Diabetes Management under a Physician Shortage

In the next few years, what are we, as diabetes patients going to be able to do? There is going to be a physician shortage which we have been hearing about from doctors and their professional organizations. Even teaching professors are talking about this and a few patients. How long are we going to be forced to wait between appointments and think about how much time the doctor spends with you now. This can only be worse and your questions may not even be answered.

Ann Bartlett, who writes at Health Central dot com has an excellent blog on July 17 that deserves your attention. She is a type 1 and in this blog writes for all people with diabetes. Because of what she writes about the numbers of practicing endocrinologists, I will disagree with her statement that everyone should see an endocrinologist at least once a year. Some people will do very well in the early stages of diabetes, especially those with type 2 diabetes that do not need to lose weight or that are able to manage their diabetes with nutrition and exercise. Many people do probably need to lose some weight and are capable of doing so.

Where I do agree that people with type 2 needing to see an endocrinologist are those people with complex diabetes and often comorbidities requiring more attention than a primary care physician (PCP) has time to devote to the patient. Many of these patients are in the need of insulin therapy, but the PCP has not kept abreast of the knowledge required and so won't prescribe insulin. Instead, he has stacked one oral medication on top of another and in some unusual cases, the patients are taking up to four different oral medications. Too many and most of the time they still are having trouble maintaining good A1c's.

Ann is right when she says, “Third-party insurance providers, the big bad boy of this debate, are finally hearing the bell toll, and need to start offering fair reimbursement to doctors for services rendered.” Unfortunately, with the Centers for Medicare and Medicaid Services not expanding their payment to PCPs and endocrinologists, the rest of the insurance industry will not step forward and help, as they want to grow their profit margin. So our doctors are continually squeezed in the pocketbooks and wallets.

As a result, I will continue to advocate for state medical boards to loosen their strangle hold on nurse practitioners and physician assistants and allow them to operate with more independence. This blog has a map showing the states that are allowing NPs the freedom to practice medicine without supervision. Only 18 states are presently allowing this. It is a shame that the same information is not available for PAs. My endocrinologist has at least two NPs on his staff and I see one of them. I also see a NP at my Veterans Affairs (VA) appointments and I am very happy with both.

The American Association of Diabetes Educators (AADE) could really help with education, but at present, they are reluctant to do so. I have been on their case for some time now and all it has gotten me is derogatory emails. Even my CDE cousin will not talk to me anymore because she knows I am serious.

The AADE is not adding CDEs at a rate needed to serve patients adequately. Therefore, the AADE should be required to open up a classification or group for peer-to-peer workers and peer mentors, give them some training and classes, and let them move out into the diabetes community and help people with all types of diabetes. Then they should provide continuing education for them. This is supported by several studies where peer-to-peer workers have helped other type 2 patients lower their A1c's. This would work for type 2 helping type 2's and type 1 helping type 1's.

Even the ADA and AADE Task Force that developed the Diabetes Self Management Educations (DSME) and the Diabetes Self Management Support (DSMS) National Standards included lay people and peer workers in the area requiring more research, yet the AADE has chosen to ignore this. Oh, yes, they will take credit for the CDC programs that they participate in for training peer workers, but will they open a designation for them and continue to assist them with more education – no. They can't wait to be separate from them and let them go their way. This is not the correct attitude to my way of thinking, especially with the shortage of certified diabetes educators.

Fortunately, some doctors in rural areas and some not so rural areas are seeing the need for peer-to-peer workers and peer mentors and having them educated. Then they are returning to help their doctor and other doctors in their areas. One doctor that I started to work with in Montana, now has three peer mentors in three chronic diseases doing what needed to be done for education of his patients.

Another area that needs to be opened up is telemedicine where doctors could practice across state borders and others could assist people in doctor sparse regions of the country.

What To Consider in a Blood Glucose Meter

Are you confused by all the hype about blood glucose meters? You should be and there is a lot of hype. Every writer approaches this from a different perspective and promotes what they feel is best. There are some general guidelines that it is often wise to follow. I want it understood that I am not promoting any meter over another, but I do urge you to consider the points I lay out and do not be afraid to talk to pharmacists and others that may assist you and provide guidance.

#1. What will your medical insurance cover. This is often what will determine the type of meter that you will chose because the cost of test strips can be prohibitive and you may need to consider this first.

#2. If you do not have insurance, then economic considerations may be the most important. There are economical meters and test strips available that are reliable and that do not have all the bells and whistles that many people think they need and never use.

#3. If you are one of the fortunate people with few economic barriers and chose to go outside your insurance, then you have a wide range of considerations in making a choice.

Once you have determined which of the above applies to you, now the choices become even more difficult. They may be very limited in selection or you may have a wide range to choose from. This will depend on your insurance company and there are some real issues under Medicare which have yet to be resolved. Unless the courts act soon, many on Medicare may be caught with no supplies.

TV ads are very deceptive and often misleading, yet many people become suckered in and spend the money. Then when they receive the meter and test strips, they realize that they have been had, but there is seldom a way to return them. These companies will be very evasive in an attempt to make you keep what you ordered.

Many of the TV ads advocate for alternate site testing and this is okay if you seldom have a hypoglycemic episode and are fairly consistent in your readings from your fingertips. You need to know that the reading you receive from an alternate testing site is an indication from 15 to 25 minutes ago depending on the area used for alternate testing. Also, there are very few alternate test sites that are totally pain free. I urge anyone on insulin not to consider alternate site testing because if you are having a low, you need the now readings of your fingertips.

Many people were enticed into the talking meters and then wondered what to do when they were out in public. I have heard them in restaurants and other places and people just could not muffle the sound. So if you are a person desiring secrecy, forget these, as secrecy is next to impossible.

If you have a computer, you may wish to consider a meter that will upload to your computer. Normally the cost is for software and a cable from a USB port to the meter.

These two blogs seem to think you have all the choice and can purchase any meter which may not be the case.

There is a growing concern about the test strip accuracy and I strongly urge people to read two blogs of many (this one by Ann Bartlett and this one on Diabetesmine) about the declining accuracy and that apparently no one is doing anything about it. I can only feel fortunate that I have one of the top two meters listed in several reports – meaning that the tests strips are considered the most accurate.

Don't Get Caught in This Hospital Greed Trap

In April, I was in the hospital because they could not determine whether I was suffering from heart problems or severe indigestion. Shortly after being put in a room, I received a paper to sign saying that I was admitted as an outpatient and not as an in-patient. Since I knew what this meant, I asked to be discharged.

Guess what they told me? They would not discharge me as I needed to remain for observation. I requested a second time and refused to sign the paper because I knew that the total bill would become mine as Medicare and my supplement insurance would not cover anything but some of the tests. I knew that once the diagnosis was for severe indigestion that all the heart tests were going to be charged to me as well and they kept doing them even though I tried to refuse them. Surprising what some sedatives can do to your will to prevent the continual testing.

They even continued to push the paper for me to sign in front of me which I somehow was able to keep from signing. Even during discharge they tried to slip it in, but I still did not sign it. Now I have the Medicare statement showing what they did and did not pay for and the hospital and I will continue to argue about the bill. Medicare did cover the first blood work only to show that I had no enzymes from a heart attack and the first EKG showing no heart irregularities, but they paid for no more of the tests the hospital insisted I needed.

Medicare did pay for the medications for the severe indigestion for the first day only and then stopped that since I should have been switched to over the counter medications. This leaves me with a substantial medical bill which I will not be able to pay and they wonder why I wanted to be discharged. Next time I will discharge myself, if I even allow myself to be admitted. Yes, I will do this “against medical advice” and think nothing about it. I am tired of the hospital greed.

I regret now that I even went to the emergency room. Yes, I bypassed the ambulance services because of my experiences with them before, where I was forced to pay for their services because they incorrectly submitted the bill to my insurance. Plus, the ambulance is required by Medicare to take me to the local hospital which I refuse to let happen.

I was fortunate that my diabetes supplies and medications were not taken away from me and I was able to maintain reasonable control of my diabetes against doctors orders. He wanted my blood glucose levels at 180 mg/dl minimum, and I was constantly at 120 mg/dl to 145 mg/dl. When he finally figured out what was happening, I was being discharged. Prior to that, the nurses only knew that I was refusing to eat the hospital food except for some sugar free jello. The diabetic meals were carb loaded and beyond what I could handle. Even the tea was loaded with sugar and I could taste it and refused to drink it. The one nurse even poured a little in a small cup, spit it out, and had to agree with me.

Well, these are lessons learned and not to be repeated.

FDA Says It Shut Down 1677 Online Pharmacies

This has to be serious when the FDA and Interpol cooperate to bring down 1677 websites selling counterfeit and substandard medications. I can only say good and maybe many of these sites will not reappear as they so often do. Only arresting 58 people is small potatoes though, but seizing more than $41 million worth of illegal medicines will be a temporary hurt for most of these businesses considering the billions in profits they rake in every year.

Either way, I am happy to see that this has happened and can only hope that they can step up this sort of action. The main points in determining if the online pharmacy is abiding by federal and state laws are the following and can be read here. I will still give the main points, as these are important to know.

The signs of a rogue Web site are as follows: Quoting

1. No prescription required: Internet drug outlets are suspect if they dispense prescription medicine without requiring the patient or doctor to submit a prescription, or without contacting the patient’s doctor to obtain a valid prescription.
2. Prescription based solely upon online questionnaire: Be wary of Internet drug outlets that dispense prescription medicines based solely on the patient completing an online questionnaire without having a pre-existing relationship with the doctor, including an in-person physical examination. Most state boards of pharmacy, boards of medicine, US Food and Drug Administration, US Drug Enforcement Administration, the Federation of State Medical Boards, the American Medical Association, and NABP agree that this practice is illegal or fails to meet the standard of care.
3. No phone number or street address: Internet drug outlets should have a toll-free phone number as well as a street address posted on their Web sites. Drug outlets that allow customers to communicate with them only by e-mail should be avoided.
4. No pharmacist consultation: Legitimate pharmacies allow patients to contact pharmacists if they have questions about their medications, whether by phone or secure Web-based communication.
5. Waivers: Legitimate pharmacies do not require patients to sign waivers to place the patient in legal jeopardy or waive all rights before providing medication.
6. Limited medicines: Many untrustworthy Internet drug outlets offer only a limited number of medicines, particularly “lifestyle” or controlled substance medicines that treat such conditions as impotence, obesity, herpes, pain, and acne.
7. International Web sites: Because foreign medicines purchased online are unapproved and not subject to the safety and efficacy standards of US Food and Drug Administration, their authenticity, purity, and safety are unknown. The safety and security of the sources from which these Web outlets obtain foreign medicines is also unknown. Some Web outlets that claim to be Canadian pharmacies actually sell medicines obtained from developing countries in Asia, Central America, the Middle East, or Eastern Europe, where regulations are more lax, and the prevalence of counterfeit medicines is significantly higher than in the United States.
8. Spam solicitations: Many Internet operations that advertise through unsolicited e-mail messages (i.e., spam) operate illegally and are not a trustworthy source for obtaining anything, especially something as critical as prescription medicine. According to the Federal Trade Commission, spam e-mails can infect computers with spyware that can slow computer performance, install software that can record and report a customer’s every keystroke, spread computer viruses, and “hijack” a consumer’s computer to distribute more spam. Deceptive spam is also sometimes used to trick consumers into divulging sensitive or personal information, including credit card numbers and other financial data.

Trisha Torrey also speaks out about the same CNN News release and gives her thoughts. For more information about the safety of American drugs, read this by Trisha Torrey and follow some of the links she provides. Even our fellow countrymen are cashing in on counterfeit drugs and spreading them out to different distributors in our own drug-buying suppliers. Even some of our trusted pharmacies are duped by the counterfeit drug suppliers.

Insulin's Place in Type 2 Diabetes Treatment

This is scientific research at its poorest. When it comes to certain oral medications and their comparison or companionship with insulin, researchers do not want to expend the resources required or the time. The drug companies, of course, will not admit that there is anything at fault with their drugs and therefore will not help with any funding. And then we have the self-anointed “experts” at the American Diabetes Association and the American Association of Clinical Endocrinologists saying that the oral medications are the first line of treatment for type 2 diabetes. When you examine the funds that the two associations receive from Big Pharma, you will understand why they would say this.

And when people will make statements like this, “In some cases, insulin is the only therapeutic option remaining,” what does this tell us? Bold is my emphasis. This has to mean that doctors have waited too long to switch to insulin therapy and have forced patients to remain on oral medications longer than should have been used. Not only have doctors done harm to patients, they don't seem to care if they can avoid prescribing insulin. This is why we need more research and well funded research to identify people that have been kept on oral medications too long.

We also need research to identify problems researchers are loathe to do because they might learn something that could prevent certain oral medications from being used with insulin.

In this study, an epidemiologic analyses, they are able to establish associations between medications and outcomes, but they can never be completely positive that the findings are unbiased. Even though many covariates were included, such as the duration and glycemic control of diabetes, one factor is fairly important, the risk of each individual outcome produced similar results suggests 1 of 3 possibilities. These are that the residual confounding remains, the outcomes are associated with each other, or that they share the same causing event.

In this, the researchers blame insulin and quote previous studies for what they lack in results and then they do what is expected for a lackluster study and say that caution is warranted and demand further study. This tells me that their study was flawed to begin with and not well planned. Why they received funding for these flawed studies still remains a mystery and why the group or committee overseeing the funding allowed the study needs investigation. Funds for studies will continue to be short in the current economy, yet poorer and more faulty studies are being funded.

As a side note, it is interesting that metformin plus insulin went a long way to lessening the increased risk found in insulin monotherapy. This may be the impetus for continuing to add metformin when insulin therapy becomes necessary.

In a recent blog here, I discussed PCORI. PCORI is the Patient-Centered Outcomes Research Institute, and is a new federal institute mandated to figure out how meaningfully to involve patients in research. Under PCORI, patients will have the rare opportunity to help make decisions about what research is conducted, some of the design, and to be involved in the research activity from the beginning. After all, isn't it the patients with the disease that have the most at stake and the largest to gain from research?

I also think there is much to be gained from research conducted under PCORI. This may also open the door to putting patients on some committees overseeing funding approvals at academic centers that are currently mishandling research funds for poorly constructed studies. I can envision patients with the disease being placed on funding boards and in other capacities for oversight.