Re: reply Re: another article

January 15, 2006

, It will help some, but to some, no matter what and how you teach them,

they will continue to use all those excuses and not do what could save their

lives.

Re: reply Re: another article

Dear and Mike, This is more then is what is on the surface. A lot

of people are still taught the old way of managing their diabetes. Some

people are instructed and are so used to doing what they want. They can't

bring themselves around to the necessity of taking care of them selves. I

have a friend who is having trouble with this very concept. She is showing

obvious signs of Hypo gloseamia. She doesn't like having to fallow any kind

of diet. Even if it may save her from some day developing Adult onset

Diabetes. Plus There are people who are not educated. Plus all the other

excuses. I am just as guilty of these very things. I am paying the price

for my stupidity. I am working to bring education to the poor disabled in

Denver. I hope it helps.

another article

>>>

>>>>>

>>>>

>>>>> In the Treatment of Diabetes, Success Often Does Not Pay

>>>>

>>>>>

>>>>

>>>>> By [3]IAN URBINA

>>>>

>>>>>

>>>>

>>>>> With much optimism, Beth Israel Medical Center in Manhattan opened

>> its

>>>>

>>>>> new [4]diabetes center in March 1999. Miss America,

>>>>

>>>>> 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 [5]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. 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 [6]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. 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.

>>>>

>>>>>

>>>>

>>>>> 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, [7]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 [8]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, [9]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.

>>>>

>>>>> 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 , 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. 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.

>>>>

>>>>>

>>>>

>>>>>

>>>>

>>>>> --

>>>>

>>>>> No virus found in this incoming message.

>>>>

>>>>> Checked by AVG Free Edition.

>>>>

>>>>> Version: 7.1.371 / Virus Database: 267.14.17/226 - Release Date:

>>>>> 1/10/2006

>>>>

>>>>>

>>>>

>>>>>

>>>>

January 15, 2006