Barriers to diabetes care

Townsend Letter for Doctors and Patients, May, 2007 by Jule Klotter

US family physicians, who care for about 90% of the nation's diabetics, face a difficult battle adjusting medications and monitoring patients for kidney disease, peripheral neuropathy, leg ulcers, and diabetic retinopathy during brief office visits. Education about nutrition and self-care help people with diabetes avoid these serious complications. Unfortunately, the health system in the US is set up to deal with acute rather than chronic disease and does not support preventive measures. Patients without insurance and/or with low incomes face an added challenge. Even if they understand the importance of monitoring blood sugar levels and seeing their physician, low-income diabetics cannot afford it. As one family physician told J.B. Brown and colleagues, "Diabetes is a fairly expensive illness. The testing, the medication, the diet and the frequency of visits."

During the late 1990s, four New York City hospitals set up "boot camps" for diabetics. At these education centers, diabetics learned about the consequences of uncontrolled diabetes, how to check their blood sugar levels accurately, and how to use nutrition to keep those levels more stable; they also began an exercise program. Specialists in endocrinology and ophthalmology monitored patients for disease progression. Within seven years, three of the four centers had closed because they were losing too much money. The fourth one at Columbia University Medical Center relies on generous donors to stay open.

US insurance companies are unwilling to reimburse centers and patients for preventive care. Insurers gamble that diabetic enrollees will have moved on to another provider before complications that require an amputation or kidney dialysis arise. People tend to change health insurers an average of every six years. Why spend money to prevent complications that the company may not have to pay for in the future? In addition, insurance companies do not want to offer services that attract diabetics. By offering preventive care and access to endocrinologists, insurers would be attracting more people with an expensive chronic illness.

Hospitals have their own bias against low-tech preventive care. Dr. Diana K. Berger told The New York Times, "'If a hospital charges, and can get reimbursed by insurance, $50,000 for a bariatric surgery [that helps control diabetes and] that takes just 40 minutes ... or it can get reimbursed $20 for the same amount of time spent with a nutritionist, where do you think priorities will be?"

Dr. Gerald Bernstein, who directed the diabetic center at Beth Israel Medical Center, believes that the US needs to restructure its reimbursement system if it hopes to deal with diabetes: "Until we address the financing and the reimbursement structure, this disease is going to rage out of control." Canadian diabetics and their family physicians have access to more options. Canada's universal health care supports family physicians' use of in-home services and diabetes education centers to help monitor and educate patients.

Brown JB, Harris SB, Webster-Bogaert S, et al. The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus. Family Practice. 2002;19(4):344-349. Available at http://fampra.oxfordjournals.org/cgi/reprint/19/4/344. Accessed February 8, 2007.

Urbina I. In the treatment of diabetes, success often does not pay. The New York Times. January 11, 2006. Available at: www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/11diabetes.html. Accessed January 30, 2006.

Zgibor JC, Songer TJ. External barriers to diabetes care: Addressing personal and health systems issues. Diabetes Spectrum 2001;14(l):23-28. Available at: http://spectrum.diabetesjournal.org/cgi/reprint/14/1/23. Accessed February 8, 2007.

briefed by Jule Klotter