Diabetes Care: The Spectrum of Success

Today’s Managing Health Care Costs Indicator is  8.3%

Diabetes is a major killer in the US – the disease strikes about one in twelve  Americans ( 8.3% in the entire population; one in four over age 65), is responsible for over 70,000 deaths, and is the leading cause of blindness and kidney failure.   The Centers for Disease Control and Prevention estimates that the annual cost of diabetes in the US is $168 billion in medical treatment, and $58 billion in lost productivity.

I’m struck by two studies published in the last week that use diametrically opposed approaches –and both appear to work.  (Both studies are small, though , so it’s possible that the results will not be sustained in larger samples).

The NEJM  published two studies showing that intensive surgical intervention helps.   Italian researchers showed that bariatric surgery (the most invasive surgical treatments) could “cure” diabetes in 75-95% of those treated, compared to NO cures in the medically treated group.  American researchers showed that those who had less-invasive surgical treatments were three times as likely to have an excellent diabetes control (Hemoglobin AIC of <6).   The conclusion –for diabetics with morbid obesity, surgical treatment is strikingly effective.  Other  studies have shown that bariatric surgery can pay off in a few years in the general population – this set of studies provides further evidence that we should cover this expensive ($11-$26,000) procedure for those with morbid obesity.

The Annals of Internal Medicine published an elegant study  which randomized 118 African American veterans with diabetes to usual care, financial rewards ($100-$200), and peer mentoring.  The financial reward for better HbAIC led to a 0.4% average decrease in HbAIC, while the peer mentoring led to a 1.1% decrease in HbAIC.

There are often many roads that lead to the right outcome in health care – and these studies are all small and did not include similar groups – so shouldn’t be compared.   It’s nice to know that both high tech and low tech solutions can have a substantial impact, and have the potential to decrease diabetic complications in our increasingly-obese population.

Read More

Curing Obesity Won’t Solve the Health Care Cost Crisis

Today’s Managing Health Care Costs Indicator is $7 billion

Kenneth Thorpe has a cheery simulation in this month’s Health Affairs postulating  that if we enroll 2.6 million Americans aged 60-64 in a nutrition training program (run by the YMCA) we could save $7 billion over their lifetimes.

The simulation is based on the National Diabetes Prevention Program.,  a huge well-designed study that resulted in 7% body weight loss sustained over 2.8 years of followup and reduced the prevalence of diabetes among the participants from 58% (and by 71% in those over 60).   The intervention cost $1340 per person

Be sure to read the fine print. 

•       This is based on a study done on 92 participants in the YMCA program, published in the American Journal of Preventive Medicine.
•       The savings are available over the beneficiaries’ lifetimes –which makes it hard to imagine what the denominator is, since we don't usually think of the average liability for a person’s Medicare costs at the moment she turns 65.
•        The intervention in the NDPP cost $1340 per person and involved individual training, while the intervention at the YMCAs cost $240 per person and used classroom education, which a smaller number of sessions.
•       The simulation assumes that this intervention could be scaled from 92 people to 2.6 million enrollees
•       The $7 billion assumes 70% of those who are eligible (at risk for diabetes) enroll.  Enrolling this many people in a program would be a staggering feat.  Weight Watchers enrolls 1.2 million members, and has 56,000 employees.

Here’s the real kicker.  If we accept all of these assumptions, believe that the very small YMCA trial is adequate proof of concept, and enroll overweight people at risk for both diabetes and heart disease, this program would save $3.7 billion over 10 years, or $370 million per year.  Medicare will spend $569 billion in 2012.

That means that this intervention would shave 0.06% off of total Medicare spending.

This program is probably a very good idea – and keeping people from getting diabetes (or delaying onset) could clearly save money and make peoples’ lives better.  But let’s not congratulate ourselves for finding a solution to cost increases in Medicare without dealing with the tougher issues.

Read More

The Paradox of Generosity: Making Insurance Coverage Broader Can Lead to More Uninsured

Today’s Managing Health Care Costs Indicator is 1.5 million

The May 4 issue of the Journal of the American Medical Association  has a comprehensive literature review of the effectiveness of structured exercise in type 2 diabetics.  Those who begin an structured  program  to exercise at least 150 minutes a week have impressive improvements in their diabetes -- improvements akin to the results of adding an additional diabetes medicine to their drug therapy.

An accompanying editorial suggests that since structured exercise is so cost effective (between $14,000 and $69, 000 per quality adjusted life year) it should be covered by health insurance.

I'm a big fan of exercise - and I do think that breaking down barriers to exercise is important.  For many, the cost of joining a gym is beyond the budget.  However, I couldn't disagree more with this JAMA editorial.

We have a huge affordability problem.   Making health plans more “generous” through offering coverage for fitness club membership also makes them these insurance plans less affordable. This is not exactly an “unfunded mandate” in all instances under the Affordable Care Act, because the government will subsidize health insurance to the extent the cost exceeds 9.5% (or less) of income. Therefore, the government has a strong incentive to keep down the cost of health insurance.

Fortune Magazine  reports that chiropractors, patient advocacy groups, and a wide range of physician specialty groups are lining up to demand that HHS include more services in its list of essential health benefits.  It reports that a 10% increase in the cost of the essential benefits package would increase spending by $67 billion through 2019 and reduce the number of insured Americans by 1.5 million. 

We have to figure out how to avoid medicalizing a large range of important social issues, and we must have the discipline to NOT cover services that are not medically necessary.  Covering fitness club memberships through health insurance might feel good.  But it would paradoxically lead to a lower rate of those with insurance for truly ‘essential’ health care coverage.

Let’s not add more mandates that would make health insurance unaffordable for more Americans.

Read More