted to blog about why self-management support and prevention are not well funded, while heart surgeries, amputations, and other treatments of complications are. I’ll get to that in a minute, but right now I’m in shock. I just read the comments to the Flashpoints piece called “ADA Supports Congress.”


I find it hard to believe most of these commenters are Diabetes Self-Management readers. Writers railed against “government-run health care,” without once recognizing that we currently have corporate-run health care, which is worse. I don’t support the “health-care reform” bills either, but we do have to change the way health-care decisions are made. Diabetes care is a prime example

A new survey shows how the twisted economics of American medicine — our lame attempts to mix profit and health care — hurt people with diabetes. In a survey of 300 physicians by Alyssa Pozniak, PhD, of Abt Associates in Cambridge, Massachusetts, only one-third said they could afford to provide medical nutrition therapy. Another third said they could not provide comprehensive diabetes care.

The most common reason cited for inadequate care was low reimbursement rates. The low rates held true for Medicare, Medicaid, and private insurance. For every one of the categories of diabetes care listed, more than two-thirds of the doctors said pay was too low.

Many doctors compensated for low pay by giving patients less time. Interestingly, primary-care physicians were more likely to provide nutrition therapy and self-management training than endocrinologists, although I’m sure the endos are paid more.

To be honest, doctors’ complaining about low rates doesn’t bother me. They’re doing OK. But how are people with diabetes supposed to get support service? The pay for diabetes educators and nutritionists can be even lower than pay for doctors.

According to the American Association of Diabetes Educators, Medicare pays for 10 hours of Diabetes Self-Management Training (DSMT) in the first year after diagnosis and two hours a year after that. Private insurers follow Medicare’s lead. Initial visits are supposed to last 30 minutes and follow-up visits 15 minutes. Is that enough time to help people with the complicated demands of self-management? And educators have to jump through all kinds of hoops to be reimbursed at all. Certification requires giving 1,000 hours of training, before being allowed to bill for it.

The American Diabetes Association has guidelines for diabetes care, but most doctors said that low reimbursement rates prevented them from following the guidelines. It’s like the Federal government telling local governments what they have to do, but not providing resources to do it (“unfunded mandates”). It’s not going to happen.

Why isn’t prevention paid for? Theresa Garnero, APRN, BC-ADM, MSN, CDE, is Clinical Nurse Manager at the Center for Diabetes Services of California Pacific Medical Center. She says, “Let’s face it. Cardiac surgery is sexy, diabetes education isn’t. Insurance often pays for the complications but not prevention through education. Reimbursement is a major issue for the survival of any diabetes self-management program.”

The American Diabetes Association says, “Our current system will pay for a leg to be amputated because of diabetes, but all too often leaves people without the tools to manage their diabetes to avoid complications.”

ADA demands reform so that all people with diabetes have “access to preventive services” and have their basic care paid for. An online petition in support of their demands can be read and signed at this Web site.

In my opinion, the bias for expensive care results from having a for-profit medical system. When health care is based on profit, we get the most profitable treatments, not the most effective ones. Drug companies, hospitals, medical equipment makers, and doctors lobby insurers and government to cover their services. The big companies have many friends in government, giving them a major marketing advantage. In fact, corporations and governments can be best seen as two different offices of the same company. Among doctors, specialists can out-lobby general practitioners. All of them profit from increasing the amount and cost of care, not so much from making people better.

Some people demand a free market in health care. But there was never such a market, and there can’t be. In a free market, customers decide what they need and how much they are willing to pay. But in health care, doctors decide what we need. They are the sellers of care, but they are in charge of purchase decisions. No wonder medical care costs so much!

Self-management and prevention save lots of money, but saving money is not what the system wants. They want to make money, so supportive services are a low priority. The current “health-care reform” won’t help. It leaves the system in the hands of the corporations and their government friends. What we need is a bill like Senator Sanders’ S 703 amendment to expand Medicare to everyone who wants it. With all expenses coming out of the same pot, we will be able to prove that self-management saves money. Maybe then it will be funded.

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  • CalgaryDiabetic

    Dear David.

    Even here in Canadian medicine there is much more emphasis on curing a disaster than on preventing it. My Endo tried to explain subsidies for the modern more expensive insulins like Lantus and Levemir to our provincial (i.e. state) health minister trying to sell him the enormous cost savings compared to emergency rooms stays of up to 4 days to treat DKA. This fell on deaf ears. Of course our health minister is super right wing and is trying to ruin medicare. People in Canada generally like a universal system on the simple logic that it is bad enough to be sick and uncivilized to have to go into bankruptcy. The very rich get private care (you could keep this feature for your very rich).

  • Steve Parker, M.D.

    Medicare already has unfunded liabilities estimated at $38 trillion. And you want to expand the program?

    For a view of Medicare different from yours, David, consider this article posted by the Association of American Physicians and Surgeons:


    What’s the main reason we have such a good quality of life now compared to a hundred years ago? Consider these two choices: government intervention or the profit motive. I submit it’s the latter. Government usually serves as a drag on prosperity. Profit motivates people to work hard and innovate. Too often, government does the opposite.


  • Donna C

    My health insurance paid for an 8 hour group training session with a dietitian and an RN who are both Certified Diabetes Educators. I had a follow up session that was covered. I’ve also gotten letters from my insurance company urging me to visit my opthomologist for a retina exam. They also have a special diabetes unit I can call with questions and they offer access to Nurse Line for general health questions.

  • Lois Pontius

    I agree wholeheartedly, but how do you break the stranglehold the powerful insurance companies have on Congress with their well-funded lobbiests and campaign contributions? It would take a massive rising up of the people, but first the people have to educated to counteract the lies and propaganda that the insurance companies are putting out there. I am ready to join the movement, not for myself, because I am over 65 and already have Medicare, which is working wonderfully for me. I mourn for those people who don’t qualify for Medicare yet and are at the mercy of the for-profit insurance companies as I once was.

  • David Spero RN

    Hi Steve,

    When it comes to “improved quality of life,” I don’t think you can credit governments OR the profit motive. It’s mostly been the advance of science and technology. Governments, private interests, individuals, and universities have all played into that.

    But if you ask what accounts for the improvement in public HEALTH over the last 200 years, it’s been 95% governmental. Clean food and water, vaccination programs, and social security have been the main drivers of improving health. Medical care doesn’t have much to do with overall health, but providing basic care to poor people who never had it before has helped some.

    Donna, I’m glad you have gotten such good care. Would you mind sharing the name of your company with us?


  • Bahamut

    Steve, do you know who Medicare covers? Medicare pretty much covers all the people that health insurance do NOT want to cover. Aka, people on Medicare are generally people who are not profitable. The simple fact that Medicare is even remotely successful proves that Medicare is better model than the for-profit corporations.

    I do not want a faceless office employee determining what I can or cannot get. A person who is accountable to no one and whose whims on whether to approve my diabetes treatment is based almost on whether the CEO wants a new summer home.

    But I do agree the current health insurance bill is not the best.

  • Steve Parker, M.D.

    Medicare in the U.S. overwhelmingly covers people over 65, regardless of health status or insurability. It covers younger people if they are disabled.

    Medicare in the U.S. takes 3% of the paycheck of young healthy people, many of whom make very little money and are struggling to support children. Medicare redistributes THEIR income to older people who are retired and often pretty well off. That 3% tax is not put in a separate account and saved for the use of the young person – it’s paid out immediately to cover the older person’s care. If that young person works all his life and dies in a car wreck at age 64, ALL of his premiums will have gone to benefit someone else, not him or his family or survivors.

    Is that fair?

    Shouldn’t charity to older people be voluntary?

    With both a government-run and private systems, you will have to deal with nameless, faceless bureaucrats.

    You will have no influence whatsoever over the government bureaucrat unless you are friends with a major polititian.

    Your influence over the private insurance bureaucrat is that you can fire his company and replace it with another if you don’t like the service. That’s why private insurers try to maintain good customer service. [Granted, there are many failures.] That’s why competetion is so important.

    In a government-run system, you have no competition because it’s a monopoly.


  • Bahamut

    Competition in health would be great. But right now, we have NONE.

    My choices:

    Employee health plan? Great if they’re actually good and cover anything. But if they don’t, I’m screwed because where else can I go?

    Individual health plans? $500 a month. Got Diabetes? Oh sorry, pre-existing condition. Oh and there is a 6 month wait time before any major coverage.

    Medicare if you’re older than 65 or disabled.

    Yes, the 3% tax takes it from healthy young people and gives it to the older people. So why not… I don’t know… let the younger people join Medicare. Raise the tax to 5% if needed. I pay more than that monthly for my health insurance premiums. 5% Medicare tax for all and no insurance premiums means I come out ahead.

    Why should I be paying the my health insurance premiums, Medicare tax AND have my taxes paying for all federal employees health insurance. Why am I paying for so much insurance when I get so little.

  • Donna C

    David: I don’t want to start a discussion about insurance companies and their individual strengths and weaknesses. My point is simply that some insurance plans are good.

    I am not in favor of Medicare-for-all for the reasons Steve Parker mentioned. With an insurance company paying your claims, you are a customer. They do have an incentive to please you. They want to keep you as a customer.

    With the government in charge, you are a number. There is no incentive to please you. You are at the mercy of Congress, and who wants that?

    I vote for the insurance companies any day over government-run health care.

  • David Spero RN

    Hi Steve and Donna,

    I was struck by a letter from a physician on the site Steve directed us to: “Medicare is immoral.
    Why?–Because it asks that some men sacrifice for others with the government as the administrator of the sacrifice.”

    I don’t see that as immoral at all. One great divide in this country is between those who think everyone should be on their own, and those who think society should help people who need it. It’s a values question, and I guess we should agree to disagree. But to the extent that young workers are being unfairly asked to “sacrifice for others,” (i.e. older people), this would be fixed by making Medicare available to all.

    But preferring a private insurance bureaucrat between you and your doctor to a government one sounds strange to me. The private insurer has an economic incentive to deny you care. The government one does not.

    I’ve been with private insurance and I’ve been with Medicare, and Medicare is the best I’ve had. I don’t think it’s ideal at all. I would prefer a national health service like they have in England. But it’s a lot better than what we have now.

  • Pamela Cramton

    Dear David,
    I am moved by your passion for this, sometimes standing at the pharmacy window trying to figure out how to juggle bills and copay’s again, I feel alone. Though I know I am not, I actually have it better than most and that deeply saddens me. I am an Insulin dependent diabetic fighting to get the care I require. I am finally getting somewhere, but I am persistent and had to get deeply in debt to do so. I can’t imagine the outlook of the diabetic who doesn’t know there rights or what questions to ask.

    I would like to share my story in that it might help another move forward with theirs, and I feel deeply moved to do so. At 14 I was borderline diabetic and overweight, and that’s all I was told. I heard “your fat, lose weight” and all I thought was heard that before. As a typical teenager already hiding behind her weight I delved deeper into food for comfort. If only…..I had been nutritionally educated then. At 21 I had this thirst and began to pee more at night than sleep.

    I was newly married and had no insurance, so I went to the county clinic. A finger-prick later a BS of 380 diagnosed me Type 2 diabetic. I was given a tri-fold brochure a RX and a follow-up appointment in 6 months. I figured if it’s not that serious to them it must not be that big of a deal. Before my 6 month follow up I was admitted to the hospital somewhere around 12 times with BS’s from 400-600. Still no education no referral and me to young to get my head out of my rear-end.

    A year or so later we have private insurance (not much better than none, and who can afford the copays?) I am told I am pregnant. This is the day that changes my life! I received my first referral to a Sweet Success program for pregnant diabetics. I will never forget the way my heart felt when I sat down and watched video after video of not only what has been happening to my body but now the body of my child. How dare I put that on someone?

    I was put on insulin weighed 265lbs at the beginning of my pregnancy and allot more at the end. I learned allot about food and happily report that a 7lb 3oz baby girl was delivered c-section at 37 weeks. Sadly she was born with two holes in her heart and an aortic valve deformity (holes have since grown closed and has had a minor effect on her life over all). The heart of a fetus develops so early I feel like it happened before I knew.

    So why didn’t I know? I had a MD I was seeing I was of the age to have children, married and very poorly controlled diabetic…why wasn’t I referred to an Endo before my daughter had to bare the scares of this? That I will never know!

    In January of 2000 I underwent RNY-Gastric Bypass I weighed 320 lbs and had developed such a resistance to insulin I was injecting somewhere around 400 units a day. Attn: Diabetics Insulin lowers your blood sugar but that should not be free license to eat anything you want because as a growth hormone it then stores that un-used sugar as fat (well in a nutshell that’s how it goes anyhow). I began to transform overnight (seriously overnight in the hospital) I no longer needed insulin at all! I thought I had been shown the light, given a second chance etc etc.

    I went back to work took my daughter got out of a bad marriage and began to learn what it meant to date and live a little. I remember thinking they weren’t lying when they said “your so pretty if you would just lose weight”. I distracted my focus from my nutrition and went a little early twenties crazy for about two years, I had lost the one thing I could hide behind no matter where I went. I was forced to step up and get out in the world.

    After awhile I met my passion and love of my life. In denial from all my coworkers and friends I reluctantly took a pregnancy test in the bathroom at work one day and found I was to have my second daughter. Immediately I went to the OBGYN and another difficult pregnancy began.

    Back on Insulin with the stress of pregnancy I was loaned an Insulin pump through the Sweet Success program. I kept my A1c around 5.5 and delivered a healthy girl at 36 weeks 6lbs 7oz. I add these details because women with this disease should know it can be done! She was early due to other medical issues, complications I still feel all related together. The insulin pump allowed me to only gain approx. 25 lbs and use less than 30 units of insulin a day while pregnant!

    She is now 7 and her sister 13, I am 35. At 33 I lost my father after a long battle due to heart and kidney complications brought on no doubt by his diabetes and AS- a primarily genetic disorder that is arthritic and auto-immune in nature. Months later I was in a deep depression and felt really ill.

    One day traveling as I stopped again to pee, the light bulb went off in my head. I made an appointment with a doctor (we had just moved so I had to wait to get into a new MD). I went to urgent care explained I am diabetic and I think my sugar is out of control. I laughed here, out of frustration because the doctor looked at me like I was crazy and said “Well what makes you think your diabetic?”, I said “I don’t think I Know!”.

    I found that once I lost weight and looked younger the doctors were even worse about paying attention and educating me. I was a healthy looking young women on the outside, so much so that once I got into that new MD, it got worse. He proceeded to convince me it was just in my head, tried all kinds of mental drugs, never mind I felt like crap and was in mourning. Both stress’s on your blood sugar. One day I looked at a bottle of Lithium (prescribed to me without any Psychology consult) and decided there is no way this is me. Up until this day I thought he must be right I must be crazy, I felt like S#[email protected]#.

    I am educated, I am a mover this is not me. I threw it away and began to think clearly again. I demanded referrals and waited (6 months), I changed primary MD’s and got back on some basic hormonal therapy’s (girls think your crazy check the hormones, wow what a difference….my husband and kids love me again!). I began to read and study as I was tested for everything under the sun. You see I finally got it into my doctors head that I wasn’t sitting at home with an Insulin syringe in one hand and donuts in the other. I knew there had to be an underlying reason for the sudden BS issues, and there was.

    This last battle started almost two years ago. I have since been diagnosed with the onset of AS, Fibromyalgia, Chrohn’s, Anemia, Thyroid issues, and am now back on an Insulin pump as I no longer make any of my own insulin. Despite all this I really think it is simpler than that, but that remains to be seen.

    My husband has had to take a job driving over the road to maintain our medical insurance, and is now gone 28 days a month. I have lost my ability to work in dentistry I am an RDAEF, a graduate of UCSF School of Dentistry’s program from Expanded Functions (graduated top of my class). I am also trained in Graphics and have taught graphic design at the University level. I am not saying these things for sympathy but reality! We are trying here to do the right thing and drowning more and more in debt daily. Today I am disabled an unable…..

    Unable? yes unable….unable to pay all the copays I have, unable to understand the years that have been stolen from me and my children, by myself and by doctor’s that only have 15 minutes scheduled for me. I actually had one say that to me. I am unable to believe how much pharmaceutical companies have gained power in our medical world. I once had a doctor give me samples after hearing him ask the rep in the hall “How should I tell her to take this?” I’m sorry does the rep know what other med’s I am on? Among other considerations.

    Mostly, I am unable to give up, today I am 35 and I know this is all for a reason, and it must be to learn something so I can help others.

    The other day my father in law had his third heart attack, his A1C was over 10, they started him on insulin, and sent him home after replacing a stint with his BS still over 250.

    He was so under educated he wasn’t sure which one as fast acting and what one was long acting. Didnt understand his sliding scale and decided to just take 8 units of fast acting. My mother inlaw was also uneducated on how to help him and what to watch. No Glucogon RX for a low BS emergency and the exptent of nutritional information was a food pyramid.

    As I looked through the materials they sent home with him and talked to him, I decided for certain this has to change, before my children suffer too!

    I want to help change the world of diabetes treatment and education I want to scream in the faces of placid doctors and overpaid drug company’s. Anyone have any ideas for me?

  • CalgaryDiabetic

    Pamela’s story is quite something. I would like to emphasize something she said:

    Attn: Diabetics Insulin lowers your blood sugar but that should not be free license to eat anything you want because as a growth hormone it then stores that un-used sugar as fat (well in a nutshell that’s how it goes anyhow).

    This is so, any amount of insulin above about 0.5 unit per Kg of body weight per day will makee you gain weight like crazy. With the build up of insulin resistance it does not do to keep uping the insulin dosage because it stops working. You must use a no carb diet, exercise like crazy and add metformin to the insulin to combat the resistance.

    In an ideal world one should get professional help. Here in Canadian medicine the information given out was not the best. But at least there were classes to show you how to inject.

    The same food pyramid that was loaded with carbs. The dietician was talking muffins and I was talking sauerkraut. The worst advice was from an End re insulin: “you don’t want to touch that s–t with a 10 foot pole.” Well a little insulin in the beginnig may have keptmy pancreas alive.

    The library was the best source of information then and now the net. Still without knowlegeable Doctors it is hard to get the right treatment in a timely mannerbecause they control the prescription pad.

  • Beth

    I just got back from my endo’s office. I need to lose weight (as usual), and want to find a form of exercise I can do without too much pain. Besides diabetes, I also have arthritis and fibromyalgia, which cause lots of pain both during and after every kind of exercise I have tried, including water exercise.

    I asked my endo for a referral to a physical therapist (PT), so we can try to work out some sort of exercise I can do. Instread she is sending me to a rheumatologist. Why? Well, if I see a rheumatologist (and bill insurance for another specialist visit), and the rheumatologist referes me to a PT, my insurance will probably pay, because for rheumatology conditions, they believe that exercise is medically necessary. But my insurance will not pay for a PT with an endocrinology referral, because they don’t think that is medically necessary.

    It’s true, exerciose can be pretty important for arthritis and fibromylagia treatment. But really, isn’t preventing heart disease, helping me lose weight, improving my diabetes control, and preserving my lower limbs and kidneys equally, or even more important? And wouldn’t it really be less expensive to pay for PT now tahn for cardiac rehab, dialysis, and amputations later?

  • Margaretha

    Dear Pamela,

    WOW! What a story, and what a survivor you are; very inspiring. Your story is enraging, especially so as you are not alone in having it.

    I can’t believe how uneducated so many of the physicians are, despite the many campaigns about obesity and diabetes. Even here in Canada, we have walk-in clinic doctors who know little about diabetes yet won’t refer someone with several neuropathy to a diabetes clinic much less a specialist.

    There are lots of informed ones, of course, and most hospitals now have diabetes education centres. Here we are covered for routine medical care from our primary physicians, who get a bit more fees for treating diabetic patients, as we do take more time, especially for counselling and advice. We are sent for education with a nutritionist/foot and other care once a year at a DEC, or more if there is a problem, and we can usually see an endocrinologist as needed. Tests are all covered. Depending on the location, there may be free support groups in our community; our diabetes associations decide whether to organize it or not. Our medications, like metformin and insulin, are covered depending on our income level–usually an initial threshold of say $200, then coverage of 70% until your limit is reached, which could be immediately or up to $10,000, depending on income. Our province has decided to cover Lantus (actually, it is a committee of physicians who decide on what to cover).There is a monthly fee for the medical coverage of about $50 per person, again with subsidies for low income, down to zero. If you have extended medical from work or Social Assistance, or can afford an insurance policy on your own(about $1300/yr) with the usual preexisting conditions excluded unless you transition from an employer policy as soon as the job ends. Not sure if you have access to that too. Extended medical usually covers a % of supplies like syringes and strips too.

    Anyway, all this is to say that with basic universal medical care we can manage our diabetes quite well here, if we are ready/willing/able to. The gap is in the prevention end, and in this province there isn’t much support once you leave your doctor and medical clinic.

  • Margaretha

    What really puzzles me is an earlier comment reported by David that “Medicare is immoral.
    Why?–Because it asks that some men sacrifice for others with the government as the administrator of the sacrifice.”

    Isn’t that a definition of what is happening with the soldiers in wars and the action overseas? Men and women sacrifice their lives, not just their money, because they believe this benefits their country?

    Doesn’t that apply with taxes for schools being paid by everyone, whether they have kids in the system or not? And don’t people who can afford a private school therefore pay twice? And the same goes for all the other taxes that are being paid by people who do not directly benefit from where that money is being used? Or abused?

    Even with the divide in values between the cowboy individualist and the bleeding heart supportive, there is some basic agreement about supporting the infrastructures of society. It is like that old joke about a man approaching a woman at a bar and offering her a million bucks to spend the night with him. When she agrees, he changes the offer to $100. She says ‘No, what do you think I am?’. He replies, ‘We already established that. Now we are negotiating the fee’. The American public has already established that it wants the government to take control over certain shared responsibilities. What is being debated now is how far those responsibilities should extend, and how much it will cost.

  • Denise

    The solution to this came to me 3 years ago when I opened my business. I am an RN and a CDE. I own my own business teaching weight management and insulin pump initiation. I will offer a corporate DSME course for a self insured company. My pay structure eliminates all need for reimbursement. I set self pay rates at prices competitive with what people pay for other things; golf, fake nails, a hair cut, etc. I have not had a problem with that, I will never be rich, but my patients get off meds for diabetes, cholesterol, and blood pressure through diet and exercise. Imagine that! If we eliminate the need for insurance to pay and set reasonable rates for those with or without insurance, people who are ready to take responsibility for their health will come to you. Your responsibility is to provide an out come driven program. i.e. one that works! We have to change the paradigm, because what the feds come up with will only be a strain of what we already have or worse. We are smart, well educated people-its time to invent a system that works. People will pay for what they want, despite the economy. It’s time we teach people that their health is their financial responsibility and that they will pay for it one way or another. ‘Might as well be with a healthy outcome that has long term value.

  • Pamela Cramton

    My training (outside of personal) lies mainly in dentistry, but even there I see lazy lack of self responsibility. Ever hear someone comment “I left that office because they never called or sent a card when I was due for a teeth cleaning”, hello….that is a nice service but isn’t the ultimate responsibility the person chewing with those teeth? The solution is not financial it never was it never will be, seems that getting any group to decide and agree when money is involved is impossible. The answer is and always has been ….Personal Responsibility.

    Personal Responsibility, to those who wish to have a say in the outcome, it is the only answer. No…not an idealist here. I just feel if a patient is ill they need to be the biggest part of the healing, however I also feel that a Dr. takes an oath that holds him personally responsible as well to offer his best. Back to the patient to filter out the abundance of the bad dr’s out there and fire them! Politicians- try Personal Responsibility sometime. An honest life doing what my body requires, and trying to keep a family together is all I ask.

    I hate that people choose between care and food or utilities etc. My mother says ….”Honey, you can’t take on a world of poor Dr’s and insurance companies”, to this I say “weak!”! Maybe though if enough patients like me together could stand up for ourselves and help each other instead maybe we would get somewhere.

    My father he would have loved that I wanted to join the fight, and encouraged me to fight on like he did, for the people! Fellow PEOPLE: Our words are our power, not sure what words to say? Knowledge is attainable in so many forms….take the Personal Responsibility and start seeking it.