Newt Gingrich, former Speaker of the US House of Representatives and shy-not commentator on the failings of medical care: served as the dinner speaker and revealed that he and a colleague from Congress have penned a soon-to-appear editorial recommending the creation of the Office of the “National Diabetes Coordinator.” Big problems warrant big solutions. He also had countless and worn anecdotes that contrasted the “world that works” vs. the “world that doesn’t work” but a fav of the DMCB was the observation that during the time a UPS driver makes a delivery to an average physician’s office, the computing power in that office is temporarily doubled.
Dan Mendelson, President Avalere Health: Republicans, Democrats and policy makers have merged into a perfect storm on the need for 1) coverage expansion, 2) cost containment, 3) quality improvement and 4) health information technology. This will probably kick off the national dialog on diabetes and chronic illness care in January 2009. Nationally sanctioned “comparative effectiveness research” (CER) is being supported by a counter-intuitive coalition of policy makers and managed care organizations: they believe it will help rationalize coverage decisions. Device manufacturers and pharma are opposed because CER can be used to deny coverage for worthwhile or innovative treatments.
Other insights from other speakers:
The ABCs: Access to a healthcare service = adequate payment. Payment in turn depends on coverage, which in turn depends on demonstrable and meaningful increases in quality. This is best demonstrated in randomized controlled clinical trails (RCTs). “RCTs don’t necessarily need to be published, you just need to know the results.” A national office for “comparative effectiveness research” will help.
Woeful physicians: Much of diabetes care for physicians is an intellectual pursuit, not a money maker. Office surveys have shown that endocrinologists consistently underbill for their services, using the Level 4 E&M code an average 53% of the time, versus oncologists using Level 5 E&M 51% of the time. Billing for group visits, diabetes self management training and continuous glucose monitoring may improve patient care and endocrinologists’ cash flow.
Medicare Coverage of medical devices is more complicated than you thought: Absent a “National Coverage Decision” (NCD) from the Medicare program, “Local Coverage Decisions” (LCDs) are used regionally at a State level to adjudicate coverage of medical devices. LCDs can be determined by evaluation (literature reviews), regulatory considerations (which may hamper a LCD) and collaboration (new device manufacturers are encouraged to enter the LCD process as early as possible).
Are we worrying about the right things? Glycemic control does not substantially increase life span in older Type 1 diabetes and does not prevent the slow progression of cardiovascular disease in Type 2 diabetes. Only 33% of vision loss in Type 2 diabetes is due to diabetic retinopathy and 90% of the retinopathy that does occur can be successfully treated despite a high A1c level. Only 10% of persons with type 2 diabetes develop kidney complications and blood pressure control is more important than the A1c.
The Disease Management Care Blog also heard about insulin pumps. It wonders if coverage of pumps should contingent on participation in an accredited disease management program.