The following is a greatly abridged list of quotes from respected medical journals on the financial and medical impact of various diabetes practices and products. These can be used in letters to HMOs and purchasers of HMO plans to impress upon them the importance and financial good sense of providing good diabetes care. Again, this list is just a short list of the many facts gathered on the subject. The more you investigate and the more you learn the stronger the case you can present to get the coverage you need and deserve.
Regarding the Importance and Cost-Effectiveness of Tight Diabetes Control:
The following three quotes are from the American Diabetes Association: Clinical Practice Recommendations 1998. (page S86)
- "Treatments and therapies that improve glycemic control and reduce complications of diabetes will also significantly reduce health care costs. Numerous studies have demonstrated that self-management education leads to reductions in the costs associated with all types of diabetes. Participants in self-management education programs have been found to have a decreased lower-extremity amputation rates, reduced medication costs and fewer emergency room visits and hospitalizations."
- "The ADA believes insurers must reimburse for medical treatment and also for self-management education programs that have met accepted standards, such as the ADA's National Standards for Diabetes. All medications and supplies, such as syringes, strips and meters, related to the daily care of diabetes must also be reimbursed by third-party payers. Organizations that purchase health care benefits for their members or employees should insist that self-management education, medications and supplies be included in the services provided, and managed care organizations should include these services and supplies in the basic plan available to all participants."
Information pertaining to the National Institutes of Health's 1993 Diabetes Control and Complications Trial (DCCT):
- The experiment showed that tight control: reduces the risk of diabetic retinopathy (a costly eye disease that can lead to blindness) by 70 percent, reduces the rate retinopathy leading to any type of treatment by 50 percent, reduces the rate of significant kidney damage (diabetic nephropathy) by 50 percent and reduces the rate of significant nerve damage (neuropathy) by 60 percent.
- According to a report by the National Institutes of Health regarding the DCCT findings, intensive therapy costs more per year, but the number of complications it effectively prevents makes it more cost-effective than standard therapy.
According to the report, intensive therapy costs approximately $4,500 per patient annually. The study defined intensive therapy as requiring three or four insulin shots and multiple blood sugar tests daily. The study found standard therapy costs $1,700 per patient annually. Standard therapy was defined as involving one or two insulin shots per day and requiring far fewer blood glucose tests.
The following three quotes are from the publication: Diabetes 1996: Vital Statistics, by the ADA. (pages 67 and 68)
- "The total estimated costs of diabetes in the United States exceeds $90 billion per year. In 1992 about 40 percent of this amount ($37 billion) was spent on hospital care ... Nearly $10 billion of the cost of inpatient care was for hospitalizations related to the chronic complications of diabetes."
- " ... it has become clear that preventative efforts for other diabetes complications are cost-effective. The current level of eye care among people with NIDDM saves the federal government nearly $250 million each year, in addition to preserving the equivalent of 5 more years of sight for 10,000 people with diabetes."
- "For every additional dollar spent in a preconception care program, $1.68 is saved in direct medical costs [in regard to comprehensive program of preconception and pregnancy diabetes care]."
The following information is from "Management of Patients with Diabetes by Nurses with Support of Subspecialists," by Ann L. Peters, MD, Mayer Davidson, MD, and R. Clifford Ossorio, published in the March 1995 issue of the periodical HMO Practice.
- The paper demonstrated how a facility dedicated to tight glucose control, operated out of Cedars Sinai Hospital in Los Angeles, reduced average HbA1c levels of patients from 12.5% to 9.5% and led to significant costs savings by avoiding acute care hospitalizations for diabetics in 244 patients over a four-year period.
The following quotes are from "The Cost to Health Plans of Poor Glycemic Control," published in the December 1997 issue of Diabetes Care.
- "Increases in HbA1c of 1% were associated with 7% increases in expected cost."
- "The most substantial cost increments occurred in individuals who had diabetes in combination with heart disease and hypertension ... A difference in HbA1c level from 9 to 8% was related to a cost reduction of $3,000 960." (For a complete list of standardized cost differentials for a 1% change in HbA1c see chart A below.)
- "In general, medical costs increased with higher baseline levels of HbA1c, with hypertension, lipid disorder and heart disease [all potential complications of diabetes]."
- •See page 22 for a graphic representation of this study's findings.
- "These data demonstrate a strong association of baseline glycemic control in 1992 with subsequent health care charges in 1993-1995. Lower baseline levels of HbA1c were associated with significantly lower subsequent charges for care, and after adjusting for age, sex and comorbidity [concomitant illness], higher baseline levels of HbA1c were associated with significantly higher subsequent charges for care. Cost differentials were greater for those with more chronic conditions and higher initial levels of HbA1c."
Regarding the importance and underutilization of various diabetes care measures necessary for proper diabetes care:
The following information is from a study by Matthew C. Riddle, MD, and Diane M. Karl, MD, published in the July/August 1996 Clinical Diabetes.
- Not intended as a substitute to daily BG testing, the HbA1c test is meant to fill in gaps for those who do not test daily glucose levels, and reinforce those who do, the study notes. "There is a strong case for using HbA1c as our main measure of outcome, both for individual patients and for populations of patients," the authors write. The study also adds that the HbA1c was used as the standard outcome measurement of BG control in the DCCT study.
The following information is from a study in the September 1996 issue of Diabetes Care. At its publication, it was the largest case study to date on the risk factors leading to diabetes complications such as kidney disease, amputation and blindness.
- More than one third of major diabetes complications could be prevented by removing avoidable risk factors. Receiving diabetes education, making regular trips to the doctor and controlling hypertension (high blood pressure) are the most important ways an individual can avoid developing a complication.
- Patients who have not received any type of outpatient education are four times more likely to develop a major complication than those who have.
- Inadequately controlled hypertension makes complications more than three times more likely. The researchers also found that people who take a fixed amount of insulin each day, rather than monitor their blood sugar levels and adjust their insulin accordingly, are 40 percent more likely to develop a complication.
The following information is taken from a study, published in the November 1996 issue of Diabetes Care, investigating the importance of testing for microalbuminuria. The study was among the first to investigate the importance of microalbumin levels in type 2 diabetes.
- Elevated protein (microalbumin) levels in the urine of people with type 2 diabetes are associated with a greater risk of developing kidney disease, heart disease and neuropathy. Elevated microalbumin levels may also signal a state of general blood vessel damage throughout the entire body, in addition to kidney disease.
- Type 2 diabetes accounts for over 90 percent of the cases of diabetes in the United States, and while reports vary, the costs from the disease and its complications may be as high as $100 billion dollars per year. The authors mention early detection as the most important step that can be taken to "minimize the human suffering and costs incurred from the disease."
The following information is from a study in the April 1996 issue of the American Journal of Medicine.
- Incidents of hypoglycemia are far less frequent for subjects on pump therapy than for subjects on insulin injection therapy. This finding was true even when the researchers tried to induce hypoglycemia.
The following information was published in a case study in the January/February 1997 issue of The Diabetes Educator.
- A nine-year-old girl with type 1 diabetes the girl was unable to achieve HbA1c levels any lower than 9.9% to 11.6% (6% to 8% is the recommended range). After an intensive education period and a 24-hour hospital stay for fear of hypoglycemia, the girl was put on pump therapy. While on the pump, her HbA1c improved to approximately 8.7% , and her growth levels returned to normal.