The NY Times turns an eye to the economics of treating diabetes as an acute disease (amputations, dialysis) vs a chronic one (nutrition counseling, training in glucose monitoring). Guess who wins? In the Treatment of Diabetes, Success Often Does Not Pay.
At four hospitals across the city, they set up centers that featured a new model of treatment. They would be boot camps for diabetics, who struggle daily to reduce the sugar levels in their blood. The centers would teach them to check those levels, count calories and exercise with discipline, while undergoing prolonged monitoring by teams of specialists.
But seven years later, even as the number of New Yorkers with Type 2 diabetes has nearly doubled, three of the four centers, including Beth Israel's, have closed.
They did not shut down because they had failed their patients. They closed because they had failed to make money. They were victims of the byzantine world of American health care, in which the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications.
The article covers a lot of issues for diabetes care and management that are shared with other chronic diseases as well:
- Patients not being counseled by their primary care physician to make changes in health behaviors (for example, patients who are obese not being told to lose weight).
- A fatalistic attitude on the part of these same physicians in being able to manage or treat the disease.
- The "time crunch" that makes in-depth behavioral counseling virtually impossible.
- Poor accessibility to specialists (in this case, endocrinologists).
- The cost of medical supplies (like test strips) that can strain the budgets of poorer patients and makes self-management a rhetorical priority rather than a national one. [OK, that was my soap box, not the reporter's.]
- A business model that rewards insurance for attracting the best (read 'healthy') customers, not the most - a reason why benefits and reimbursement policies do not favor people with chronic care conditions. At least an amputation or dialysis costs are fixed and predictable, and maybe they never have to pay out for them - the patient dies first [Whoops, did it again!]. And then of course, as the article notes, people tend to change their health care coverage every six years - though I have heard it's more like every three years, especially for those covered by their employer.
The remedy suggested by health economists is a restructuring of the financial and reimbursement mechanisms to better align supply and demand and meet health care goals. I suggest another idea that refers back to the Ottawa Charter for Health Promotion (a curiously neglected document in the US that serves as the benchmark for national health promotion programs around the world): reorient health services. I don't believe financial carrots and sticks (price mechanisms) will completely accomplish the job. The country needs to look at its medical care (prevention included) products and services, the accessibility of various segments of our population to opportunities for self-care and health care, and the promotion of health behaviors to which many people aspire (see yesterday's NYT article) but are undermined by more muscular and effective promotions and marketing (or just inattention) from other sources.
For those grappling with health care policy issues, what can social marketing bring to the table - not simply in launching a "national campaign" of one sort or another, and putting more money into an advertising agency's pocket, but by contributing to real market-based analysis and approaches to reform?
Oh, and the one diabetes center that is still operating in NYC is just barely doing so - assisted by over $20 million in private donations. As one person was quoted in the article: "Diabetes centers are for hospitals what discounted two-liter bottles of Coke are to grocery stores," she said. "They are not profitable but they're sold to get dedicated customers, and with the hospitals the hope is to get customers who will come back for the big moneymaking surgeries."
Technorati Tags: Diabetes, Disease Management, Health Care Policy
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