Why Diabetes Prevention and Management and the U.S. Health Care System Are At Odds

Diabetes Current-State and Changes to Come

Unless you are Cro-Magnon-man and just emerged from a glacial field you are probably aware of some of the 2010 health care reforms. This article reviews how the United States got to be in such poor shape, health-wise and how some provisions of the 2010 reforms will create incremental changes.
Since I am nearly finished with my second book, the Russell Guide for Diabetes: Type I or Type II This Could Happen To You, let me share some mind boggling information about this scourge. The American statistics on this disease have a huge impact on government funded health plans, including Medicare and these metrics from the CDC explain why :
• The proportion of diagnosed diabetics in the United States has increased by more than 50% since 2007; 17.7 million in 2007 and 25.5 million in 2010
• Fully one third of the U.S. population is expected to be diabetic by 2025; 115 million
• In 2010 18.7% of the 25,564,000 U.S. residents diagnosed as diabetic were African Americans and 10.2% of that number were non Hispanic ( White)
• More than 90% of all diabetics are Type II, which is controllable by diet and exercise
• The CDC estimates that 33% of the country is in pre-diabetic mode in 2011

Obesity
Type II Diabetes is caused from obesity and a diet high in simple sugars and carbohydrates (think fast food, doughnuts, etc,) Being over-weight significantly increases your chances of becoming diabetic. I think it is time we Americans call a-spade-a-spade, so if one of these criteria fit you are fat:
1. 20 lbs. over weight-Yes, you are fat
2. 50 lbs. overweight-This qualifies you as obese
3. 100 or more lbs. overweight-Then you are exogenously obese
4. Body Mass Index or BMI exceeds 30 you are fat
5. If you have to replace the shocks on the driver’s side of your car more frequently than the passenger side, this is a clue that your girth has impacted vehicular performance.
6. If you have broken chairs in your house or someone else’s by sitting in them, yes my friend you are fat.
7. If you need to buy your clothes at Tacoma Tent and Awning, need I say more?
It is time we as Americans put down the doughnuts and look in the mirror. The country needs to go on a 12-Step Program for Over Eaters Anonymous. No more excuses, just bust a hump and get out there. Like everyone else I have had to battle-the-bulge as I’ve aged, but so far I do not qualify in any of the categories above.

Diet
Food is fuel and it really does matter what you consume. If you are going to persist in a diet that is high in simple sugars, lacking in fiber, and complex carbohydrates, it is similar to starving your body of essential food, so it craves more food. Diets which are high in “the whites” meaning white rice, white pasta, white bread, and sugar cause spiking in glycogen which is what the body creates when it breaks down food. Foods that convert to simple sugars cause the glycogen rush and over time damage the pancreas which ultimately ceases to work properly. At that point, listlessness, fatigue, and a sudden weight loss may be symptoms of diabetes. The United States has at least 5 million more people who are undiagnosed diabetics. The later diabetes is diagnosed the worse the damage is to the body systems. Here are some tips on wise food choices:
1. The large pizza is not intended for one person
2. 32 ounces of a soda-you may as well drink three beers calorically speaking; put down that big gulp unless you want the catheter that goes with it when you are on kidney dialysis later

What Happens If America Doesn’t Slim Down
Diabetes was the 7th leading cause of death in the United States as reported by the CDC for 2006 and it is advancing all of the time. And death from diabetes is not a quick process, but a torturous route of injections, circulatory problems (including amputations), hyper tension, and kidney failure. In the United States, 40% of diabetics end up on kidney dialysis. These metrics contrast sharply with other industrialized countries that have much lower renal failure rates, such as Austria at 30% or 34% in Germany. Life expectancy for someone on kidney dialysis in the United States is only a few years.

The link between heart failure and kidney dialysis is pronounced and a 2011 study showed that 36.1% of dialysis patient had high blood pressure, 38.2% had a history of heart infection, and 25% had excessive weight gain between dialysis sessions. All of these symptoms are exacerbated by the dialysis treatment process in the United States, which pushes patients to conform to business practice hours and not optimal clinical outcomes.

What are the Costs
The U.S. Medicare program has financed the cost for kidney dialysis for all persons who have Social Security numbers and are legal residents since 1973. President Nixon signed the legislation and at that time renal dialysis cost $12,273 per patient and 11,000 people needed it in the country. Fast forward to current time and dialysis now costs $77,000 per patient and there are over 350,000 people on it. The vast majority of people on dialysis are diabetic, with age being correlated with an increased incidence of renal failure. In 2010, Medicare spent 20 billion dollars on the renal dialysis program.

What Can Be Done
The vast majority of renal dialysis centers in the United States are operated by for-profit companies, like DaVita, fueled by Medicare’s reimbursement policy which rewards the process not clinical outcomes for dialysis centers. This may all be changing with President Obama’s endorsement of the Comparative Effectiveness Research Institute in 2010. This institute will look at clinical processes and outcomes across systems and compare them to global data to find ways for improvements. For example, the mortality or death rate for patients on kidney dialysis is much worse in the U.S.A. than in other industrialized countries, so this needs to be reviewed. And of course, a much greater percentage of American diabetics end up on dialysis than in other countries.

Another aspect of the 2010 Health care reforms was to require insurance companies to offer wellness or preventive care benefits. In my former career in the insurance business there was always a lot of teeth gnashing over offering preventive benefits because the industry promoted the idea the employees should pay for this service themselves. The industry also discouraged low co-payments or cost sharing as a means to lower the insurance premiums for the employer group. The problem with this mentality is it is inherently short term and the health of a person is a long term process. This is just one example of how the insurance industry has been at odds with promoting health for our country. Though it should be obvious, let me state that by mandating a base level national health surveillance system, such as an annual physical, offered gratis, we can find the people that are hypertensive or pre-diabetic and prevent more serious health damage. By reaching out and treating people earlier we will save money in government funded health programs. In order to accomplish this goal as a nation the country needs to continue to look at aligning provider incentives and reimbursements to promote national health not just a medical service. The goal of the country should be to work towards optimizing the health of its citizens not just treating their illnesses and injuries . If private sector insurance is to be a part of that equation, disease prevention services that are measureable and effective need to be included. Perhaps another model could include national clinics where physicals are administered by public health officials, which would provide privacy for the employee who may not wish to share his personal health metrics with the employer. Despite all of the HIPAA privacy hype, I can assure you there are a myriad of ways for an employer to discover employee health data, especially for a group which is self-insured.

On that note the healthpolicymaven is going to sign off and log my eight miles, which I have averaged per day this year. I recommend that you also slam down that pizza and put on your shoes.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.