Part 1 – some 500 physicians and other practitioners gathered in Scottsdale, AZ to learn the most recent trends in the care of patients with diabetes.
I find it curious that not ALL people with diabetes are overweight. At least 1 in 10 are of normal weight, or even underweight. So clearly weight has something to do with the diabetes, but cannot be the only explanation for the development of this increasingly prevalent disease.
It’s not just Arizona – all over the country the figures are similar. 30.3 million Americans are diagnosed with diabetes, 84 million with pre‐diabetes, resulting in $237 billion a year in medical costs.
It is clear that genetics play a part. The disease is most prevalent in those of Native American descent (including Eskimo), least prevalent in those of European descent. Asian Americans have different rates depending on their population of origin – least prevalent in Chinese Americans, most prevalent in Asian Indians. Of the Hispanic Americans, the disease is most prevalent in those of Mexican descent, least prevalent in those of Central and South American origin.
Chances are excellent that other factors such as diet and environment also play a part. Diabetes was diagnosed in 0.93% of Americans in 1958, and has risen almost one‐thousand‐fold to 7.4% in 2015. Genetic/chromosomal changes in a population take thousands of years to have an effect. The change in incident of diabetes occurred over 55 years – a genetic blink of an eye.
Insulin was discovered in 1923, and was the first drug used for therapy of diabetes. Since that time, the pharmaceutical industry has been hard at work. Drugs to treat diabetes have increased significantly – if not exponentially.
With the drugs have come some problems.
They can induce hypoglycemia – even insulin, if given in too high a dose, can lower blood sugar to dangerously low levels, causing brain damage and even death. Other drugs, taken by injection or orally, can do the same thing – perhaps not quite as dramatically as insulin, but certainly equally effectively.
Metformin was one of the earliest drugs used orally. It is used as adjunctive therapy for cancer patients, helping to increase their muscle utilization of glucose and lower their blood sugar levels, thus potentially taking away of the of sources of fuel for glucose‐requiring cancer cells. Metformin, alas, can induce a profound hypoglycemia, and is also associated with vitamin B12 deficiency. This information was first published in 1971, but I do not recall that ever being a point of discussion in any lecture on treatment of diabetes until this lecture at the SW Diabetes Symposium.
SGLT2 inhibitors which prevent reabsorption of glucose by the kidneys (like increasing the size of the bathtub drain, rather than slowing the flow of water from the tap), are associated in increased risk of amputation in those with pre‐existing ASCVD – small blood vessel disease. Canaglifozin (Invokana®) is one example of such a drug – it has caused severe diabetic keto‐acidosis despite “normal” serum glucose levels.
Ertugliflozin (Steglatro®) is another drug with similar action, recommended to be used with metformin and approved for use in 2018. It is not to be used for patients with severe kidney disease, and will increase the incidence of lower leg amputation, just like canaglifozin, although this is not mentioned in a 2018 online article describing its use.
The Oregon Health Authority published a good review online in July 2018 of both semaglutide and ertugliflozin and combinations.
GLP‐1 RA drugs ‐ Semaglutide results in increased risk of diabetic retinopathy.
Statin drugs: generics (overall) increase insulin resistance. However, brand names Pitavastatin and Pravastatin are glucose neutral. No further mention of statin drugs and diabetes was made during the day‐long symposium.
In Arizona there is some free assistance with learning about diabetes: Diabetes Academy was founded and granted a 501 c 3 IRS designation as a charity on June 27, 2007.
A free class given by a Diabetes Educator to help patients learn about managing diabetes. Curriculum includes:
– Diabetes Management – Diabetes 101‐covers basic diabetes information and terminology
– Staying Healthy – provides convenient tips for eating healthy and staying active
– Diabetes Medication – reviews the basics about insulin and noninsulin injectables and demonstrates how to use injection devices.
Tomkin, G. H., et al. “Vitamin-B12 status of patients on long-term metformin therapy.” Br Med J 2.5763 (1971): 685-687.
Bhatnagar, R. K., et al. “Euglycaemic DKA secondary to Canaglifozin, an easily missed diagnosis.” Acute medicine 16.4 (2017): 196-199.
Cannon, Christopher P., et al. “Design and baseline characteristics of the eValuation of ERTugliflozin effIcacy and Safety CardioVascular outcomes trial (VERTIS-CV).” American heart journal 206 (2018): 11-23.
Sentena, Kathy. “Newer Diabetes Treatments Drug Class Update with New Drug Evaluation: Semaglutide and Ertugliflozin.” (2012).
Scott, Lesley J. “Ertugliflozin in type 2 diabetes: a profile of its use.” Drugs & Therapy Perspectives 35.8 (2019): 351-362.
Sentena, Kathy. “Newer Diabetes Treatments Drug Class Update with New Drug Evaluation: Semaglutide and Ertugliflozin.” (2012).
One lecture dealt with insurance reimbursement for care of patients with diabetes. That lecture made me feel beyond relieved that I am no longer a Medicare participant, and that I do not subscribe to the insurance model. The lecture was given by a professional certified endocrinology coder and registered dietician, Mary Ann Hodorowicz, and was pretty overwhelming. The bottom line seemed to be: charge for diabetes nutrition and education services at your own peril. Physicians can charge Medicare or Insurance for counseling, but not for nutritional counseling (at least not using those nutritional counseling codes), as best I understand it, but they can hire a registered dietician/nutritionist to do the counseling, and the physician can then of course charge a lower rate for those services. Not much financial incentive for physicians to take an active interest in their patients’ nutritional choices, is there?
Even if the physician is qualified to use the nutrition counseling codes, they will be reimbursed for a limited number of visits in a limited but very specific amount of time, before insurance stops payment, declaring that the services are no longer reimbursed, whether they are still needed or not. The physician may not charge per visit, but only after a certain number of visits have been made (no wonder there is such interest in “patient compliance”!). And the more diagnosis codes on the chart and in the medical record, AND ON THE CLAIM FORM, the more money a doctor/practice gets paid NEXT year (not at the time the services are rendered) for treating the patient. And that information has to be placed on the chart every calendar year, AND ON THE CLAIM FORM, or it “falls off the record” and reimbursement accordingly drops to lower levels.
The system appears to me to be beyond convoluted, and virtually guaranteed to allow insurance companies not to cover non-pharmaceutical and nutritional services. Pharmaceutical drugs are pretty much covered without question. The physician has only to write a prescription for the drugs. Easy peasy…
Is it any wonder that conventionally trained physicians are reluctant to enter the nutritional battleground? Their patients might actually experience improvement in their health without pharmaceutical drugs, and all the complications associated with those drugs. On the flip side…
If the physician over-codes (i.e. charges too much, based on chart documentation) insurance companies can demand their money back. If the physicians under-code (i.e. charge too little for their services based on chart documentation), they can be assessed fines for fraudulent billing.
The whole exercise puts the physician in an untenable position of helplessness and hopelessness, because big brother is way too big to fight. The codes are convoluted and require specialty certification to understand and apply. The fines are large. The rewards for correct coding are relatively paltry. The rewards for treating a patient successfully are huge – but not reflected in the world of finances and professional approval.
Living in the “family” of conventional medicine is a lot like being the child whose parent never speaks a word of approval, only of chastisement and shame, and then wonders why the child has no self-confidence.
Remember the quote from Lao-Tzu about “give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” Our insurance companies have apparently forgotten this ancient wisdom, to their great financial benefit, and the patient’s detriment. We are reimbursed less for teaching the man to fish than we are for giving him the fish (and the drugs) year after year after year…
In fact, Education and training for patient self-management is NOT covered by Medicare, even when done is group sessions. Preventive Medicine Counseling or Risk Factor Reduction counseling is NOT covered by Medicare. Diabetic management programs are NOT covered by Medicare.
Intensive behavioral therapy is covered by Medicare for obesity – but not nutritional therapy, is that not a curious state of affairs? The frequency of allowed visits is reasonable. Just remember that Metabolic Syndrome (obesity, high waist/hip ratio, elevated fasting blood glucose) is NOT an allowed code if you wish to charge for Diabetes Prevention Services in the Medicare-defined Diabetes Prevention Program. Specific codes are allowed or not allowed, but not actually explained in the Medicare literature available to physicians.
Bottom line for physicians who accept Medicare payments – experienced and well-trained coders are essential to obtain maximum reimbursement with minimum charges of fraudulent billing. If you don’t know what an RAF is (risk adjustment factor) or into which Bin the ICD-10 codes go, be prepared to (a) spend an inordinate amount of time learning insurance coding and reimbursement or (b) pay an exorbitant fee to have someone else do your billing. I personally find that billing my time by the hour is a much more efficient way for me to be paid for what I have been trained to do in this lifetime.
And that information above was contained in the first two hours of the five-hour symposium…
The third lecture was on motivating our patients to “become compliant” with our advice, how to get them to improve their lifestyle and behavior in order to improve their health. The discussion centered on the inevitable ups and downs of any attempt to change ingrained lifestyle behaviors and nutritional choices. Motivational interviewing has an interesting definition: “Motivational interviewing is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship.”
The most significant take-aways from this lecture were the concepts of shame and blame – if we the interviewers can talk to our patients about a disease like diabetes without blaming them for getting the disease by eating too much sugar over the course of a lifetime, or for not having the character to stop whatever it is they are doing – drinking too many diet sodas, for instance – they we can actually help them become motivated to change. Of course that demands that we ourselves, the interviewers, genuinely feel that diabetes is a disease, and it is caused by abnormal blood sugar metabolism, not a weakness of willpower, and that the individual diabetic has total control over his/her choice of addictive substance – carbohydrates, sugars.
Patient interviews and the healing process takes place in an atmosphere of hope and non-judgmentalism, if the therapy is to be effective. Thus far, I found the lecture to be helpful.
Miller, William R., and Stephen Rollnick. Motivational interviewing: Helping people change. Guilford press, 2012.
However, there was no mention of the fact that the patient actually has to be willing to change their behavior. It is easy to take a pill to treat a disease. It is much harder to change one’s food choices and efforts to exercise. Without the willingness to change, there will be no change in the patient’s behavior or in the course of the disease. Without the willingness to accept that sugar is an addictive substance, every bit as bad as cocaine or alcohol, there will be no change in behavior, no matter how many drugs we add to the system. This is the piece which I felt was lacking in the lecture.
If we start with the idea that diabetes is something that can be treated adequately with drugs, we are already missing a huge part of the origins of diabetes. Diabetes was not a significant problem in our population until we had ready access to large amounts of non-nutritive carbohydrates – sweetened beverages like Coca-Cola®, snack foods like Doritos®, potato chips, and sugar in every “food” substance manufactured by the food industry and purchased off the shelf of the grocery store.
Is diabetes associated with depression? Certainly – it is very hard to realize that one has a disease which is likely not curable, and which will demand significant change in lifestyle, eating habits, and in the way we interact with the world around us. Several different scales to measure degree of depression were identified. Depression was correlated with increased risk of complications of diabetes – retinal disease, kidney disease, neurologic impairment, sexual dysfunction, blood vessel complications like heart disease, stroke, peripheral vascular disease with eventual limb amputation. Treating depression with pharmaceuticals does apparently lower the A1C by a fraction of a percentage point.
The recommendation was for anti-depressant medication – without mention of the fact that 50% relief of symptoms is considered to be effective treatment in the world of pharmaco-psychology.
Nevertheless, the speaker discussed a very important point – the stigma associated with development of diabetes. The blame for lack of self-control and weight gain, the shame of the lack of motivation for any form of exercise, the idea that diabetes is a character flaw.
The most instructive part of this lecture, to me, happened when the lecturer said to us: “Do not talk about diabetics. Talk about people with diabetes. Do not talk about diabetic education. Talk about education to help people with diabetes deal with their disease.”
By labeling our patients, we make it more difficult for them to modify their behavior. By naming their disease, we give them something to modify, without taking away their motivation to change.
The same concept holds true for obesity. Obesity has been defined as a disease in 2013 – like any other disease, obesity is determined by genetics (the gun), the environment (the ammunition and the trigger) and behavior (the person who actually pulls the trigger). Depending on genetic predisposition, the trigger may be stiff or it may be a hair trigger. But obesity is always related to impairment of some normal function of the body – hormones relating a satiety, no longer experiencing the need to eat.
Continued in part 2 of this article