January 14, 2015
Diabetes, Why Isn't Medicine Doing What It Should?
This was published in the British Journal of Diabetes and Vascular Disease. Some of you might like to read the article. In reading this, I have to wonder why the doctors in the United States cannot do anything right. For this, I think some of the blame belongs to the American Diabetes Association and the American Association of Clinical Endocrinologists. More of the blame belongs to the certified diabetes educators that do not educate, but use mandates and mantras.
Most of the blame has to fall on our medical insurance industry that listens to the Centers for Medicare and Medicaid Services (CMS), especially now that the insurance industry has learned how to sidestep the no prior exclusion part of the Affordable Care Act, by almost monthly changing the formulary from which they will reimburse for diabetes and other medications. Some insurance companies are doing exactly this and as a result, many people with diabetes are having a difficult time staying on one medication that is doing well for them. Some of the better companies are consistent in their formulary which is a good thing.
Diabetes care cannot prevent complications in every patient, but surely, doctors could prevent much of the tissue damage that happens in their patients' lives. Unlike in England, here the electronic medical records (EMRs) are very proprietary so that data on diabetes is impossible to obtain. Presently there is not a government agency that can collect data on a national basis to track diabetes and what works and what does not work. These same government agencies rely on information provided on a voluntary basis, which leaves gaping holes in the successes and adverse events that happen with diabetes medications.
The information collection and sharing needs to improve or more doctors will be leaving the practice of medicine. Yet, with the government not staying ahead of the progress, it could be another decade or more before EMRs become usable for the benefit of all – government, health care providers, and patients. Maybe then, the insurance industry will be forced into compliance.
The United States medical system relies on voluntary reporting for much of the data that the different government agencies rely on and report to the public. They cannot give accurate numbers of people at different ages with any type of diabetes. They presently use algorithms for most reporting which gives a very good estimate, but not an accurate number.
When people with diabetes are in the hospital, care has been improving, but still too many errors happen. The first is some nurses that don't understand the ratio for insulin to grams of carbohydrates for each individual. Then many doctors over use basal insulin and cause hypoglycemia. The other big problem is that the food plan for people with diabetes that is promoted by dietitians. It is overloaded with carbohydrates at a time our body needs fat and protein to aid healing, but the dietitians will not allow this.
I can understand that young doctors are less likely to choose Diabetes and Endocrinology as a career. It is a well-known fact that medical, nursing, and other healthcare students have little training in diabetes. There are not enough certified diabetes educators to serve the current diabetes population and with the projected increase, there is little effort to train more. One CDE organization says they are working on this, but when everything is tied up in committee, who is to know what intentions have priority. The other CDE organization is trying to put a strangle hold on who can practice as a CDE. Both organizations work with so few people with type 2 diabetes that I must wonder when they will force their members to stay away from mandates and mantras and start teaching diabetes education.
Until the Federal and State governments start requiring insurance to cover telemedicine, little growth in treating rural diabetes patients will happen. When I think of the diabetes education that could be taught by a form of telemedicine, it stinks that most healthcare providers will not use this. Then we have other medical professions working to stop telemedicine through state medical boards. This is protectionism rather than education at its worst.