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.
