Endodoc

The “Group”
For quite a number of years now, I have been a member of a group composed of University of Misouri-Columbia professors. The group (which is also officially known as “The Group”), meets once a month during the academic year to hear a reasonably scholarly presentation from one of our members about whatever they wish. Invariably, presenters discuss topics related to their academic disciplines. As a physician (one of two in the group), I am expected to enlighten the attendees about something medical. Last spring, I gave a talk about the obesity epidemic and last week I spoke about type 2 diabetes, a logical extension of the talk about obesity.

My Presentation

I started out talking about what diabetes is (you already know that it’s really a group of medical disorders with three things in common- insulin deficiency, hyperglycemia, and risks for serious vascular complications). Type 2 diabetes, which used to be called maturity-onset diabetes and more recently, non-insulin-dependent diabetes (NIDDM), is the most common form of diabetes, affecting about 9.5% of the U.S. population. About 20% of people over 60 years of age have type 2 diabetes. Treating the condition accounts for a large chunk of of the money spent on health care in the U.S. (at least 35% of all Medicare expenditures!). Anyway, I was moving along through all the background information and got to the part where I stated that data show that as many as 90% of people in the U.S. with type 2 diabetes are not achieving recommended care goals, when th presentation got seriously derailed; the distinguished professors wanted to focus on how things could possibly be so bad in the richest country in the world, with the best high-tech mecical care, and which spends (by far) more than any other country in the world on health care?

Why are so many people with diabetes not achieving recommended care goals and what are the consequences?

It is much easier to address the consequences of of poor diabetes care than why it is happening. What makes diabetes serious is not the major inconvenience of the currently recommended treatment plans, but the complications that develop in so many of the patients. In fact, most of the costs of treating diabetes are for treating the complications (e.g., kidney failure, heart disease, nerve disease, peripheral vascular disease, limb amputations), all of which are preventable with currently available therapies.

The “why” part is more complicated and I will only touch on what I told my professor friends last week. First of all, U.S. health care is definitely not what it could and should be, particularly given how much money we spend on it. The U.S. is far down the list of economically developed nations in the quality of health care (as measured by longevity, infant mortality rates, etc,). The reasons include (in no order of relative importance) the following: more than 40 million people without health insurance and many more with inadequate insurance; inadequate numbers of well-trained health care providers, particularly in non-urban areas; high costs which are rising rapidly- many people cannot afford ther prescribed medications, even with insurance/Mediacare. I could go on and on and it was a bit uncomfortable presenting this information to my professor friends who seemed truly shocked by the discussion.

Where to go from here?

When it came to the part about what to do about the problems, I didn’t really have any convincing answers for my professor friends, at least in terms of a comprehensive “solution.” I have been giving this quite a bit of thought lately and will come back to health care issues soon, in future entries. Clearly, it doesn’t matter how smart a doctor is and how many great medications he has in his therapeutic armamentarium, if a patient with diabetes can’t afford the clinic visit or the medications or can’t even get an appointment for 6-7 months even with good insurance coverage, we are in trouble. We are in trouble.

I was interested to read an article in yesterday’s (Friday, November 16, 2007) Business section of the New York Times about a new inhaled insulin preparation which is being tested. The article was written by Andrew Pollack. You may recall that Pfizer recently announced that it was dumping its inhaled insulin, Exubera, apparently because of poor sales. Alfred E. Mann, the founder of MannKind Corporation is betting his personal fortune that his new inhaled insulin will be a big hit.

Is Mr. Mann’s inhaled insulin going to be a success?

If I were an investor, I probably wouldn’t rush out and buy lots of stock in MannKind Corporation (I don’t even know if it is publically traded) but I’m glad we may have an inhaled insulin available; it’s just another treatment tool that may be useful for some patients. As I discussed in an earlier entry, I was not very impressed with Exubera when our group studied its use in teenagers with diabetes; the patients learned that just taking the shots (or using an insulin pump) was quite a bit easier (for teens, “easier” means quicker) than messing with the inhaled stuff. Unfortunately, unless one takes an inhalation every 2-3 hours around-the-clock, it is still necessary to take at least one daily injection with a long-acting insulin. The article says that Mr. Mann feels that “his” inhaled insulin will be a success because it acts quicker than any of the current fast-acting insulins, including Exubera, and that the delivery device is much smaller than the Exubera device. Well, we’ll see. I am not “sold” on the idea that quicker action (both on and off) is necessarily a big benefit since it may make it trickier to deal with the long-acting insulin needs. Also, the theory that post-meal high blood sugars are bad for a person even if overall blood sugar control is good, has never been proven despite the many drugs on the market that give their raison d’etre that the drugs are an aid (generally a very very expensive aid) in controlling post-meal highs. I’m not sold on that idea, but who knows?
Given how long it took Pfizer to clear the FDA safetly hurdles with Exubera, it may be quite a while before Mr. Mann’s insulin hits the streets. As I mentioned, the more treatment options the better. I would like to see some companies make decisions about patient care products not only on the “bottom line.”

There was an interesting article today in the New York Times Business News section, entitled ” A Model for Health Care that Pays for Quality.” written by Milt Freudenheim. Apparently, the National Committee for Quality Assurance (NCQA), “a nonprofit focused on health care plans” (this is the organization that has for many years orchestrated reporting of quality data by HMOs and other large health care delivery organizations) is working on ways to get physicians to spend more face-to-face time with patients as a means of improving patient care outcomes. I guess the idea is to reward physicians for spending more time with patients- I assume this means paying them more? The article says that many large employers and insurers are “getting on board” with the idea, which is already being studied here and there.

How much time do physicians spend with patients now?

There are lots of data to show that the average face-to-face time between physicians and patients at clinic visits is brief- the average time is about 7 minutes. In contrast, the waiting room time before scheduled visits is quite impressively lengthy. There are also lots of data to show that many physicians do not follow recommended guidelines for patient care for this or that condition or for a given set of symptoms. I am not aware, however, of any data to show that longer encounters would make any difference in outcomes.

What is going on?

As best I can tell, employers and insurers would like to see better patient care outcomes because that’s nice (I asume that’s one reason?) and because it might have an impact on the high and steadily rising costs of health care. Of course we already know, notably from Kaiser-Permanente studies, that “better” health care saves money by resulting in better outcomes, at least in the areas of cancer, diabetes, and heart disease. Putting lots of effort into managing chronic disorders before preventable complications develop really works (I have discussed the Kaiser data in earlier entries). I do not know if focusing on physician-patient time is of any benefit. I would doubt it. I do not mean to imply that more time for patient clinic visits wouldn’t help, but trying to reward physicians who are not presently practicing high quality medicine by rewarding them simply for spending more time with their patients would not necessarily result in better care. In fact, if it is true that we have a big physician shortage and poor access to physicians by patients, slowing down the clinics will only make things worse.

What makes for a “good” physician?

It is very difficult to describe what makes one physician a good one and another one not so good. In my experience, patients generally don’t have a clue in determining which physician truly knows what he is doing or not. Often, patients mistakenly confuse the difference between a likeable doc and a competent one. It drives me crazy when I see people in a social setting who tell me how wonderful their physicians are when I know the docs are truly menaces (it is, of course, a  moral/ethical dilemma of whether to offer an opinion- so far I have been chicken to do so, unless the person is truly seeking my medical opinion about the physician).

“Good” physicians already spend what time is necessary to sort out what is going on with their patients. It may mean they make less money (time is money even in medicine) but it’s just something they have decided to do. Also, some physicians are very good at sorting things out quickly- some can never figure out what’s going on no matter how much time they take (it’s a good thing my doctoring skills are not judged by how quickly I can get New York Times cross word puzzles done!).

What should be done?

The NCQA should focus its energy on those things it knows best- developing parameters for assessing quality of care. They have already done a very good job in the area of diabetes care. They need to extend well-validated measurements of quality to many other chronic and acute conditions. Organizations can audit charts to determine how well their physicians are doing to with regard to the quality measures. These data can then be shared with the physicians (many insurers already do this).

I believe that a very worthy addition to the process is a “required” (I don’t know how to force a patient to do it, although the Japanese do) annual health assessment by ones primary care physician. This assessment could include a questionnaire that the patient fills out in advance which can help alert the physician to possible health problems and to the patient’s preventive heatlh care status (e.g., ? needing a PSA, a mammogram, herpes zoster vaccination). Of course, we will need an adequate number of primary care docs who have the necessary time to spend to accomplish all this- that is one of the biggest obstacles to my proposal.