Diabetes Economics

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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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