The ABC Homeopathy Forum
12.5% of New Yorkers are Diabetics.
New York TimesJanuary 9, 2006
Bad Blood
Diabetes and Its Awful Toll Quietly Emerge as a Crisis
By N. R. KLEINFIELD
Begin on the sixth floor, third room from the end, swathed in fluorescence: a 60-year-old woman was having two toes sawed off. One floor up, corner room: a middle-aged man sprawled, recuperating from a kidney transplant. Next door: nerve damage. Eighth floor, first room to the left: stroke. Two doors down: more toes being removed. Next room: a flawed heart.
As always, the beds at Montefiore Medical Center in the Bronx were filled with a universe of afflictions. In truth, these assorted burdens were all the work of a single illness: diabetes. Room after room, floor after floor, diabetes. On any given day, hospital officials say, nearly half the patients are there for some trouble precipitated by the disease.
An estimated 800,000 adult New Yorkers - more than one in every eight - now have diabetes, and city health officials describe the problem as a bona fide epidemic. Diabetes is the only major disease in the city that is growing, both in the number of new cases and the number of people it kills. And it is growing quickly, even as other scourges like heart disease and cancers are stable or in decline.
Already, diabetes has swept through families, entire neighborhoods in the Bronx and broad slices of Brooklyn, where it is such a fact of life that people describe it casually, almost comfortably, as "getting the sugar" or having "the sweet blood."
But as alarmed as health officials are about the present, they worry more about what is to come.
Within a generation or so, doctors fear, a huge wave of new cases could overwhelm the public health system and engulf growing numbers of the young, creating a city where hospitals are swamped by the disease's handiwork, schools scramble for resources as they accommodate diabetic children, and the work force abounds with the blind and the halt.
The prospect is frightening, but it has gone largely unnoticed outside public health circles. As epidemics go, diabetes has been a quiet one, provoking little of the fear or the prevention efforts inspired by AIDS or lung cancer.
In its most common form, diabetes, which allows excess sugar to build up in the blood and exact ferocious damage throughout the body, retains an outdated reputation as a relatively benign sickness of the old. Those who get it do not usually suffer any symptoms for years, and many have a hard time believing that they are truly ill.
Yet a close look at its surge in New York offers a disturbing glimpse of where the city, and the rest of the world, may be headed if diabetes remains unchecked.
The percentage of diabetics in the city is nearly a third higher than in the nation. New cases have been cropping up close to twice as fast as cases nationally. And of adults believed to have the illness, health officials estimate, nearly one-third do not know it.
One in three children born in the United States five years ago are expected to become diabetic in their lifetimes, according to a projection by the Centers for Disease Control and Prevention. The forecast is even bleaker for Latinos: one in every two.
New York, perhaps more than any other big city, harbors all the ingredients for a continued epidemic. It has large numbers of the poor and obese, who are at higher risk. It has a growing population of Latinos, who get the disease in disproportionate numbers, and of Asians, who can develop it at much lower weights than people of other races.
It is a city of immigrants, where newcomers eating American diets for the first time are especially vulnerable. It is also yielding to the same forces that have driven diabetes nationally: an aging population, a food supply spiked with sugars and fats, and a culture that promotes overeating and discourages exercise.
Diabetes has no cure. It is progressive and often fatal, and while the patient lives, the welter of medical complications it sets off can attack every major organ. As many war veterans lost lower limbs last year to the disease as American soldiers did to combat injuries in the entire Vietnam War. Diabetes is the principal reason adults go blind.
So-called Type 2 diabetes, the predominant form and the focus of this series, is creeping into children, something almost unheard of two decades ago. The American Diabetes Association says the disease could actually lower the average life expectancy of Americans for the first time in more than a century.
Even those who do not get diabetes will eventually feel it, experts say - in time spent caring for relatives, in higher taxes and insurance premiums, and in public spending diverted to this single illness.
"Either we fall apart or we stop this," said Dr. Thomas R. Frieden, commissioner of the New York City Department of Health and Mental Hygiene.
Yet he and other public health officials acknowledge that their ability to slow the disease is limited. Type 2 can often be postponed and possibly prevented by eating less and exercising more. But getting millions of people to change their behavior, he said, will require some kind of national crusade.
The disease can be controlled through careful monitoring, lifestyle changes and medication that is constantly improving, and plenty of people live with diabetes for years without serious symptoms. But managing it takes enormous effort. Even among Americans who know they have the disease, about two-thirds are not doing enough to treat it.
Nearly 21 million Americans are believed to be diabetic, according to the Centers for Disease Control, and 41 million more are prediabetic; their blood sugar is high, and could reach the diabetic level if they do not alter their living habits.
In this sedentary nation, New York is often seen as an island of thin people who walk everywhere. But as the ranks of American diabetics have swelled by a distressing 80 percent in the last decade, New York has seen an explosion of cases: 140 percent more, according to the city's health department. The proportion of diabetics in its adult population is higher than that of Los Angeles or Chicago, and more than double that of Boston.
There was a pronounced increase in diagnosed cases nationwide in 1997, part of which was undoubtedly due to changes in the definition of diabetes and in the way data was collected, though there has continued to be a marked rise ever since.
Yet for years, public health authorities around the country have all but ignored chronic illnesses like diabetes, focusing instead on communicable diseases, which kill far fewer people. New York, with its ambitious and highly praised public health system, has just three people and a $950,000 budget to outwit diabetes, a disease soon expected to afflict more than a million people in the city.
Tuberculosis, which infected about 1,000 New Yorkers last year, gets $27 million and a staff of almost 400.
Diabetes is "the Rodney Dangerfield of diseases," said Dr. James L. Rosenzweig, the director of disease management at the Joslin Diabetes Center in Boston. As fresh cases and their medical complications pile up, the health care system tinkers with new models of dispensing care and then forsakes them, unable to wring out profits. Insurers shun diabetics as too expensive. In Albany, bills aimed at the problem go nowhere.
"I will go out on a limb," said Dr. Frieden, the health commissioner, "and say, 20 years from now people will look back and say: 'What were they thinking? They're in the middle of an epidemic and kids are watching 20,000 hours of commercials for junk food.' "
Of course, revolutionary new treatments or a cure could change everything. Otherwise, the price will be steep. Nationwide, the disease's cost just for 2002 - from medical bills to disability payments and lost workdays - was conservatively put by the American Diabetes Association at $132 billion. All cancers, taken together, cost the country an estimated $171 billion a year.
"How bad is the diabetes epidemic?" asked Frank Vinicor, associate director for public health practice at the Centers for Disease Control. "There are several ways of telling. One might be how many different occurrences in a 24-hour period of time, between when you wake up in the morning and when you go to sleep. So, 4,100 people diagnosed with diabetes, 230 amputations in people with diabetes, 120 people who enter end-stage kidney disease programs and 55 people who go blind.
"That's going to happen every day, on the weekends and on the Fourth of July," he said. "That's diabetes."
One Day in the Trenches
The rounds began on the seventh floor with IrisRobles. She was 26, young for this, supine in bed. She wore a pink "Chicks Rule" T-shirt; an IV line protruded from her arm. For more than a year, she had had a recurrent skin infection. The pain overwhelmed her. Then came extreme thirst and the loss of 50 pounds in six weeks. In the emergency room, she found out she had diabetes.
She was out of work, wanted to be an R & B singer, had no insurance. It was her fourth day in Montefiore Medical Center. Her grandmother, aunt and two cousins have diabetes.
"I'm scared," she said. "I'm still adjusting to it."
Next came Richard Dul, watching news chatter on a compact TV. Now 64, he has had diabetes since he was 22. A month before, he had a blockage in his heart and needed open-heart surgery. He was home a few days, but an infection arose and he was back. Postoperative infections are more common with diabetes. This was his 21st straight day in the hospital.
Here, then, was the price of diabetes, not just the dollars and cents but the high cost in quality of life.
Simply put, diabetes is a condition in which the body has trouble turning food into energy. All bodies break down digested food into a sugar called glucose, their main source of fuel. In a healthy person, the hormone insulin helps glucose enter the cells. But in a diabetic, the pancreas fails to produce enough insulin, or the body does not properly use it. Cells starve while glucose builds up in the blood.
There are two predominant types of diabetes. In Type 1, the immune system destroys the cells in the pancreas that make insulin. In Type 2, which accounts for an estimated 90 percent to 95 percent of all cases, the body's cells are not sufficiently receptive to insulin, or the pancreas makes too little of it, or both.
Type 1 used to be called "juvenile diabetes" and Type 2 "adult-onset diabetes." By 1997, so many children had developed Type 2 that the Diabetes Association changed the names.
What is especially disturbing about the rise of Type 2 is that it can be delayed and perhaps prevented with changes in diet and exercise. For although both types are believed to stem in part from genetic factors, Type 2 is also spurred by obesity and inactivity. This is particularly true in those prone to the illness. Plenty of fat, slothful people do not get diabetes. And some thin, vigorous people do.
The health care system is good at dispensing pills and opening up bodies, and with diabetes it had better be, because it has proved ineffectual at stopping the disease. People typically have it for 7 to 10 years before it is even diagnosed, and by that time it will often have begun to set off grievous consequences. Thus, most treatment is simply triage, doctors coping with the poisonous complications of patients who return again and again.
Diabetics are two to four times more likely than others to develop heart disease or have a stroke, and three times more likely to die of complications from flu or pneumonia, according to the Centers for Disease Control. Most diabetics suffer nervous-system damage and poor circulation, which can lead to amputations of toes, feet and entire legs; even a tiny cut on the foot can lead to gangrene because it will not be seen or felt.
Women with diabetes are at higher risk for complications in pregnancy, including miscarriages and birth defects. Men run a higher risk of impotence. Young adults have twice the chance of getting gum disease and losing teeth.
And people with Type 2 are often hounded by parallel problems - high blood pressure and high cholesterol, among others - brought on not by the diabetes, but by the behavior that led to it, or by genetics.
Dr. Monica Sweeney, medical director of the Bedford-Stuyvesant Family Health Center, offered an analogy: "It's like bad kids. If you have one bad kid, not so bad. Two bad kids, it's worse. Put five bad kids together and it's unmanageable. Diabetes is like five bad kids together. You want to scream."
The Caro Research Institute, a consulting firm that evaluates the burden of diseases, estimates that a diabetic without complications will incur medical costs of $1,600 a year - unpleasant, but not especially punishing. But the price tag ratchets up quickly as related ailments set in: an average $30,400 for a heart attack or amputation, $40,200 for a stroke, $37,000 for end-stage kidney disease.
One of the most horrific consequences is losing a leg. According to the federal Agency for Healthcare Research and Quality, some 70 percent of lower-limb amputations in 2003 were performed on diabetics. Sometimes, the subtraction is cumulative. One toe goes. Two more. The ankle. Everything to the knee. The other leg. Studies suggest that as many as 70 percent of amputees die within five years.
Yet medical experts believe that most diabetes-related amputations are preventable with scrupulous care, and that is why the offices of conscientious doctors post signs like this: "All patients with diabetes: Don't forget to bare your feet each visit."
To witness the pitiless course that diabetes can take, simply continue on the hospital tour. This one day will do. Dr. Rita Louard, an endocrinologist, and Anne Levine, a nurse diabetes educator, were making their way through the rooms at Montefiore.
Here was Julius Rivers, 58, on the sixth floor. Three years with diabetes. He had been at home in bed when he saw a light like a starburst and told his wife to take him to the emergency room. His blood sugar was 1,400, beyond the pale. (A fasting level of 126 milligrams per deciliter is the demarcation point of diabetes.)
This was his third trip to the hospital in seven months. At the moment, he had a blood clot in his left leg. He had a heart attack a few years ago. He was on dialysis. "Tuesday, Thursday and Saturday," he said.
On the sixth floor was Mauri Stein, 58, a guidance counselor, a diabetic for 20 years. She had been at a party recently and "zoned out." Her words slurred. Foam appeared on her mouth. She had had a mild stroke.
Now she tried to control her emotions, tried not to cry. She had had repeated laser surgery on her eyes, and was effectively blind in one. She had recovered from the stroke, but doctors had also found a tumor on her heart and said it would need surgery.
"My feet burn," she said. "My toes burn all the time. My days of wearing my pumps are over. I've gotten more cortisone shots in my feet than I'm sure are legal."
She mentioned her brother, who lived in California. Diabetes had ransacked his body - an amputation, kidney dialysis, heart disease, blindness in one eye. He now resided in an assisted-living center. He was 53.
Ms. Stein's husband walked in and sat on the bed. Six months ago, he found out the same truth: he had diabetes.
This was one day in one hospital.
Inside the Incubator
Little about diabetes is straightforward, and to comprehend why New York is such an incubator for the disease, it is necessary to grasp that diabetes is as much a sociological and anthropological story as a medical one. While it assaults all classes, ages and ethnic groups, it is inextricably bound up with race and money.
Diabetes bears an inverse relationship to income, for poverty usually means less access to fresh food, exercise and health care. New York's poverty rate, 20.3 percent, is much higher than the nation's, 12.7 percent.
African-Americans and Latinos, particularly Mexican-Americans and Puerto Ricans, incur diabetes at close to twice the rate of whites. More than half of all New Yorkers are black or Hispanic, and the Hispanic population is growing rapidly, as it is around the nation.
Some Asian-Americans and Pacific Islanders also appear more prone, and they can develop the disease at much lower weights. Asians constitute one-tenth of New York's population, more than twice their proportion nationwide.
The nature of these groups' susceptibility remains under study, but researchers generally blame an interplay of genetic and socioeconomic forces. Many researchers believe that higher proportions of these groups have a "thrifty gene" that enabled ancestors who farmed and hunted to stockpile fat during times of plenty so they would not starve during periods of want. In modern America, with food beckoning on every corner, the gene works perversely, causing them to accumulate unhealthy quantities of fat.
But the velocity of new cases among all races has accelerated significantly from just a few decades ago. Genetics cannot explain this surge, because the human gene pool does not change that fast. Instead, the culprit is thought to be behavior: faulty diet and inactivity. Dr. Vinicor, of the Centers for Disease Control, likes to use this expression: "Genetics may load the cannon, but human behavior pulls the trigger."
Of the country's spike in diabetes cases over the last two decades, C.D.C. studies suggest that about 60 percent stem from demographic changes: a population increasingly comprising older people and ethnic groups with a higher risk.
The studies ascribe the other 40 percent to lifestyle changes: the fundamental shift that has people eating jumbo meals and shunning exercise as if it were illegal. At every turn, technology has made physical activity unnecessary or unappealing. Gym class has largely been deleted from schools. Fewer than a third of junior high schools require physical education at all, the C.D.C. says.
On the whole, New York's corpulence is below the national average, with 20 percent of adults qualifying as obese, compared with 30 percent for the country, the C.D.C. says. But the figure is much higher in poor areas like the South Bronx and East Harlem.
When the health department studied diabetes in the city's 34 major neighborhoods, the distribution echoed demographic patterns: Diabetes left only a light imprint on more affluent, white areas like the Upper West Side and Brooklyn Heights. The prevalence was about average in working-class Ridgewood, Queens, and almost nil on the Upper East Side.
But that apparent immunity is weakening. Of those 34 neighborhoods, 22 already have diabetes rates above the national average, and the numbers are rising all over as the city continually remakes itself.
"New York is switching from a mom-and-pop type of environment to a chain-store type of environment, a proliferation of fast food, even in high-rent neighborhoods they haven't had access to before, like the East Village and Lower Manhattan," said Peter Muennig, an assistant professor of health policy and management at Columbia.
If changes in daily living can bring on diabetes, they can also delay it, though it is uncertain for how long.
A federal program studied people around the country at high risk of getting diabetes, and concluded that 58 percent of new cases could be postponed by shifts in behavior - most notably, shedding pounds.
But Dr. Frieden, New York's health commissioner, says meaningful prevention cannot be achieved at the city level. "I can urge people until I'm blue in the face to walk and take the stairs and eat less, and it won't make much difference," he said.
His emphasis is on trying to better treat those who already have diabetes, an ambitious goal in its own right. Most primary care doctors treat too many patients to provide the attention that diabetics need, or to check for the disease, he said. Specialists are scarce. And compliance among patients is notoriously poor.
Even the most basic step in controlling the disease - watching one's blood sugar - is too much for many diabetics. Doctors recommend that two to four times a year, patients take a so-called A1c test, which gauges the average sugar level over the prior 90 days and is more revealing than daily at-home measurements.
But in 2002 , the health department found that 89 percent of diabetics did not know their A1c levels. Of those who did, presumably the most conscientious, four out of five had readings over the level the American Diabetes Association says separates well-controlled from poorly controlled diabetes.
The patients in the survey were not much better at knowing their blood pressure and cholesterol, which are also crucial for diabetics to control.
"Diabetes is an interesting beast," said Dr. Diana K. Berger, who heads the diabetes division at the health department. "It's probably one of the easier conditions to diagnose but one of the hardest to manage."
Shortages and Shipwrecks
There is an underappreciated truth about disease: it will harm you even if you never get it. Disease reverberates outward, and if the illness gets big enough, it brushes everyone. Diabetes is big enough.
Predicting the path of a disease is always speculative, but without bold intervention diabetes threatens to hamper some of society's most basic functions.
For instance, no one with diabetes can join the military, though service members whose disease is diagnosed after enlisting can sometimes stay. No insulin-dependent diabetic can become a commercial pilot.
Shereen Arent, director of legal advocacy for the American Diabetes Association, says she already fields 150 calls a month from diabetics who complain that they are being discriminated against in the workplace, double the number just a couple of years ago. She mentioned a typical case, a man rejected for a job at a baked-bean factory in Texas as a safety risk. "If this continues," she said, "we're in big trouble."
Dr. Daniel Lorber is an endocrinologist in Queens who thinks a lot about the disease's present and future. "The work force 50 years from now is going to look fat, one-legged, blind, a diminution of able-bodied workers at every level," he said, presuming that current trends persist.
As more women contract diabetes in their reproductive years, Dr. Lorber said, more babies will be born with birth defects. Those needy babies will be raised by parents increasingly crippled by their diabetes.
"At a time when we are trying to shift health care out of hospitals, with diabetics you don't have a choice," he said. "Nursing homes are going to be crammed to the gills with amputees in rehab. Kidney dialysis centers will multiply like rabbits. We will have a tremendous amount of people not blind but with low vision. And we have lousy facilities in this country for low-vision problems. These people will not be able to function in society without significant aid."
Cost pressures have been slashing the number of hospital beds, and some exasperated doctors are known to denigrate advanced diabetics as "shipwrecks," because they have so many health problems and virtually live in the hospital.
Not only will the future mean too few beds and unsupportable drains on Medicaid and Medicare, Mr. Muennig said, but if an emergency strikes - a terrorist attack, an earthquake - the city health system's ability to respond may be compromised because all the beds will be full of diabetics.
Most schools do not have full-time nurses. Some public schools, Ms. Arent said, try to turn away children with diabetes, even though that is illegal. Others ban them from field trips and sports teams. And this is now, when diabetes is still relatively rare among children.
If trends continue, people will live through years blighted by disability, then die too young. Diabetes is thought to shave 5 to 10 years off a life.
"Life expectancy usually decreases because there's a plague or there's a massive economic trauma," Mr. Muennig said. "In this case, we will see a decline in life expectancy due to a chronic condition."
In 2003, diabetes vaulted past stroke and AIDS from the sixth-leading cause of death in New York to the fourth. It was fifth, slightly behind stroke, in 2004. But the health department says it believes the actual toll is much worse because doctors who fill out death certificates may ascribe the death to a complication rather than to the diabetes at its root. Lorna Thorpe, deputy health commissioner, combed through medical charts and concluded that diabetes should be third, trailing cardiovascular disease and cancer.
Laurie Raps is a claims representative for Social Security on Staten Island, 31 years on the job. From her perspective, interviewing people embarking on full-time disability, she has seen the disease's long tentacles. When she started, she saw people in their 50's and 60's, hobbled by the usual problems of age: arthritis, herniated discs, heart conditions. Now, every week, she gets diabetic after diabetic, people as young as 30.
In fact, a 2004 study by UnumProvident, a major provider of disability insurance, found that the number of workers filing claims for Type 2 diabetes doubled between 2001 and 2003.
"It's a double whammy," Ms. Raps said. "You don't have these people working and paying into the system, and then you have these people collecting from the system."
Ten years ago, Ms. Raps developed diabetes. Her husband has it. Both her parents have it, their lives being washed away.
"When I look at the people who sit before me with disability claims, I have to check the birth date in their records," she said. "They look 10 or 20 years older. Diabetes does that. It wears you down and wears you down. We're looking at a future of people 10 or 20 years older in sickness than they are. What kind of future is that?"
'A 15-Year-Old Is Immortal'
"I'm Linda and I've had diabetes for 13 years."
"I'm Dominique and I've had diabetes for seven years."
"I'm Joseph and I've had diabetes for two months."
The brisk introductions went on, the ritual start to the monthly meeting of a support group called Sugar Babes Place. All the members had diabetes. All were children.
Sugar Babes is the idea of Dr. Yolaine St. Louis, chief of pediatric endocrinology at Bronx-Lebanon Hospital Center. When she started practicing medicine 16 years ago, the only children she saw with diabetes had Type 1.
Now, of Sugar Babes' 90 official members, roughly 40 percent have Type 2. One is 8. Another is 7.
It scares Dr. St. Louis. It scares many doctors who see the same thing, because they know it does not have to be. Type 2 was supposed to be an old person's disease. Diabetes still increases with age in an almost linear fashion - today, one in five New Yorkers age 65 and older have it - but the starting point used to be mostly in their 50's.
Dr. Alan Shapiro, a pediatrician with the Children's Health Fund and Montefiore Medical Center who has spent 13 years ministering to children in the South Bronx, said there was an easy way to illustrate the change. When he began, there was a "failure-to-thrive" clinic, meant to address the undernourished, because so many children were dangerously thin and small.
"Now I don't think we hardly ever see a failure-to-thrive case," he said.
In the clinic's place is an obesity program. Dr. Shapiro never saw children with Type 2 diabetes in his early years in medicine. Now, the program has about 10 cases.
One concern he and fellow doctors have is the surge in children who take antipsychotic drugs for anxiety and conditions like autism. Some newer drugs can promote weight gain and thus elevate the risk of diabetes. Dr. Shapiro has an autistic patient who he feels needs the new medication. But since taking it, the young man has markedly put on weight and, at 18, developed diabetes.
This extension of the disease to the young is where health care professionals feel society and public policy have most glaringly failed. Diabetes, they say, should never have gotten there.
There has been little research into the long-term impact of Type 2 diabetes on children. But doctors have a rough idea. The harsh consequences that can accompany diabetes tend to arrive 10 to 15 years after onset.
If people contract diabetes when they are 15, 10 or even 5, they may well start developing complications, not on the cusp of retirement but in the prime of their lives.
There is a big difference between losing a limb at 21 and at 70. There is a big difference between going on dialysis at 30 and at 65.
"I heard a horror story a few weeks ago," Dr. Lorber said, "of a girl who was born deaf, got diabetes at 11 or 12 and went blind from diabetes at 30."
The C.D.C. has projected that a child found to have Type 2 diabetes at age 10 will see his life shortened by 19 years.
"Imagine if kids were showing up at emergency rooms in cardiac arrest," said Dr. David L. Katz, director of the Prevention Research Center at the Yale University School of Medicine. "Frankly, I think that's the next big thing. It's that dramatic. If diabetes doesn't respect age, why should coronary disease? Lord knows, I hope this never happens. But this is what keeps me up at night."
Yet children can be the most reluctant to accept the truths of their condition.
"A lot of them are in denial," Dr. St. Louis said. "They have blood sugars of 300, 400, and they tell me right to my face they don't have diabetes. 'You're wrong,' they say. 'I don't feel anything.' I tell them what can happen down the road, and they shrug. A 15-year-old doesn't care what's going to happen at 35 or 45. A 15-year-old is immortal."
The doctor was telling the Sugar Babes that everyone should have two compact blood-sugar meters, one for home and one for school. Then she warned them, "If your sugar is bad and you don't do anything, you're going to be dropping down all over the Bronx."
Interest was tepid. Some children couldn't keep their eyes off the waiting dinner arranged at a buffet table by the wall. No rapt attention from Joseph, 12, who had begged not to come, until his mother put her foot down. He moaned that he had schoolwork.
"Look at that," said Dorothy Morris-Swaby, a diabetes nurse educator who worked with Dr. St. Louis, nodding at a girl who was talking on her phone. "We're educating about diabetes, and she's on her cellphone. Typical teenager."
As time ran out, hula hoops were brought out. Dr. St. Louis was trying to identify activities other than video games and TV that the children might try. Last meeting, they held a jump-rope contest.
"They have 10,000 excuses why they can't do something," the doctor said. "So you have to give them ideas and then hope."
The meeting wound up. The hoops were stashed away. Some of the children stepped toward the buffet table and began to eat.
♥ Joe De Livera on 2006-01-09
This is just a forum. Assume posts are not from medical professionals.
Joe, I read this article at the Times online yesterday. For a number of years now, there have been more and more articles about the ever increasing number of diabetics in the US. What puzzles me is they always devote little time to explaining the cause for the dramatic increases, usually mentioning high fat diets and eating too much in general, and insufficient exercise.
Of course, genetics plays a part, but what's seldom given much mention is the incredible increase of the amout of sugar and rich carbohydrates in the American diet over the past couple of decades. Many drink soft drinks throughout the day, even for breakfast, and every fast food joint pushes their supersized drinks which can contain the equivalent of more than 20 teaspoons of sugar. I think this increase in sugar and other carbs, plus less exercise is THE reason for this epidemic of diabetes. But sugar and carbs are usually mentioned as no more important than dietary fats and less exercise. But once the diagnosis is made, it's the dietary sugar and carbs that that mostly determine the daily insulin dose.
A minority of diet and health practitioners believe high sugar and refined carbohydrate consumption is the most detrimental habit one can have, and I believe they'll be proven correct over time.
Of course, genetics plays a part, but what's seldom given much mention is the incredible increase of the amout of sugar and rich carbohydrates in the American diet over the past couple of decades. Many drink soft drinks throughout the day, even for breakfast, and every fast food joint pushes their supersized drinks which can contain the equivalent of more than 20 teaspoons of sugar. I think this increase in sugar and other carbs, plus less exercise is THE reason for this epidemic of diabetes. But sugar and carbs are usually mentioned as no more important than dietary fats and less exercise. But once the diagnosis is made, it's the dietary sugar and carbs that that mostly determine the daily insulin dose.
A minority of diet and health practitioners believe high sugar and refined carbohydrate consumption is the most detrimental habit one can have, and I believe they'll be proven correct over time.
Will88 last decade
This article deals only with the incidence of Diabetes in NY.
It is the incidence of Obesity that should be of greater concern to the authorities concerned, as it is now officially accepted to be 65%. I believe that this is symptomatic of the life in the US which is geared on achieving a higher income at the expense of losing the values which we accept as the norm in Asian countries like Sri Lanka.
I was in the US recently and was appalled to note the incidence of Obesity which one observes in the street where almost every other person is so fat that to us who are used to see people who are of a normal size, they all seem to be so very fat that it blows the mind. Upon inquiry I discovered that they did not consider 90kg fat as this seems to be the average.
It is just over a year ago that I discovered that Nat Phos 6x acts as an excellent weight reduction agent. This has now been proved by many thousands throughout the world after I first announced it on this forum on Christmas Day 2004, the day before our Tsunami. Since that time it has been used by many and I am informed that it has also caught on in the Health Farms who have discovered that it is far safer than the drugs that they used for weight reduction of their clients and is also very cost effective.
It only requires some action on the part of the health authorities in the US to use this remedy which is very safe in use and also very cheap to purchase as the average reduction of weight is around 1kg per week. It seems to work by accelerating the passage of food through the gut and the client does not feel the loss which is perceptible in a week when they usually feel much lighter and more energetic as a result of the gradual loss of the excess weight.
I discovered that my favourite remedy Arnica which I have used for many ailments not listed in the classical texts is also very effective in the control of Diabetes. It has been used by a few Homeopathic hospitals in Kerala and they have confirmed that they can control Diabetes with this remedy more effectively than with the other remedies commonly used for this purpose. I had read about the effectiveness of Cinnamon which is grown in Sri Lanka being able to help diabetics and have advised patients to use 1/4 teaspoonful of Cinnamon powder twice daily as this too has a positive effect on the control of this ailment . Patients who have used both the Arnica and the Cinnamon powder have reported that they can safely stop dependence on the drugs that they were using to control Diabetes.
I do hope that the US government will open its eyes and carry out tests with these two remedies and after they have passed the FDA standards, they can hopefully be used to help their citizens to avoid Obesity and Diabetes.
It is the incidence of Obesity that should be of greater concern to the authorities concerned, as it is now officially accepted to be 65%. I believe that this is symptomatic of the life in the US which is geared on achieving a higher income at the expense of losing the values which we accept as the norm in Asian countries like Sri Lanka.
I was in the US recently and was appalled to note the incidence of Obesity which one observes in the street where almost every other person is so fat that to us who are used to see people who are of a normal size, they all seem to be so very fat that it blows the mind. Upon inquiry I discovered that they did not consider 90kg fat as this seems to be the average.
It is just over a year ago that I discovered that Nat Phos 6x acts as an excellent weight reduction agent. This has now been proved by many thousands throughout the world after I first announced it on this forum on Christmas Day 2004, the day before our Tsunami. Since that time it has been used by many and I am informed that it has also caught on in the Health Farms who have discovered that it is far safer than the drugs that they used for weight reduction of their clients and is also very cost effective.
It only requires some action on the part of the health authorities in the US to use this remedy which is very safe in use and also very cheap to purchase as the average reduction of weight is around 1kg per week. It seems to work by accelerating the passage of food through the gut and the client does not feel the loss which is perceptible in a week when they usually feel much lighter and more energetic as a result of the gradual loss of the excess weight.
I discovered that my favourite remedy Arnica which I have used for many ailments not listed in the classical texts is also very effective in the control of Diabetes. It has been used by a few Homeopathic hospitals in Kerala and they have confirmed that they can control Diabetes with this remedy more effectively than with the other remedies commonly used for this purpose. I had read about the effectiveness of Cinnamon which is grown in Sri Lanka being able to help diabetics and have advised patients to use 1/4 teaspoonful of Cinnamon powder twice daily as this too has a positive effect on the control of this ailment . Patients who have used both the Arnica and the Cinnamon powder have reported that they can safely stop dependence on the drugs that they were using to control Diabetes.
I do hope that the US government will open its eyes and carry out tests with these two remedies and after they have passed the FDA standards, they can hopefully be used to help their citizens to avoid Obesity and Diabetes.
♡ Joe De Livera last decade
As "Will88" states ..."What puzzles me is they always devote little time to explaining the cause...."
This is how I ALWAYS look at things. The cause is not always known, but it must be sought after. Then the course of events can be traced and intelligent action can be taken.
This article explains what one of the main causes of diabetes is. There is hope with knowledge. :-)
http://www.imva.info
Half way down the page just under the "ENTER", select "The Hun Hordes of Mercury" from the selector, and press "TO IMVA PUBLICATIONS".
Browse the other articles on the site and then "ENTER" the site.
Below are some files worth their weight in gold
http://www.alternative-doctor.com/downloads/Cry_of_the_Heart...
http://www.alternative-doctor.com/downloads/Homeopathic_Vacc...
http://www.alternative-doctor.com/downloads/how_to_live_to_b...
God Bless,
Tim
This is how I ALWAYS look at things. The cause is not always known, but it must be sought after. Then the course of events can be traced and intelligent action can be taken.
This article explains what one of the main causes of diabetes is. There is hope with knowledge. :-)
http://www.imva.info
Half way down the page just under the "ENTER", select "The Hun Hordes of Mercury" from the selector, and press "TO IMVA PUBLICATIONS".
Browse the other articles on the site and then "ENTER" the site.
Below are some files worth their weight in gold
http://www.alternative-doctor.com/downloads/Cry_of_the_Heart...
http://www.alternative-doctor.com/downloads/Homeopathic_Vacc...
http://www.alternative-doctor.com/downloads/how_to_live_to_b...
God Bless,
Tim
TimCam last decade
Here is the sequel to the first article that I copied from the NYT which indicates that it is not in the interest of the Health Authorities in the US to prevent Diabetes.
New York Times
January 11, 2006
Bad Blood
In the Treatment of Diabetes, Success Often Does Not Pay
By IAN URBINA
With much optimism, Beth Israel Medical Center in Manhattan opened its new diabetes center in March 1999. Miss America, Nicole Johnson Baker, herself a diabetic, showed up for promotional pictures, wearing her insulin pump.
In one photo, she posed with a man dressed as a giant foot - a comical if dark reminder of the roughly 2,000 largely avoidable diabetes-related amputations in New York City each year. Doctors, alarmed by the cost and rapid growth of the disease, were getting serious.
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.
Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000.
Patients have trouble securing a reimbursement for a $75 visit to the nutritionist who counsels them on controlling their diabetes. Insurers do not balk, however, at paying $315 for a single session of dialysis, which treats one of the disease's serious complications.
Not surprising, as the epidemic of Type 2 diabetes has grown, more than 100 dialysis centers have opened in the city.
"It's almost as though the system encourages people to get sick and then people get paid to treat them," said Dr. Matthew E. Fink, a former president of Beth Israel.
Ten months after the hospital's center was founded, it had hemorrhaged more than $1.1 million. And the hospital gave its director, Dr. Gerald Bernstein, three and a half months to direct its patients elsewhere.
The center's demise, its founders and other experts say, is evidence of a medical system so focused on acute illnesses that it is struggling to respond to diabetes, a chronic disease that looms as the largest health crisis facing the city.
America's high-tech, pharmaceutical-driven system may excel at treating serious short-term illnesses like coronary blockages, experts say, but it is flailing when it comes to Type 2 diabetes, a condition that builds over time and cannot be solved by surgery or a few weeks of taking pills.
Type 2 , the subject of this series, has been linked to obesity and inactivity, as well as to heredity. (Type 1, which comprises only 5 percent to 10 percent of cases, is not associated with behavior, and is believed to stem almost entirely from genetic factors.)
Instead of receiving comprehensive treatment, New York's Type 2 diabetics often suffer under substandard care.
They do not test their blood as often as they should because they cannot afford the equipment. Patients wait months to see endocrinologists - who provide critical diabetes care - because lower pay has drawn too few doctors to the specialty. And insurers limit diabetes benefits for fear they will draw the sickest, most expensive patients to their rolls.
Dr. Diana K. Berger, who directs the diabetes prevention program for the City Department of Health and Mental Hygiene, said the bias against effective care for chronic illnesses could be seen in the new popularity of another high-profit quick fix: bariatric surgery, which shrinks stomach size and has been shown to be effective at helping to control diabetes.
"If a hospital charges, and can get reimbursed by insurance, $50,000 for a bariatric surgery that takes just 40 minutes," she said, "or it can get reimbursed $20 for the same amount of time spent with a nutritionist, where do you think priorities will be?"
Back in the Pantsuit
Calorie by calorie, the staff of Beth Israel's center tried to turn diabetic lives around from their base of operations: a classroom and three adjoining offices on the seventh floor of Fierman Hall, a hospital building on East 17th Street.
The stark, white-walled classroom did not look like much. But it was functional and clean and several times a week, a dozen or so people would crowd around a rectangular table that was meant for eight, listening attentively, staff members said.
Claudia Slavin, the center's dietitian, remembers asking the patients to stand, one by one.
"Tell me what your waking blood sugar was," she told them, "and then try to explain why it is high or low."
People whose sugars soar damage themselves irreparably, even if the consequences are not felt for 10 or 20 years. Unchecked, diabetes can lead to kidney failure, blindness, heart disease, amputations - a challenging slate for any single physician with a busy caseload to manage.
One patient, Ella M. Hammond, a retired school administrator, recalled standing up in the classroom one day in 1999.
"Has anyone noticed what's different about me?" Ms. Hammond asked.
Blank stares.
"Now, come on," she said, ruffling the fabric of a black gabardine pantsuit she had not worn since slimmer days, years earlier.
"Don't y'all notice 20 pounds when it goes away?" she asked.
Ms. Slavin, one of four full-time staff members who worked at the center, remembers laughing. There were worse reasons for an interruption than a success story.
Like many Type 2 diabetics, Ms. Hammond had been warned repeatedly by her primary care doctor that her weight was too high, her lifestyle too inactive and her diet too rich. And then she had been shown the door, until her next appointment a year later.
"The center was a totally different experience," Ms. Hammond said. "What they did worked because they taught me how to deal with the disease, and then they forced me to do it."
Two hours a day, twice a week for five weeks, Ms. Hammond learned how to manage her disease. How the pancreas works to create insulin, a hormone needed to process sugar. Why it is important to leave four hours between meals so insulin can finish breaking down the sugar. She counted the grams of carbohydrates in a bag of Ruffles salt and vinegar potato chips, her favorite, and traded vegetarian recipes.
After ignoring her condition for 20 years, Ms. Hammond, 63, began to ride a bicycle twice a week and mastered a special sauce, "more garlic than butter," that made asparagus palatable.
She also learned how to decipher the reading on her A1c test, a periodic blood-sugar measurement that is a crucial yardstick of whether a person's diabetes is under control.
"I was just happy to finally know what that number really meant," she said.
Many doctors who treat diabetics say they have long been frustrated because they feel they are struggling single-handedly to reverse a disease with the gale force of popular culture behind it.
Type 2 diabetes grows hand in glove with obesity, and America is becoming fatter. Undoubtedly, many of these diabetics are often their own worst enemies. Some do not exercise. Others view salad as a foreign substance and, like smokers, often see complications as a distant threat.
To fix Type 2 diabetes, experts agree, you have to fix people. Change lifestyles. Adjust thinking. Get diabetics to give up sweets and prick their fingers to test their blood several times a day.
It is a tall order for the primary care doctors who are the sole health care providers for 90 percent of diabetics.
Too tall, many doctors say. When office visits typically last as little as eight minutes, doctors say there is no time to retool patients so they can adopt an entirely new approach to food and life.
"Think of it this way," said Dr. Berger. "An average person spends less than .03 percent of their entire life meeting with a clinician. The rest of the time they're being bombarded with all the societal influences that make this disease so common."
As a result, primary care doctors often have a fatalistic attitude about controlling the disease. They monitor patients less closely than specialists, studies show.
For those under specialty care, there is often little coordination of treatment, and patients end up Ping-Ponging between their appointments with little sense of their prognosis or of how to take control of their condition.
Consequently, ignorance prevails. Of 12,000 obese people in a 1999 federal study, more than half said they were never told to curb their weight.
Fewer than 40 percent of those with newly diagnosed diabetes receive any follow-up, according to another study. In New York City, officials say, nearly 9 out of 10 diabetics do not know their A1c scores, that most fundamental of statistics.
In fact, without symptoms or pain, most Type 2 diabetics find it hard to believe they are truly sick until it is too late to avoid the complications that can overwhelm them. The city comptroller recently found that even in neighborhoods with accessible and adequate health care, most diabetics suffer serious complications that could have been prevented.
This grim reality persuaded hospital officials in the 1990's to try something different. The new centers would provide the tricks for changing behavior and the methods of tracking complications that were lacking from most care.
Instead of having rushed conversations with harried primary care physicians, patients would discuss their weights and habits for months with a team of diabetes educators, and have their conditions tracked by a panel of endocrinologists, ophthalmologists and podiatrists.
"The entire country was watching," said Dr. Bernstein, director of the Beth Israel center, who was then president of the American Diabetes Association.
By all apparent measures, the aggressive strategy worked. Five months into the program, more than 60 percent of the center's patients who were tested had their blood sugar under control. Close to half the patients who were measured had already lost weight. Competing hospitals directed patients to the program.
"For the first time in my 23 years of diabetes work I felt like we had momentum," said Jane Seley, the center's nurse practitioner. "And it wasn't backwards momentum."
Failure for Profit
From the outset, everyone knew diabetes centers were financially risky ventures. That is why Beth Israel took a distinctive approach before sinking $1.5 million into its plan.
Instead of being top-heavy with endocrinologists, who are expensive specialists, Beth Israel relied more on nutritionists and diabetes educators with lower salaries, said Dr. Fink, the hospital's former president.
The other centers that opened took similar precautions.
The St. Luke's-Joslin diabetes center, on the Upper West Side, tried lowering doctors' salaries, hiring dietitians only part time and being aggressive about getting reimbursed by insurers, said Dr. Xavier Pi-Sunyer, who ran the center.
Mount Sinai Hospital's diabetes center hired an accounting firm to calculate just how many bypass surgeries, kidney transplants and other profitable procedures the center would have to send to the hospital to offset the cost of keeping the center running, said Dr. Andrew Drexler, the center's director.
Nonetheless, both of these centers closed for financial reasons within five years of opening.
In hindsight, the financial flaws were hardly mysterious, experts say. Chronic care is simply not as profitable as acute care because insurers, and consumers, do not want to pay as much for care that is not urgent, according to Dr. Arnold Milstein, medical director of the Pacific Business Group on Health.
By the time a situation is acute, when dialysis and amputations are necessary, the insurer, which has been gambling on never being asked to cover procedures that far down the road, has little choice but to cover them, if only to avoid lawsuits, analysts said.
Patients are also more inclined to pay high prices when severe health consequences are imminent. When the danger is distant, perhaps uncertain, as with chronic conditions, there is less willingness to pay, which undercuts prices and profits, Dr. Milstein explained.
"There is a lesser sense of alarm associated with slow-moving threats, so prices and profits for chronic and preventive care remain low," he said. "Doctors, insurers and hospitals can command much higher prices and profit margins for a bypass surgery that a patient needs today than they can for nutrition counseling likely to prevent a bypass tomorrow."
Ms. Seley said the belief was that however marginal the centers might be financially, they would bring in business.
"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."
Indeed, former officials of the Beth Israel center said they anticipated that operating costs would be underwritten by the amputations and dialysis that some of their diabetic patients would end up needing anyway, despite the center's best efforts. "In other words, our financial success in part depended on our medical failure," Ms. Slavin said.
The other option was to have a Russ Berrie.
Mr. Berrie, a toymaker from the Bronx, made a fortune in the 1980's through the wild popularity of a product he sold, the Troll doll, a three-inch plastic monster with a puff of fluorescent hair. Mr. Berrie took more than $20 million of his doll money and used it to finance the diabetes center at Columbia University Medical Center in memory of his mother, Naomi, who had died of the disease. The center was also helped by a million-dollar grant from a company that makes diabetes drugs and equipment.
Even with its stable of generous donors, even with more than 10,000 patients filing through the doors each year, the Columbia center struggles financially, said Dr. Robin Goland, a co-director. That, she said, is because the center runs a deficit of at least $50 for each patient it sees.
Without wealthy benefactors, Beth Israel's center had an even tougher time surviving its financial strains.
Ms. Slavin said the center often scheduled patients for multiple visits with doctors and educators on the same day because it needed to take advantage of the limited time it had with its patients. But every time a Medicaid patient went to a diabetes education class, and then saw a specialist, the center lost money, she said. Medicaid, the government insurance program for the poor, will pay for only one service a day under its rules.
The center also lost money, its former staff members said, every time a nurse called a patient at home to check on his diet or contacted a physician to relate a patient's progress. Both calls are considered essential to getting people to change their habits. But medical professionals, unlike lawyers and accountants, cannot bill for phone time, so more money was lost.
And the insurance reimbursement for an hourlong diabetes class did not come close to covering the cost. Most insurers paid less than $25 for a class, said Denise Rivera, the secretary for the center.
"That wasn't even enough to pay for what it cost to have me to do the paperwork to get the reimbursement," she said.
Beth Israel was not alone in this predicament. Dr. C. Ronald Kahn, president and director of the Joslin Diabetes Center in Boston, the nation's largest such center, with 23 affiliates around the country, said that for every dollar spent on care, the Joslin centers lost 35 cents. They close the gap, but just barely, with philanthropy, he said.
"So you have the institutions, which are doing much of the work in dealing with this major health epidemic, depending on charity," he said. "In the long run, this is definitely not a tenable system."
Plastic Strips and Red Tape
Sidney Schonfeld was not a patient at Beth Israel, but he ran into his own set of financial obstacles in trying to manage his disease.
"Controlling my condition isn't that hard," said Mr. Schonfeld, 82, a retired businessman from Washington Heights. "The hard part are the things outside my control, like getting the test strips and the medicines."
Test strips are not complicated pieces of medical equipment. They are inch-long pieces of plastic with tiny metal tabs that diabetics use to measure the sugar in their blood. After pricking their finger, diabetics place a drop of blood on the strip and then insert it into the side of a handheld meter that analyzes their sugar levels.
Each strip costs only about 75 cents, but many diabetics are poor and, over the course of a year, those who test their blood frequently, as instructed, will spend more than $500 on strips.
Mr. Schonfeld, like many diabetics, is supposed to test his blood at least twice a day so he can make adjustments to his diet and medications that can ward off serious complications. But many insurers cover only one strip per day unless a patient obtains written justification from a doctor. Even with letters from his doctor, Mr. Schonfeld has had a tough time getting insurers to pay for his strips, his doctor and nurse said.
"Fighting the disease is only half of this job," said Mr. Schonfeld's doctor, Dr. Goland. She held up a manila folder thick with letters that she had sent to his insurer explaining Mr. Schonfeld's case. Mr. Schonfeld had his own pile of letters: the rejection notices he got back.
Dr. Goland says that Mr. Schonfeld has good reason to be vigilant. His mother lost her left foot to Type 2 diabetes. She died several months later after gangrene spread to her right. Mr. Schonfeld's six uncles and aunts on his mother's side had the disease. Three of them underwent amputations. His son, Gary, is also diabetic.
"You can't get a more textbook high-risk case than Sidney," Dr. Goland said.
Though the health care system asks diabetics to become rigorously involved in daily management of their conditions, red tape and the cost of drugs and supplies put self-management out of reach for many patients. As a result, many diabetics either do without or pay out of their own pockets. Some resort to other means to get their supplies.
In Indiana, hospital workers organized Diabetes Bingo Night last May to collect money for strips and supplies. In California, F.B.I agents found that diabetics were buying stolen strips on eBay. Last year, the agents charged a couple with mail fraud and accused them of having sold $2.5 million worth of stolen test strips and supplies.
In East Harlem, doctors at Mount Sinai were mystified by a number of cases in 2002: patients came into the hospital asserting that they had been testing themselves daily and were sure that their blood sugar was under control. Hospital tests, however, showed just the opposite.
"We finally figured out," said Dr. Carol R. Horowitz, an assistant professor at the Mount Sinai School of Medicine, "that patients who could not afford the strips for their blood monitor were buying cheaper strips that were incompatible and that were giving false reads."
At least they knew they had the disease. A third of diabetics do not, in part because doctors do not screen as often as they should, studies show. Since symptoms do not appear for 7 to 10 years on average, the effects of the elevated sugars begin to build and become irreversible.
Mr. Schonfeld has known about his diabetes for more than 20 years and prides himself on keeping it in check.
"I've seen what it can do," he said. "So I know better than to ignore it."
When Dr. Goland told him to limit the chocolate mousse and frankfurters, he did.
When she told him to start walking two miles a day, he did that, too. But her instructions to test his blood at least twice a day were not as easy to follow.
Mr. Schonfeld runs out of strips even though he tries to plan ahead by ordering extras, said Kathy Person, his nurse. "The insurance reps say they don't want the strips to end up on the black market, so they don't let people preorder extras," she said.
The Naomi Berrie Diabetes Center has a full-time staff member who tries to do the clerical work associated with insurance coverage. "Still, it's a struggle to keep up with the paperwork," Dr. Goland said.
Some doctors simply do not have time and patients are left to haggle with insurers - usually unsuccessfully - on their own.
Although a recent federal study found that an increasing number of health insurers cover strips, few cover more than one a day, according to strip manufacturers. In fact, a study last year by Georgetown University found that insurance restrictions on strips and other services for diabetics were reducing the quality of care.
"I was a businessman for more than 40 years," said Mr. Schonfeld, a former food importer. "What I just don't understand is how these insurance companies can operate the way they do and keep their customers."
Sick Patient? Expensive Patient
As it turns out, keeping customers who are diabetic is not the goal of most health insurance companies, experts said. Avoiding diabetics is actually more the point.
Understanding why, the experts said, requires an appreciation of one of the crucial obstacles to better diabetes care.
Most insurers do not operate the way Mr. Schonfeld did in the import business, luring additional customers by advertising a good product at a fair price. Were they to operate in that fashion, health plans looking to grow might advertise better coverage for diabetics, such as a wide choice of blood-sugar monitors.
But in the insurance business - and virtually all businesses based on risk - the point is not to attract the most customers but rather the best ones. As businesses, not charities, insurers need to attract healthy customers, not sick ones, said David Knutson, a former insurance executive who studies the industry's economics for the Park Nicollet Institute, a health research organization in Minneapolis.
As a result, experts say, insurance executives usually think twice before bolstering their diabetes benefits, for fear they will attract the chronically ill.
In a 2003 survey, 87 percent of health insurance actuaries queried by Mr. Knutson said that if they were to improve coverage with richer drug benefits or easier access to specialists, they would incur financial problems by attracting the sickest, most expensive patients.
"Insurers are as eager to attract the chronically ill as banks are interested in loaning to the unemployed," Mr. Knutson said. "The chances of losing money are simply too high."
Insurers are not alone in these concerns. Large employers, many of which devise and finance their own employee health plans, know that their allotted reserves are jeopardized if too much of their work force is seriously ill. Last year, for example, a Wal-Mart executive suggested in an internal memo that the company could reduce costs by discouraging unhealthy people from applying for work.
Even when insurers are simply third-party administrators, processing claims but not covering the actual medical expenses, they try to keep claims down by attracting healthier patients to their plans, Mr. Knutson said.
Similarly, coverage for Medicaid recipients, though underwritten by the government, can be subject to the same private-sector pressures. More than 70 percent of Medicaid recipients in New York now receive their health care through private health maintenance organizations that operate under government contract. These H.M.O.'s get the same annual flat fee from the government, regardless of whether the patient is robustly healthy or chronically ill, thus creating an incentive to attract the healthiest customers.
For insurers, the high cost of attracting the sick is far from a hypothetical problem, said David V. Axene, president of Axene Health Partners, a consulting firm that advises these companies. For each additional session of nutritional counseling, he said, an insurer must account for the likely cost of luring sick patients away from its competitors.
Mr. Axene cited an example from several years ago when, he said, an insurer became puzzled about why a provider network that it had set up at a Boston hospital was consistently over budget. Mr. Axene's company found that two-thirds of the hospital's diabetics had chosen to enroll in that network over others.
The reason? The insurer had mistakenly listed an endocrinologist on its network's primary care physician list, he said.
"These patients no longer needed to get a referral to see the endocrinologist, and with one visit they could get their general and their diabetes needs filled," Mr. Axene said. Within months, the network had redrafted its lists, dropping the endocrinologist, he said.
Mohit Ghose, a spokesman for America's Health Insurance Plans, an industry trade association, said insurers were working to improve chronic care coverage. Many have created disease management programs to track their sickest patients and pay bonuses to doctors who show results in treating the chronically ill.
"Is there still a long way to go? Yes, definitely," Mr. Ghose said. "But we're on the right track."
Some preventive measures would, at first glance, seem sure money savers for health insurers since they might eliminate or forestall expensive diabetes complications down the road. But many insurers do not think that way. They figure that complications are often so far into the future, insurance analysts say, that many people will have already switched jobs or insurers, or have even died, by the time they hit. As a result, any savings from preventive measures will only go to their competitors anyway, analysts say.
In fact, experts say, people generally change their health insurance about every six years.
"It's perverse," Mr. Knutson said. "But it's the reality of there being a weak business case for quality when it comes to handling chronic care."
'Jerry, We Need to Talk'
It usually took Dr. Bernstein seven minutes to walk from his office in Fierman Hall to the hospital president's office across 17th Street. On Jan. 4, 2000, he had a bounce in his step, and it took him half that time, he recalled.
He had a good story to tell, and graphs and tables to back it up. The Beth Israel center was an unqualified medical success. In fact, patient loads were growing by 20 percent each month as its reputation spread.
When he arrived, Dr. Fink, then the hospital's president, asked the three other executives to take their seats. Dr. Bernstein began talking before he had reached his chair.
"Things are really coming along well," he said as he handed out a spreadsheet. "Patients are starting to turn their lives around."
Pausing, Dr. Bernstein looked around the table. He was struck by an awkward silence.
"Jerry, we need to talk about what is happening at the hospital," Dr. Fink said. "We're going to have to close your program."
Dr. Bernstein cannot say which was more jarring: the news or the way it arrived.
Numb, he kept his composure for 25 minutes, he said. The administrators explained that the hospital was running a deficit. The diabetes program was not helping matters.
"It was really not about the medicine but the business," Dr. Fink said recently about the meeting. "That didn't make it any easier to deliver the news, especially since I had been one of the main advocates behind getting the center started."
After the meeting, as Dr. Bernstein walked back to his office, he wondered where he would direct the program's 300 or so patients. Still, he remained sympathetic to the hospital's plight.
"I was not of the belief that we should save the center only to end up losing the hospital," he said.
For many of the patients, the news was a second strike of lightning. They had come to Dr. Bernstein only after being cut loose by the closing of the St Luke's diabetes center earlier that year. Now they were being cut loose again, to drift back to a life of limited care options: understaffed and overwhelmed clinics; general practitioners with too little time; a city with about 100 overbooked diabetes educators surrounded by 800,000 patients; and a shortage of endocrinologists, the specialists who are often critical providers of diabetes care.
Since endocrinology is one of the lower-paying specialties, there is a national shortage of such doctors. In New York, with its armies of diabetics, patients must often wait months for an appointment with one of fewer than 200 endocrinologists. The poorest patients face the biggest problem, as only a fraction of the specialists accept Medicaid.
Once the center had closed, Dr. Bernstein continued to teach at Beth Israel, but he began to devote more and more time to a side project. He was working on an inhaler that delivers insulin in the form of a mist. The product is being developed by Generex, and it is designed to appeal to patients who are reluctant to use insulin because they do not like the idea of injections or needles.
But the device will probably cost about 15 percent more than traditional insulin and is likely to be too expensive for many of the poorest diabetics, who are often the patients who need it most because their illness is most severe.
"The center was a way to really make a dent in this epidemic," Dr. Bernstein said. "The inhaler is a promising breakthrough. But it's mostly a business opportunity."
Other pharmaceutical innovations are likely to soften the toll of diabetes for many patients in coming years, doctors said. With an average diabetic spending more than $2,500 per year on drugs and equipment, pharmaceutical companies have good reason to focus their attention on the more than $10 billion market in controlling the disease's complications.
But there is only so much the drugs can do, they add, if they are not accompanied by the sort of changes in patient habits that the centers fostered through education and monitoring.
Health economists suggest that if these preventive measures were practiced on a wide scale, complications from diabetes would be largely eliminated and the American medical system, and by extension taxpayers, could save as much as $30 billion over 10 years. The experts disagree on what such an effort would cost. (How much nutrition counseling does it take to wean the average person from French fries?) Nonetheless, many of them believe the cost would be largely offset by the savings.
Dr. Bernstein says the lone hope on the horizon is a restructured reimbursement system that puts the business of chronic care on a more competitive footing with acute care. Experts say this restructuring could start if government insurance programs like Medicaid began paying more for preventive efforts like education, a move that the private sector would be likely to follow.
"Until we address the financing and the reimbursement structure, this disease is going to rage out of control," Dr. Bernstein said.
Not everyone believes the centers were the best answer to diabetes care. Even with their demise, many hospitals, clinics and endocrinology practices say they are providing cost-effective, quality treatment.
"The care we provide now is on the par with what was offered before," said Dr. Leonid Poretsky, who became director of Beth Israel's endocrinology division after the diabetes program closed. "The main difference is that we are financially viable because half of our patients are not diabetic."
These facilities, though, often find themselves in the same position the centers did: financing prevention efforts with profits from the very kidney transplants and amputations that preventive care is meant to deter.
It is tough to convince a former patient like Ms. Hammond that the closing of the Beth Israel center was anything but a mistake. She had started to make critical changes in her lifestyle after just a few weeks there. She did not find out it had closed, she said, until several months after the doors had shut, when she called looking to sign up for a refresher class. She was starting to fall back into old habits.
"I needed reminding," she said.
With the center gone, Ms. Hammond said she has had to try to muddle through. She goes to the podiatrist once a year, but she said she could not remember the last time she visited an eye doctor. She has gained about 40 pounds.
Some days she wakes up and her blood sugar is high. Other mornings she doesn't bother to check, she said.
"I couldn't get to where I was before," she said.
Two years ago, she said, she took a last look at that favorite gabardine pantsuit she had once modeled for her class. Then, she said, she gave it to her cousin.
Copyright 2006The New York Times Company
New York Times
January 11, 2006
Bad Blood
In the Treatment of Diabetes, Success Often Does Not Pay
By IAN URBINA
With much optimism, Beth Israel Medical Center in Manhattan opened its new diabetes center in March 1999. Miss America, Nicole Johnson Baker, herself a diabetic, showed up for promotional pictures, wearing her insulin pump.
In one photo, she posed with a man dressed as a giant foot - a comical if dark reminder of the roughly 2,000 largely avoidable diabetes-related amputations in New York City each year. Doctors, alarmed by the cost and rapid growth of the disease, were getting serious.
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.
Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000.
Patients have trouble securing a reimbursement for a $75 visit to the nutritionist who counsels them on controlling their diabetes. Insurers do not balk, however, at paying $315 for a single session of dialysis, which treats one of the disease's serious complications.
Not surprising, as the epidemic of Type 2 diabetes has grown, more than 100 dialysis centers have opened in the city.
"It's almost as though the system encourages people to get sick and then people get paid to treat them," said Dr. Matthew E. Fink, a former president of Beth Israel.
Ten months after the hospital's center was founded, it had hemorrhaged more than $1.1 million. And the hospital gave its director, Dr. Gerald Bernstein, three and a half months to direct its patients elsewhere.
The center's demise, its founders and other experts say, is evidence of a medical system so focused on acute illnesses that it is struggling to respond to diabetes, a chronic disease that looms as the largest health crisis facing the city.
America's high-tech, pharmaceutical-driven system may excel at treating serious short-term illnesses like coronary blockages, experts say, but it is flailing when it comes to Type 2 diabetes, a condition that builds over time and cannot be solved by surgery or a few weeks of taking pills.
Type 2 , the subject of this series, has been linked to obesity and inactivity, as well as to heredity. (Type 1, which comprises only 5 percent to 10 percent of cases, is not associated with behavior, and is believed to stem almost entirely from genetic factors.)
Instead of receiving comprehensive treatment, New York's Type 2 diabetics often suffer under substandard care.
They do not test their blood as often as they should because they cannot afford the equipment. Patients wait months to see endocrinologists - who provide critical diabetes care - because lower pay has drawn too few doctors to the specialty. And insurers limit diabetes benefits for fear they will draw the sickest, most expensive patients to their rolls.
Dr. Diana K. Berger, who directs the diabetes prevention program for the City Department of Health and Mental Hygiene, said the bias against effective care for chronic illnesses could be seen in the new popularity of another high-profit quick fix: bariatric surgery, which shrinks stomach size and has been shown to be effective at helping to control diabetes.
"If a hospital charges, and can get reimbursed by insurance, $50,000 for a bariatric surgery that takes just 40 minutes," she said, "or it can get reimbursed $20 for the same amount of time spent with a nutritionist, where do you think priorities will be?"
Back in the Pantsuit
Calorie by calorie, the staff of Beth Israel's center tried to turn diabetic lives around from their base of operations: a classroom and three adjoining offices on the seventh floor of Fierman Hall, a hospital building on East 17th Street.
The stark, white-walled classroom did not look like much. But it was functional and clean and several times a week, a dozen or so people would crowd around a rectangular table that was meant for eight, listening attentively, staff members said.
Claudia Slavin, the center's dietitian, remembers asking the patients to stand, one by one.
"Tell me what your waking blood sugar was," she told them, "and then try to explain why it is high or low."
People whose sugars soar damage themselves irreparably, even if the consequences are not felt for 10 or 20 years. Unchecked, diabetes can lead to kidney failure, blindness, heart disease, amputations - a challenging slate for any single physician with a busy caseload to manage.
One patient, Ella M. Hammond, a retired school administrator, recalled standing up in the classroom one day in 1999.
"Has anyone noticed what's different about me?" Ms. Hammond asked.
Blank stares.
"Now, come on," she said, ruffling the fabric of a black gabardine pantsuit she had not worn since slimmer days, years earlier.
"Don't y'all notice 20 pounds when it goes away?" she asked.
Ms. Slavin, one of four full-time staff members who worked at the center, remembers laughing. There were worse reasons for an interruption than a success story.
Like many Type 2 diabetics, Ms. Hammond had been warned repeatedly by her primary care doctor that her weight was too high, her lifestyle too inactive and her diet too rich. And then she had been shown the door, until her next appointment a year later.
"The center was a totally different experience," Ms. Hammond said. "What they did worked because they taught me how to deal with the disease, and then they forced me to do it."
Two hours a day, twice a week for five weeks, Ms. Hammond learned how to manage her disease. How the pancreas works to create insulin, a hormone needed to process sugar. Why it is important to leave four hours between meals so insulin can finish breaking down the sugar. She counted the grams of carbohydrates in a bag of Ruffles salt and vinegar potato chips, her favorite, and traded vegetarian recipes.
After ignoring her condition for 20 years, Ms. Hammond, 63, began to ride a bicycle twice a week and mastered a special sauce, "more garlic than butter," that made asparagus palatable.
She also learned how to decipher the reading on her A1c test, a periodic blood-sugar measurement that is a crucial yardstick of whether a person's diabetes is under control.
"I was just happy to finally know what that number really meant," she said.
Many doctors who treat diabetics say they have long been frustrated because they feel they are struggling single-handedly to reverse a disease with the gale force of popular culture behind it.
Type 2 diabetes grows hand in glove with obesity, and America is becoming fatter. Undoubtedly, many of these diabetics are often their own worst enemies. Some do not exercise. Others view salad as a foreign substance and, like smokers, often see complications as a distant threat.
To fix Type 2 diabetes, experts agree, you have to fix people. Change lifestyles. Adjust thinking. Get diabetics to give up sweets and prick their fingers to test their blood several times a day.
It is a tall order for the primary care doctors who are the sole health care providers for 90 percent of diabetics.
Too tall, many doctors say. When office visits typically last as little as eight minutes, doctors say there is no time to retool patients so they can adopt an entirely new approach to food and life.
"Think of it this way," said Dr. Berger. "An average person spends less than .03 percent of their entire life meeting with a clinician. The rest of the time they're being bombarded with all the societal influences that make this disease so common."
As a result, primary care doctors often have a fatalistic attitude about controlling the disease. They monitor patients less closely than specialists, studies show.
For those under specialty care, there is often little coordination of treatment, and patients end up Ping-Ponging between their appointments with little sense of their prognosis or of how to take control of their condition.
Consequently, ignorance prevails. Of 12,000 obese people in a 1999 federal study, more than half said they were never told to curb their weight.
Fewer than 40 percent of those with newly diagnosed diabetes receive any follow-up, according to another study. In New York City, officials say, nearly 9 out of 10 diabetics do not know their A1c scores, that most fundamental of statistics.
In fact, without symptoms or pain, most Type 2 diabetics find it hard to believe they are truly sick until it is too late to avoid the complications that can overwhelm them. The city comptroller recently found that even in neighborhoods with accessible and adequate health care, most diabetics suffer serious complications that could have been prevented.
This grim reality persuaded hospital officials in the 1990's to try something different. The new centers would provide the tricks for changing behavior and the methods of tracking complications that were lacking from most care.
Instead of having rushed conversations with harried primary care physicians, patients would discuss their weights and habits for months with a team of diabetes educators, and have their conditions tracked by a panel of endocrinologists, ophthalmologists and podiatrists.
"The entire country was watching," said Dr. Bernstein, director of the Beth Israel center, who was then president of the American Diabetes Association.
By all apparent measures, the aggressive strategy worked. Five months into the program, more than 60 percent of the center's patients who were tested had their blood sugar under control. Close to half the patients who were measured had already lost weight. Competing hospitals directed patients to the program.
"For the first time in my 23 years of diabetes work I felt like we had momentum," said Jane Seley, the center's nurse practitioner. "And it wasn't backwards momentum."
Failure for Profit
From the outset, everyone knew diabetes centers were financially risky ventures. That is why Beth Israel took a distinctive approach before sinking $1.5 million into its plan.
Instead of being top-heavy with endocrinologists, who are expensive specialists, Beth Israel relied more on nutritionists and diabetes educators with lower salaries, said Dr. Fink, the hospital's former president.
The other centers that opened took similar precautions.
The St. Luke's-Joslin diabetes center, on the Upper West Side, tried lowering doctors' salaries, hiring dietitians only part time and being aggressive about getting reimbursed by insurers, said Dr. Xavier Pi-Sunyer, who ran the center.
Mount Sinai Hospital's diabetes center hired an accounting firm to calculate just how many bypass surgeries, kidney transplants and other profitable procedures the center would have to send to the hospital to offset the cost of keeping the center running, said Dr. Andrew Drexler, the center's director.
Nonetheless, both of these centers closed for financial reasons within five years of opening.
In hindsight, the financial flaws were hardly mysterious, experts say. Chronic care is simply not as profitable as acute care because insurers, and consumers, do not want to pay as much for care that is not urgent, according to Dr. Arnold Milstein, medical director of the Pacific Business Group on Health.
By the time a situation is acute, when dialysis and amputations are necessary, the insurer, which has been gambling on never being asked to cover procedures that far down the road, has little choice but to cover them, if only to avoid lawsuits, analysts said.
Patients are also more inclined to pay high prices when severe health consequences are imminent. When the danger is distant, perhaps uncertain, as with chronic conditions, there is less willingness to pay, which undercuts prices and profits, Dr. Milstein explained.
"There is a lesser sense of alarm associated with slow-moving threats, so prices and profits for chronic and preventive care remain low," he said. "Doctors, insurers and hospitals can command much higher prices and profit margins for a bypass surgery that a patient needs today than they can for nutrition counseling likely to prevent a bypass tomorrow."
Ms. Seley said the belief was that however marginal the centers might be financially, they would bring in business.
"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."
Indeed, former officials of the Beth Israel center said they anticipated that operating costs would be underwritten by the amputations and dialysis that some of their diabetic patients would end up needing anyway, despite the center's best efforts. "In other words, our financial success in part depended on our medical failure," Ms. Slavin said.
The other option was to have a Russ Berrie.
Mr. Berrie, a toymaker from the Bronx, made a fortune in the 1980's through the wild popularity of a product he sold, the Troll doll, a three-inch plastic monster with a puff of fluorescent hair. Mr. Berrie took more than $20 million of his doll money and used it to finance the diabetes center at Columbia University Medical Center in memory of his mother, Naomi, who had died of the disease. The center was also helped by a million-dollar grant from a company that makes diabetes drugs and equipment.
Even with its stable of generous donors, even with more than 10,000 patients filing through the doors each year, the Columbia center struggles financially, said Dr. Robin Goland, a co-director. That, she said, is because the center runs a deficit of at least $50 for each patient it sees.
Without wealthy benefactors, Beth Israel's center had an even tougher time surviving its financial strains.
Ms. Slavin said the center often scheduled patients for multiple visits with doctors and educators on the same day because it needed to take advantage of the limited time it had with its patients. But every time a Medicaid patient went to a diabetes education class, and then saw a specialist, the center lost money, she said. Medicaid, the government insurance program for the poor, will pay for only one service a day under its rules.
The center also lost money, its former staff members said, every time a nurse called a patient at home to check on his diet or contacted a physician to relate a patient's progress. Both calls are considered essential to getting people to change their habits. But medical professionals, unlike lawyers and accountants, cannot bill for phone time, so more money was lost.
And the insurance reimbursement for an hourlong diabetes class did not come close to covering the cost. Most insurers paid less than $25 for a class, said Denise Rivera, the secretary for the center.
"That wasn't even enough to pay for what it cost to have me to do the paperwork to get the reimbursement," she said.
Beth Israel was not alone in this predicament. Dr. C. Ronald Kahn, president and director of the Joslin Diabetes Center in Boston, the nation's largest such center, with 23 affiliates around the country, said that for every dollar spent on care, the Joslin centers lost 35 cents. They close the gap, but just barely, with philanthropy, he said.
"So you have the institutions, which are doing much of the work in dealing with this major health epidemic, depending on charity," he said. "In the long run, this is definitely not a tenable system."
Plastic Strips and Red Tape
Sidney Schonfeld was not a patient at Beth Israel, but he ran into his own set of financial obstacles in trying to manage his disease.
"Controlling my condition isn't that hard," said Mr. Schonfeld, 82, a retired businessman from Washington Heights. "The hard part are the things outside my control, like getting the test strips and the medicines."
Test strips are not complicated pieces of medical equipment. They are inch-long pieces of plastic with tiny metal tabs that diabetics use to measure the sugar in their blood. After pricking their finger, diabetics place a drop of blood on the strip and then insert it into the side of a handheld meter that analyzes their sugar levels.
Each strip costs only about 75 cents, but many diabetics are poor and, over the course of a year, those who test their blood frequently, as instructed, will spend more than $500 on strips.
Mr. Schonfeld, like many diabetics, is supposed to test his blood at least twice a day so he can make adjustments to his diet and medications that can ward off serious complications. But many insurers cover only one strip per day unless a patient obtains written justification from a doctor. Even with letters from his doctor, Mr. Schonfeld has had a tough time getting insurers to pay for his strips, his doctor and nurse said.
"Fighting the disease is only half of this job," said Mr. Schonfeld's doctor, Dr. Goland. She held up a manila folder thick with letters that she had sent to his insurer explaining Mr. Schonfeld's case. Mr. Schonfeld had his own pile of letters: the rejection notices he got back.
Dr. Goland says that Mr. Schonfeld has good reason to be vigilant. His mother lost her left foot to Type 2 diabetes. She died several months later after gangrene spread to her right. Mr. Schonfeld's six uncles and aunts on his mother's side had the disease. Three of them underwent amputations. His son, Gary, is also diabetic.
"You can't get a more textbook high-risk case than Sidney," Dr. Goland said.
Though the health care system asks diabetics to become rigorously involved in daily management of their conditions, red tape and the cost of drugs and supplies put self-management out of reach for many patients. As a result, many diabetics either do without or pay out of their own pockets. Some resort to other means to get their supplies.
In Indiana, hospital workers organized Diabetes Bingo Night last May to collect money for strips and supplies. In California, F.B.I agents found that diabetics were buying stolen strips on eBay. Last year, the agents charged a couple with mail fraud and accused them of having sold $2.5 million worth of stolen test strips and supplies.
In East Harlem, doctors at Mount Sinai were mystified by a number of cases in 2002: patients came into the hospital asserting that they had been testing themselves daily and were sure that their blood sugar was under control. Hospital tests, however, showed just the opposite.
"We finally figured out," said Dr. Carol R. Horowitz, an assistant professor at the Mount Sinai School of Medicine, "that patients who could not afford the strips for their blood monitor were buying cheaper strips that were incompatible and that were giving false reads."
At least they knew they had the disease. A third of diabetics do not, in part because doctors do not screen as often as they should, studies show. Since symptoms do not appear for 7 to 10 years on average, the effects of the elevated sugars begin to build and become irreversible.
Mr. Schonfeld has known about his diabetes for more than 20 years and prides himself on keeping it in check.
"I've seen what it can do," he said. "So I know better than to ignore it."
When Dr. Goland told him to limit the chocolate mousse and frankfurters, he did.
When she told him to start walking two miles a day, he did that, too. But her instructions to test his blood at least twice a day were not as easy to follow.
Mr. Schonfeld runs out of strips even though he tries to plan ahead by ordering extras, said Kathy Person, his nurse. "The insurance reps say they don't want the strips to end up on the black market, so they don't let people preorder extras," she said.
The Naomi Berrie Diabetes Center has a full-time staff member who tries to do the clerical work associated with insurance coverage. "Still, it's a struggle to keep up with the paperwork," Dr. Goland said.
Some doctors simply do not have time and patients are left to haggle with insurers - usually unsuccessfully - on their own.
Although a recent federal study found that an increasing number of health insurers cover strips, few cover more than one a day, according to strip manufacturers. In fact, a study last year by Georgetown University found that insurance restrictions on strips and other services for diabetics were reducing the quality of care.
"I was a businessman for more than 40 years," said Mr. Schonfeld, a former food importer. "What I just don't understand is how these insurance companies can operate the way they do and keep their customers."
Sick Patient? Expensive Patient
As it turns out, keeping customers who are diabetic is not the goal of most health insurance companies, experts said. Avoiding diabetics is actually more the point.
Understanding why, the experts said, requires an appreciation of one of the crucial obstacles to better diabetes care.
Most insurers do not operate the way Mr. Schonfeld did in the import business, luring additional customers by advertising a good product at a fair price. Were they to operate in that fashion, health plans looking to grow might advertise better coverage for diabetics, such as a wide choice of blood-sugar monitors.
But in the insurance business - and virtually all businesses based on risk - the point is not to attract the most customers but rather the best ones. As businesses, not charities, insurers need to attract healthy customers, not sick ones, said David Knutson, a former insurance executive who studies the industry's economics for the Park Nicollet Institute, a health research organization in Minneapolis.
As a result, experts say, insurance executives usually think twice before bolstering their diabetes benefits, for fear they will attract the chronically ill.
In a 2003 survey, 87 percent of health insurance actuaries queried by Mr. Knutson said that if they were to improve coverage with richer drug benefits or easier access to specialists, they would incur financial problems by attracting the sickest, most expensive patients.
"Insurers are as eager to attract the chronically ill as banks are interested in loaning to the unemployed," Mr. Knutson said. "The chances of losing money are simply too high."
Insurers are not alone in these concerns. Large employers, many of which devise and finance their own employee health plans, know that their allotted reserves are jeopardized if too much of their work force is seriously ill. Last year, for example, a Wal-Mart executive suggested in an internal memo that the company could reduce costs by discouraging unhealthy people from applying for work.
Even when insurers are simply third-party administrators, processing claims but not covering the actual medical expenses, they try to keep claims down by attracting healthier patients to their plans, Mr. Knutson said.
Similarly, coverage for Medicaid recipients, though underwritten by the government, can be subject to the same private-sector pressures. More than 70 percent of Medicaid recipients in New York now receive their health care through private health maintenance organizations that operate under government contract. These H.M.O.'s get the same annual flat fee from the government, regardless of whether the patient is robustly healthy or chronically ill, thus creating an incentive to attract the healthiest customers.
For insurers, the high cost of attracting the sick is far from a hypothetical problem, said David V. Axene, president of Axene Health Partners, a consulting firm that advises these companies. For each additional session of nutritional counseling, he said, an insurer must account for the likely cost of luring sick patients away from its competitors.
Mr. Axene cited an example from several years ago when, he said, an insurer became puzzled about why a provider network that it had set up at a Boston hospital was consistently over budget. Mr. Axene's company found that two-thirds of the hospital's diabetics had chosen to enroll in that network over others.
The reason? The insurer had mistakenly listed an endocrinologist on its network's primary care physician list, he said.
"These patients no longer needed to get a referral to see the endocrinologist, and with one visit they could get their general and their diabetes needs filled," Mr. Axene said. Within months, the network had redrafted its lists, dropping the endocrinologist, he said.
Mohit Ghose, a spokesman for America's Health Insurance Plans, an industry trade association, said insurers were working to improve chronic care coverage. Many have created disease management programs to track their sickest patients and pay bonuses to doctors who show results in treating the chronically ill.
"Is there still a long way to go? Yes, definitely," Mr. Ghose said. "But we're on the right track."
Some preventive measures would, at first glance, seem sure money savers for health insurers since they might eliminate or forestall expensive diabetes complications down the road. But many insurers do not think that way. They figure that complications are often so far into the future, insurance analysts say, that many people will have already switched jobs or insurers, or have even died, by the time they hit. As a result, any savings from preventive measures will only go to their competitors anyway, analysts say.
In fact, experts say, people generally change their health insurance about every six years.
"It's perverse," Mr. Knutson said. "But it's the reality of there being a weak business case for quality when it comes to handling chronic care."
'Jerry, We Need to Talk'
It usually took Dr. Bernstein seven minutes to walk from his office in Fierman Hall to the hospital president's office across 17th Street. On Jan. 4, 2000, he had a bounce in his step, and it took him half that time, he recalled.
He had a good story to tell, and graphs and tables to back it up. The Beth Israel center was an unqualified medical success. In fact, patient loads were growing by 20 percent each month as its reputation spread.
When he arrived, Dr. Fink, then the hospital's president, asked the three other executives to take their seats. Dr. Bernstein began talking before he had reached his chair.
"Things are really coming along well," he said as he handed out a spreadsheet. "Patients are starting to turn their lives around."
Pausing, Dr. Bernstein looked around the table. He was struck by an awkward silence.
"Jerry, we need to talk about what is happening at the hospital," Dr. Fink said. "We're going to have to close your program."
Dr. Bernstein cannot say which was more jarring: the news or the way it arrived.
Numb, he kept his composure for 25 minutes, he said. The administrators explained that the hospital was running a deficit. The diabetes program was not helping matters.
"It was really not about the medicine but the business," Dr. Fink said recently about the meeting. "That didn't make it any easier to deliver the news, especially since I had been one of the main advocates behind getting the center started."
After the meeting, as Dr. Bernstein walked back to his office, he wondered where he would direct the program's 300 or so patients. Still, he remained sympathetic to the hospital's plight.
"I was not of the belief that we should save the center only to end up losing the hospital," he said.
For many of the patients, the news was a second strike of lightning. They had come to Dr. Bernstein only after being cut loose by the closing of the St Luke's diabetes center earlier that year. Now they were being cut loose again, to drift back to a life of limited care options: understaffed and overwhelmed clinics; general practitioners with too little time; a city with about 100 overbooked diabetes educators surrounded by 800,000 patients; and a shortage of endocrinologists, the specialists who are often critical providers of diabetes care.
Since endocrinology is one of the lower-paying specialties, there is a national shortage of such doctors. In New York, with its armies of diabetics, patients must often wait months for an appointment with one of fewer than 200 endocrinologists. The poorest patients face the biggest problem, as only a fraction of the specialists accept Medicaid.
Once the center had closed, Dr. Bernstein continued to teach at Beth Israel, but he began to devote more and more time to a side project. He was working on an inhaler that delivers insulin in the form of a mist. The product is being developed by Generex, and it is designed to appeal to patients who are reluctant to use insulin because they do not like the idea of injections or needles.
But the device will probably cost about 15 percent more than traditional insulin and is likely to be too expensive for many of the poorest diabetics, who are often the patients who need it most because their illness is most severe.
"The center was a way to really make a dent in this epidemic," Dr. Bernstein said. "The inhaler is a promising breakthrough. But it's mostly a business opportunity."
Other pharmaceutical innovations are likely to soften the toll of diabetes for many patients in coming years, doctors said. With an average diabetic spending more than $2,500 per year on drugs and equipment, pharmaceutical companies have good reason to focus their attention on the more than $10 billion market in controlling the disease's complications.
But there is only so much the drugs can do, they add, if they are not accompanied by the sort of changes in patient habits that the centers fostered through education and monitoring.
Health economists suggest that if these preventive measures were practiced on a wide scale, complications from diabetes would be largely eliminated and the American medical system, and by extension taxpayers, could save as much as $30 billion over 10 years. The experts disagree on what such an effort would cost. (How much nutrition counseling does it take to wean the average person from French fries?) Nonetheless, many of them believe the cost would be largely offset by the savings.
Dr. Bernstein says the lone hope on the horizon is a restructured reimbursement system that puts the business of chronic care on a more competitive footing with acute care. Experts say this restructuring could start if government insurance programs like Medicaid began paying more for preventive efforts like education, a move that the private sector would be likely to follow.
"Until we address the financing and the reimbursement structure, this disease is going to rage out of control," Dr. Bernstein said.
Not everyone believes the centers were the best answer to diabetes care. Even with their demise, many hospitals, clinics and endocrinology practices say they are providing cost-effective, quality treatment.
"The care we provide now is on the par with what was offered before," said Dr. Leonid Poretsky, who became director of Beth Israel's endocrinology division after the diabetes program closed. "The main difference is that we are financially viable because half of our patients are not diabetic."
These facilities, though, often find themselves in the same position the centers did: financing prevention efforts with profits from the very kidney transplants and amputations that preventive care is meant to deter.
It is tough to convince a former patient like Ms. Hammond that the closing of the Beth Israel center was anything but a mistake. She had started to make critical changes in her lifestyle after just a few weeks there. She did not find out it had closed, she said, until several months after the doors had shut, when she called looking to sign up for a refresher class. She was starting to fall back into old habits.
"I needed reminding," she said.
With the center gone, Ms. Hammond said she has had to try to muddle through. She goes to the podiatrist once a year, but she said she could not remember the last time she visited an eye doctor. She has gained about 40 pounds.
Some days she wakes up and her blood sugar is high. Other mornings she doesn't bother to check, she said.
"I couldn't get to where I was before," she said.
Two years ago, she said, she took a last look at that favorite gabardine pantsuit she had once modeled for her class. Then, she said, she gave it to her cousin.
Copyright 2006The New York Times Company
♡ Joe De Livera last decade
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