One of the subjects I would like to discuss is diabetes legislation currently in the pipeline. These are pieces of pending legislation that will impact everyone affected by diabetes in one way or another. Most of the bills I will talk about are still in the House of Representatives, awaiting further action.
For my first blog on this topic, I wanted to talk about Bill: H.R.1274, otherwise known as the Access to Quality Diabetes Education Act of 2013.
This legislation was referred to the House Health subcommittee in March of 2013, and it is currently in the House Ways And Means.
What I would like to do is include parts of the legislative bill below here and add some commentary. So as not to confuse, I will place parts of the legislative language in quotes and my comments associated with the bill will be in bolded text.
The first thing I would like to point out is that this legislative bill needs to remove every occurrence of the words “prevent” and “reverse.”
In order to “prevent” something, you must first understand what “causes” them. Also keep in mind that there are many forms of diabetes, each one of them needing findings based on the fact we cannot “prevent” diabetes no matter what form, at least for now.
This bill correctly recognizes certified diabetes educators (CDE) as providers under this context, and also includes telehealth services, under part B of the Medicare program. Now let’s dive in and identify any shortcomings that we find and should be brought to the attention of the legislators in your state.
In a nutshell, Bill: H.R.1274 gives access to the proposed Quality Diabetes Education Act of 2013. The bill would make a technical clarification to recognize CDEs as providers for Medicare diabetes outpatient self-management training services (DSMT). CDEs are the only health professionals who are specially trained and uniquely qualified to teach patients with diabetes how to improve their health and avoid serious diabetes-related complications. The authorizing DSMT statute from 1997 did not include CDEs as Medicare providers and it has become increasingly difficult to ensure that DSMT is available to patients who need these services, particularly those with unique cultural needs or who reside in rural areas.
“The Minority Diabetes Initiative Act Amends the Public Health Service Act, to allow the Secretary of Health and Human Services (HHS) to make grants to public and nonprofit private health care providers to provide treatment for diabetes in minority communities; requires the Secretary to ensure that such grants cover a variety of diabetes-related health care services, including routine care for diabetic patients, public education on diabetes prevention and control, eye care, foot care, and treatment for kidney disease and other complications of diabetes; to amend title XVIII of the Social Security Act to improve access to diabetes self-management training (DSMT) by authorizing certified diabetes educators to provide diabetes self-management training services, including as part of telehealth services, under part B of the Medicare program.”
So far, so good except for the term “telehealth.” I see the term “telehealth” pop up in many of the items I peruse. Also, there is no contextual basis defined. What is “telehealth” and how are people with diabetes expected to do “DSMT” if we do not have access to a CDE?
Let’s move on to the Findings section of the bill and identify any shortcomings that may exist.
“SECTION 2. FINDINGS.
Congress finds the following:
(1) According to the Centers for Disease Control and Prevention (CDC), there are 79,000,000 adults with pre-diabetes in America. The CDC estimates that 50 percent of adults who are 65 years of age or older have pre-diabetes. More than 90 percent of adults with pre-diabetes are unaware they have it.”
When we get passed the “WOW” factor, the statistics above are scary even if they are incorrect, which I propose they are. Are we seeing that among the nearly 80 million “pre-diabetics,” 50% are older adults? Where does the other 50% fit in this equation? And does the nearly 80 million represent the 90% undiagnosed? Where are the people that are under 65 years of age, and what percentage of the nearly 80 million are either pre-diabetic, or don’t know they are? I would do the math, except my calculator blew up trying.
“(2) For a significant number of people with pre-diabetes, early intervention can reverse elevated blood glucose levels to normal range and prevent diabetes and its complications completely or can significantly delay its onset. According to the Institute for Alternative Futures, if 50 percent of adults with pre-diabetes were able to successfully make lifestyle changes proven to prevent or delay diabetes, then by 2025 approximately 4,700,000 new cases of diabetes could be prevented at a cost savings of $300 billion.”
Where do the “significant number of people” fit into the above percentages? The above statements and stats presume there can be a reversal or delay. Now we need an intervention to “reverse” elevated blood glucose(BGL)? We already have a way to get BGL’s lowered–it’s called insulin, and even then some need to raise their BGL’s. Yes, make it higher or face mortal consequences.
“(3) Nearly 1 in 5 hospitalizations in 2008 were related to diabetes according to the Agency for Healthcare Research and Quality.”
So 20% of hospitalizations were “related” to diabetes? That’s if they even have a protocol in place to check bgls in the first place. Perhaps the “other” 80% are the 80,000,000 adults with pre-diabetes?
“(4) Preventing diabetes and its complications can save money and lives. The average annual cost to treat someone with diabetes is $11,744, compared to $2,935 for someone who does not have diabetes. One out of every three Medicare dollars is spent on diabetes.”
Since we cannot “prevent,” then how about we spend more money in preventing “complications” of diabetes, or taking a large chunk of money and put it into “cure” based research? Since there are so many people not diagnosed with diabetes, what is happening to and about the undiagnosed? I won’t go into the disparity in mortality rates, whereas they do not represent the cause of death as diabetes, even when primary care doctors are aware. Even then, the possibility of comorbidity (complication, health condition) as the cause of death, is not written as the cause of death.
“(5) Diabetes is unique because its complications and their associated health care costs are often preventable with currently available medical treatment and lifestyle changes.”
Again, diabetes, at least now, is not preventable, nor do lifestyle changes have a great impact, especially on diagnosed diabetes. It is also known that “Your Diabetes May Vary.”
“(6) In 2002, the Diabetes Prevention Program study conducted by the National Institutes of Health found that participants (all of whom were at increased risk of developing type 2 diabetes) who made lifestyle changes reduced their risk of developing type 2 diabetes by 58 percent and that participants who are 60 years of age or older reduced their risk of developing diabetes by 71 percent.”
How about I don’t touch this one at all, especially since the data is 12 years old. Again, put the prevention dollars towards a cure. Because when we have a cure for diabetes that, it means we know what causes diabetes, thus making it preventable or reversible.
“(7) The Agency for Healthcare Research and Quality has demonstrated that $2,500,000,000 in hospitalization costs related to the treatment of diabetes or complications resulting from diabetes could be saved by providing seniors with appropriate primary care to prevent the onset of diabetes.”
Take half of the $2.5 BILLION and put it towards cure-based research–simple! How about we implement a protocol of BGL testing at every birth, and doctor appointments, and any other screening efforts currently in place (i.e. mammograms, blood pressure testing). How about including an A1c test (current standard for diagnosing diabetes) when a doctor orders lab work.
“(8) The Medicare program currently provides coverage for screening and identifying beneficiaries with pre-diabetes but does not provide adequate services to such beneficiaries to help them prevent or delay the onset of diabetes.”
Ok, we think there are 80 million people that are pre-diabetic, and more than 90 percent of adults with pre-diabetes are unaware they have it. Now we are told that “Medicare [B] does not provide adequate services to such beneficiaries.” Screening can be done and acted on in Finding number 7 listed above.
There is an upwards of 300 medications approved to treat diabetes. Why not take half of that chunk of change and put it towards–yep, you guessed it–cure-based research. Let’s be real. If Medicare provides coverage for screening (A1c), then the 90 million of pre-diabetics would know they have pre-diabetes.
Yes the recognition of certified diabetes educators as authorized providers of Medicare diabetes outpatient self-management training services (DSMT) is a great thing. Yes, allowing CDEs to provide treatment as a practitioner, including for telehealth services is a great thing. There is also a shortage of CDEs in the pipeline now to perform DSMT.
WHAT COMES NEXT:
“The Director of the Agency for Healthcare Research and Quality shall, through use of a workshop and other appropriate means, develop a series of recommendations on effective outreach methods to educate physicians and other health care providers as well as the public about the benefits of diabetes self-management training in order to promote better health outcomes for patients with diabetes.”
WHEN IS IT COMING:
“Not later than 1 year after the date of the enactment of this Act, the Director of the Agency for Healthcare Research and Quality shall submit to Congress a report on the recommendations developed.”
Stay tuned for my observations of federal bill, H.R. 1257, the Preventing Diabetes in Medicare Act of 2013. It’s going to be fun discussing prevention again!
To contact your Legislators and give your feedback on this matter visit here.
