October 23, 2014

Another Questionable One-Size-Fits-All Pronouncement

Fortunately, there is still time to comment about this – until November 3, but this draft proposal is typical of their actions and they seldom back down or change little from the draft. Granted, they need to start someplace, but they need some flexibility in their pronouncements.

The draft statement by the US Preventive Services Task Force (USPSTF) says that the new focus is on identifying people with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). This is according to task force member Michael P. Pignone, MD, professor, department of medicine, and chief, division of general internal medicine, at the University of North Carolina, Chapel Hill, NC.

Since the USPSTF is a prevention and screening task force, I had to ask the doctors how they reacted to the Medscape article. They did agree that there needs to be some variables spelled out, but they could live with it.

The recommendation calls for screening everyone beginning at age 45 years, as well as younger adults with risk factors including overweight or obesity, a first-degree relative with diabetes, women with a history of gestational diabetes or polycystic ovarian syndrome, and certain racial/ethnic minority groups. This includes African Americans, American Indians/Alaskan Natives, Asian Americans, Hispanics/Latinos, and Native Hawaiians/Pacific Islanders.

The task force spokesman says that the proposed recommendations are generally in line with diabetes screening recommendations previously made by other groups, including the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists, the American Academy of Family Physicians, Diabetes Australia, Diabetes UK, and the Canadian Task Force on Preventive Health Care.

Both doctors felt good about some of it, but emphasized that they gave family history more importance than obesity, and felt that testing should be done earlier for women that had gestational diabetes. Both doctors agreed with this statement - Part of the task force's intent is to get physicians to think about lifestyle intervention more, and it's also a call to make effective lifestyle programs more available. They said this was important to make all doctors more aware and focus on this more.

I asked if they felt Medicare would allow this and reimburse doctors for the time. Both felt this would be the barrier and prevent this from becoming a reality. They also agreed that a major issue is how to follow up with those who screen positively. The felt that the cost of screening itself is quite inexpensive, but we have to think of the full spectrum of care that's required. Apart from cost, it's going to be hard to deliver good lifestyle-intervention programs to the large number of US adults who might benefit from them.

I appreciate my conversation via email about their perspectives and respect their putting me in a better mood

October 22, 2014

CMS Stranglehold on Medical Testing and Diagnostics

The Centers for Medicare and Medicaid Services (CMS) is up to its dirty tricks continually. CMS may become the laughing stock of the medical care world if they continue to restrict what health care providers can do. The rules are becoming so restrictive that even the CMS employees cannot keep up with the changes. With this, is it any surprise, that Medicare is projected to be insolvent by 2026, only twelve years from now?

More from the bad news side: Medicare will not pay for more than one test a year that is not directly related to the illness currently being treated by the doctor. In addition, Medicare rules forbid your doctor to treat (and therefore to test for) more than one ailment per office visit. What is the patient to do? Many people using Medicare have more that one medical problem and often three or more.

In theory, the patient could pay for the additional testing, but if those tests are deemed “medically unnecessary,” your doctor could go to jail for writing that prescription if he or she bills Medicare for the test. And if she or he wants to discuss the results of the test and prescribe a course of treatment, all discussion and treatment must be about that original ailment, even if you’re now sick with bronchitis instead. I am only guessing, but this sounds like if you have more than one illness, then you will need to see a different doctor for each disease or illness. How ridiculous CMS is becoming!

If a product or diagnostic test is new, getting Medicare to create a new billing code for it can take a long time and cost doctors a significant amount of money in lost reimbursements. And if a billing code exists, Medicare must agree to pay for the service. Medicare has not been willing to pay for genetic testing, except in screening for compatibility for kidney and bone marrow transplants. And with genetic testing to help individualize and personalized medicine, Medicare is unwilling to cover the level of genetic testing need for this to become a reality.

Medicare won't pay for physicians to consult with patients by email or over the phone, even if the patient is old, disabled, or too ill to come to the doctor's office. Medicare will not pay for doctors to teach diabetics how to monitor their glucose levels or manage their diabetes in other ways. The same goes for other chronic illnesses.

Read about Medicare and their restrictions and follow the many links in this article.

October 21, 2014

Diabetes, The Poorly Managed and Invisible Disease

Diabetes is one peculiar disease. There are few illnesses and fewer diseases where the patient is totally responsible for his/her own care. Yes, the doctor is there for guidance and is the one issuing the prescriptions, but even the doctor is limited in caring for you. Most doctors are not reimbursed for education, extra advice, and will not be reimbursed for anything extra. Very few doctors will go beyond the tests and finding out the medications you are taking to decide what medications you can take.

Too many doctors do not even do the tests necessary to be sure they have the correct diagnosis. Then to make matters worse, most doctors do not have certified diabetes educators available for diabetes education. A few that do have found them useless because of the mandates they use and lack of true diabetes education. Many doctors have found that even having registered dietitians available is hard to come by and more have found them promoting too many carbohydrates and whole grains so heavy that the patients have a difficult time lowering their HbA1cs.

This is one reason many of the local doctors prefer working with diabetes support groups and promoting support groups. They can spend time with us away from the office and promote education one time a month and then follow up the next month. This has surprised some of us and since the group I take part in has no doctor as a leader, they are surprised that we will not let a doctor become our leader. Yet they let us help educate their groups and take part in meetings when we bring several groups together for a meeting.

What many patients desire is more access to the doctor. However, what they often do not understand is that the insurance companies, Medicare, and Medicaid limit the time that they will reimburse doctors for in a year. So if the patient could get unfettered access to the doctor, they would soon not be able to see the doctor for much of the year, because they have used up the limit for the year.

Many people with type 2 diabetes have a difficult time in realizing that the doctor cannot be with them 24/7 and refuse to learn how they can manage their diabetes. Back a few years ago, there could have been good reasons for not learning, but with the internet of today, learning how should be the goal of every person with type 2 diabetes. I will be the first to admit that there a many charlatans on the internet trying to convince people that they have a cure for you. Of course all they want is your money for something that will not cure diabetes.

Even though they claim to have been cured, they have not had diabetes in the first place and make their claims knowing they are lying to take money from you. This is a common scam.

There are some social media and other sites that help people with all types of diabetes. Some are reputable and very reliable, some are good and generally give out good information, and some are unreliable. A few follow the ADA guidelines to the extreme and are not good for the majority of people with type 2 diabetes.

There are some very good sites that basically tell it like it is for people with diabetes and by gleaning the information carefully, many can learn how to manage their diabetes.

October 20, 2014

Is Internet DSME Beneficial?

People with type 2 diabetes can benefit from diabetes self-management education (DSME) and it does not need to be taught by certified diabetes educators. If done correctly and people with type 2 diabetes will learn, the internet can be a great place to learn and sharpen diabetes management skills.

Self-management of diabetes, includes medication, nutrition (food plan), and lifestyle strategies. This is essential for optimal glycemic control and minimizing complications of the diabetes. Education to teach and improve self-management skills is critical for success and, when delivered via the Internet, can lead to better glycemic control and enhanced diabetes knowledge compared to usual care.

Katherine Pereira, DNP, Beth Phillips, MSN, Constance Johnson, PhD, and Allison Vorderstrasse DNSc, Duke University School of Nursing (Durham, NC), review various methods of delivering diabetes education via the Internet and compare their effectiveness in improving diabetes-related outcomes. In the article "Internet Delivered Diabetes Self-Management Education: A Review," the authors describe some of the benefits of this method of educating patients, including ease of access and the ability to self-pace through the materials.”

DSME delivered via the Internet is effective at improving measures of glycemic control and diabetes knowledge compared with usual care. In addition, results demonstrate that improved eating habits and increased attendance at clinic appointments occur after the online DSME. The researchers discovered that engagement and usage of Internet materials waned over time. Interventions that included an element of interaction with healthcare providers were seen as attractive to participants.

Internet-delivered diabetes education has the added benefit of easier access for many individuals, and patients can self-pace themselves through materials. More research on the cost-benefits of Internet diabetes education and best methods to maintain patient engagement are needed, along with more studies assessing the long-term impact of Internet-delivered DSME.

I commend the individuals involved for realizing that the Internet could help with diabetes self-management education. The increasing numbers of people with diabetes is resulting in limited availability and access to diabetes care services. This includes access to certified diabetes educators. It is estimated that there is about one certified diabetes educator per 1,400 patients with diabetes in the United States. Because of the many factors limiting access to diabetes education, innovative delivery methods for DSME will need to be developed. One potential avenue that has been studied over the last decade for addressing the reach and accessibility of DSME is the use of Internet-based interventions.

DSME as a vital component of the care of patients with diabetes and the ADA recommends that DSME be provided for every patient at the time of diagnosis of diabetes and as needed thereafter. Despite these recommendations and the proven effectiveness of DSME, many patients with diabetes never receive DSME or any form of diabetes education.

If the future plans of the American Association of Diabetes Educators come to fruition, then there may be some hope. With the Academy of Certified Diabetes Educators staying with the exclusive idea that they are the only ones capable of providing diabetes education, we cannot expect any help from them.

The full copy of the report is available to read here until November 6 and then it goes behind a pay wall.

October 19, 2014

The Diabetes Support Groups and Conflicts

When a new doctor was changing the landscape and diagnosing more type 2 patients and many patients with prediabetes, he was promoting membership in the different support groups, he then realized that two of the support groups did not have doctors leading them. He started telling his patients to avoid the two support groups without a doctor as a leader.

Both support groups have since talked to Dr. Tom and the doctor has been set straight. He has learned that Dr. Tom works with both support groups in an advisory capacity, but that our support group seems to do well on its own and does more research and has better programs than any other support group.

Dr. Tom called both Tim and Greg and asked them to bring in one other member to meet with him and the other doctor. This happened on October 16 and Tim did ask me. When we were all present, Dr. Tom asked the new doctor why he would not support the two groups without doctors leading them. Dr. Jay as we nicknamed him, said because they may not follow the American Diabetes Association guidelines. I could tell the other members were rolling their eyes. I said because we would rather follow guidelines set by the American Association of Clinical Endocrinologists if we followed any guidelines, and the ADA guidelines were too high and in the area that encourages the complications to flourish.

Greg said an A1c of 7% was too high and even the A1c of 6.5% was even higher than most of the group members wanted to tolerate. Greg continued that most of the members in the support group he was part of tried to keep their A1cs under 6% or near that level. Tim added that was very much like the group he led and while we read the guidelines, it was only to know what was being said and not to follow the ADA. Tim stated that it is true we do not follow the ADA guidelines and will not until they put the patients first and not their own wallets.

Tim continued that we ask Dr. Tom questions and when we have meetings with several groups, we include other doctors. Greg said we don't have meetings with other groups, but do participate in meetings with other groups led by Tim's group. We do consult with other doctors about some topics and have had doctors speak to our group.

Dr. Tom then asked Dr. Jay if he was going to continue opposing the two support groups. Dr. Jay said that he still had questions and both Tim and Greg told him to ask them. Dr. Jay asked how many were in each group. Greg said they now had 13 members and felt that they would be adding more. Tim said we have 17 members and will know if we will be adding six more members on the last Saturday of this month.

Next, Dr. Jay asked why we did not have a doctor as a leader. Greg bit his tongue and politely said that they started out without one and liked the fact that we did not have to worry about what we say. Plus if we came up with research that said something like statins that cause diabetes, we could use the sources and not have to worry about something getting back to our doctors.

Dr. Jay asked Tim if he agreed. Tim said yes, we had started out as a group of three and then two groups combined making it six. Tim continued that Bob is a blogger, worked to help all of us become more interested in learning about diabetes, and has helped some of us more than others, but we have grown because of him. Greg added that I was the one that had brought them into Tim's group and they had left over the fact that they wanted to remain an informal group and those that left wanted a more formal group. They have included us in group meetings and we have learned a lot and enjoyed their programs.

Dr. Jay then asked what besides group formality separated the groups. I said most groups are on oral medications while most of our group is type 2 people using insulin. Yes, four of our members are now off all diabetes medications, but the rest of us are on insulin. Dr. Tom spoke then and told Dr. Jay that they were successful because they went about it correctly and have presented this to other diabetes support groups. He admitted that he now has two members of the group he leads that are off all diabetes medications. Three had tried, but because they did it correctly, when the one was having problems, he went back on medications immediately and was not ridiculed for it.

Dr. Jay turned to Tim and asked if we would accept a doctor as a leader. Tim looked at me and then said we would need to put it to a vote, but he felt that the answer would be no. We consider Dr. Tom as an advisor, but not a leader of our group. We like our more informal nature, have received support from several businesses, and have larger meeting rooms available to us for our meetings of groups. Dr. Tom interrupted and said that we were not the largest group in the area, but only two groups were larger, one in a town north of us (about 28 active members with three doctors) and another in a town about half an hour south of us (about 35 active members with one doctor and a nurse practitioner).

Greg was asked the same question and Greg said he could not speak for the group, but he would be discouraging this. Jessie said she would also discourage a doctor leader. She liked their more formal group with Dr. Tom as being available as a consultant.

Dr. Tom concluded the meeting by saying he was welcome to come with him when Tim's group presents to the group of 35 members or attend the meeting of groups next year. With that, we left.

October 18, 2014

Finding Financial Help for People with Diabetes

When I did this blog on January 10,2013, I knew it was only a start, but I did not realize what would result in more questions. Then with a newsletter from “DiabetesConnect” and a blog on DiabetesMine dot com, I have received several more emails from people asking for more information. This is telling me that there is a greater need for information about finding financial assistance for diabetes supplies and medications.

It is with some trepidation that I tackle it at this time with all the changes that are expected in January 2015 under the Affordable Care Act (ACA), a.k.a., Obamacare. Will any of us be able to afford medical insurance the way it is expected to increase in cost – in come cases? At the same time, we need to be aware of what is presently available to assist people with poor medical insurance or no medical insurance.

I am very happy to give credit for the work others have done to enlighten us, but we need the information put together to prevent people from looking at too many sources and becoming discouraged. One of my questions came from a person that was using a computer in a library, and because of the lines waiting for computers he asked that I send him an email when it was complete so that he could print it off and come back to it when he can get computer time. Because of this, I was able to get the library URL and email them asking for extra time for him. I am very happy for him, as the library has gone beyond the extra step, did a lot of research for him, and help provide him with many local resources. They have put him in touch with several agencies that are helping him. He has written me many thanks and is very thankful for the help the library has given him. He says this is the first time in over two years that he has been able to test his blood glucose and have a dependable supply of insulin. Yes, he was without work, but now has a part-time job and a roof over his head even if it is at a shelter. He is also a veteran of the war in Iraq and having a very difficult time.

Based on this, I will start with the Veterans Administration and their benefits for veterans. First, let me be very specific as veteran's services vary from state to state and each state has their own setup for the location of veteran service offices. The state that you currently reside in determines where the offices are located. In the examples I am using, Iowa is the place that this applies to and I think we are fortunate in that each county has a veteran's assistance office. Normally they are located in the county seat and are generally in the telephone book under Veterans Affairs.

For the state of Iowa, it is part of the Iowa law and required to have an office in each county. Each office is staffed by at least one certified county veterans service officer (CVSO). This means that they have taken an examination and passed it on the state and federal level to be certified at the state and federal level. I know that they help a lot of veterans and in addition, they answer to a three or five member board of veterans that can dismiss CVSOs for cause.

Current service personnel being discharged from active duty are automatically eligible for veteran's benefits for five years from date of discharge. Other prior military service veterans must file an application for benefits and include all copies of DD Form 214 for each period of service. This application can be obtained from the county Veterans Affairs Office.

All VA offices and most VA clinics in Iowa have a booklet titled Iowa Department of Veterans Affairs – State and Federal Benefits for Veterans and Dependents. It is spiral bound at the top, but I haven't counted the pages. It is 3.5 inches wide by 4.5 inches high.

I highly recommend that all veterans find their local VA office and find out what you are eligible for and when.

October 17, 2014

Another Article to Put Down High Fat Diets

The advocates against high fat diets are at it again. Only this time they may have crossed to the danger side. This time they are talking about grapefruit juice being able to curb the effects of a high fat diet. While more studies are being promoted, there are a few items that need consideration before adopting grapefruit juice.

I must emphasize that many of today's medications can become toxic when taken with grapefruit or grapefruit juice. The grapefruit family can cause very serious problems when taken with about 100 medications, at latest count.

The list includes some statins that lower cholesterol (such as atorvastatin, lovastatin, and simvastatin), some antibiotics, cancer drugs, and heart drugs. Most at risk are older people who use more prescriptions and buy more grapefruit. The gist of the situation is the grapefruit, which contains furanocoumarins, which block an enzyme that normally breaks down certain medications in the body. When this happens, medication levels in the body can become toxic. This is still not on the FDA's list of things to watch for, but should be. Read my blog here from December 10, 2012.

Some doctors are aware of this, but many just are not. This is one side effect of many medications that grapefruit and grapefruit juice that can be extremely dangerous to your health. Doctors were saying it was not new news. I wish this would get more publicity, but the media does not think it is important enough or will generate enough interest.

A new study by researchers at the University of California-Berkeley claims it did for mice fed a high-fat diet, and it even lowered blood glucose levels and improved insulin tolerance. This could lead readers to believe that the diet could have been low carb, but that is not stated is the study.

The researchers say, “It is common knowledge that a diet high in fat can lead to weight gain.” This adds to the confusion and indicates a high carb diet. This is also not stated in the study.

The study was actually using rodents, which indicates nothing as the dietary habits seldom translate to humans.

The researchers stated that the research was funded by the California Grapefruit Growers Cooperative.

October 16, 2014

Frequency Important in HbA1c Testing

I must state that after reading this short piece in Diabetes in Control, I started this blog and then I tried to follow the link at the bottom. This led to more confusion and much doubt. It turns out that the link was not to the correct article in Diabetes Care, but to a Pub Med article titled “The relationship between alcohol consumption and vascular complications and mortality in individuals with type 2 diabetes.” I had expected the article to be behind a pay wall, but not this.

The short article made no mention of where the study happened, but the article alluded to the ADA. False, the study was done in the United Kingdom and in my reading of the full study, kindly provided to me by David Mendosa, I have more questions than answers, to the point of actually thinking junk research.

Some of the points that raise questions include:
#1. Data collected after the fact from laboratory reports.
#2. Data not from a randomized-controlled trail, although this is made as a suggestion by the researchers. Of course, they want more funds for this type of a trial.
#3. Dosage adjustments and other interventions are not documented.
#4. Data for too short a time frame.
#5. Data too general and not specific – example for those receiving quarterly A1c tests and had initial A1c greater than 7% had an A1c reduction of 3.8 percent. If the average were 8%, this would be greater than 7.1%.

I would agree with the research just in the fact that among our support group members, those that test quarterly have a lower overall A1c average than the two individuals that are tested on a six-month schedule.

Then there are those that use the home A1c test on a monthly basis, two members, and they have in general the best A1c levels. One is on insulin and one is on no medications. For more information on home testing read this blog by David Mendosa.

The practice pearls offered by the Diabetes in Control author are reasonable and I will quote them.
  1. While clinical guidelines are in place for HbA1c monitoring frequency, the recommended intervals are often not followed appropriately in practice.
  2. This study showed that following the recommended testing interval recommendation was associated with a lowered HbA1c, particularly in those patients with HbA1c's of >7%.
  3. Patients with testing intervals of 6 months or more were associated with increases in their HbA1c values.

The testing of A1c should not replace the testing done by individuals, but as a way of informing patients that their testing is either showing them that they are doing it right, or that they are not testing often enough or at the right time.

The recommendations by the ADA and AACE of relying only on the A1c by patients should never be followed, as this leaves the patient managing his or her diabetes in the dark and makes it more difficult to understand what is being done right or wrong.

If you have made it this far, you should read David's blog from yesterday.  He is able to put a positive light on the study.  I was upset by the false link provided by a fairly reputable service and let my negative side take over.  For this I make no apologies, as we need to be aware of weaknesses in studies and when studies are not telling us the whole story.