According to recent statistics from the American Diabetic Association, 25.8 million Americans have diabetes mellitus, a condition where the body does not process glucose, or sugar, efficiently. Instead of glucose making it's way into cells, it stays in the blood stream, causing a slew of medical problems over time, including but not limited to blindness, kidney failure, heart disease and vascular disease, which increases risk of amputation.
The cost of diabetes in America is staggering. In 2007, the cost of providing care for this disease was $218 billion dollars. That is not a typo. To put this in perspective, heart disease in 2009 cost us $316 billion (and is a complication of diabetes), and cancer care in the U.S. is expected to reach ~$160 billion by 2020.
The incidence of diabetes in America is increasing, so the above statistic is just the beginning. Americans are more and more sedentary (both at home and at work), and our diets are high in starchy foods, such as pizza, pasta, rice, potatoes and breads. We have trended away from preparing our own meals, instead opting for fast food. Our intake of fruits and vegetables isn't enough, and when we do eat them, it's usually with a caramel dipping sauce or ranch dressing. It's not good.
Once someone becomes diabetic, I aggressively educate them on behavior modification. Exercise more, even if it's going for a long brisk walk. Cut back on those starchy food, and replace them with more proteins or veggies. Drink more water. Really count your calories for a few days, just to see how much you are eating (people are usually amazed they are eating as much as they are). Information is power, and once you show the patient the data, it really can change their behaviors.
Part of that data is blood glucose testing. Each physician is different, but I tell my patients to check their fasting morning sugars, before breakfast, and the to check 2 hours after meals, to see how high their numbers go. If their sugars are really high, they can correlate that high number with what and how much they ate. It's pretty easy.
Data is king in this disease, and it brings me to the crux of this post. The cost of testing.
I am simply amazed at how much diabetic testing supplies cost. For some of my patients, the cost of testing is significantly more than the cost of their medicines. I have patients tell me regularly that they don't test their sugars as much as they would like because of the cost. This simply is unacceptable.
Data is a funny thing. It's just information. It lacks emotion. That changes when the data comes from a drop of someone's blood. It's a snapshot of how someone "is". When patients see their how abnormal their blood sugars are, they respond emotionally. They feel bad about it, ashamed, angry. They take it personally. This emotional reaction becomes a powerful tool for change, specifically, behavioral change. Once patients improve their behaviors, their blood sugars also improve, and it feels good to see that objective change in their data. It's positive emotional reinforcement.
I challenge the system to provide testing supplies to all diabetics. For free. No strings attached. If you remove the financial disincentive to testing, patients will be more apt to do it. In order to make a dent in the end cost of this disease, we need to improve the access of diabetics to their own blood sugar data. I would expect the cost savings to be significant. Improved glycemic control means fewer heart attacks, amputations, dialysis and blindness. It's not rocket science.
There isn't a reason why this simple plan couldn't be put into place immediately. Big Medicine - are you listening?
Monday, June 13, 2011
Monday, June 6, 2011
Drug seeking - a lesson in creativity
After 14 years of private practice, I think I've seen my fair share of the unbelievable. This week, I saw something new. A patient misspelled their name when they registered with our office. On purpose. You'll understand the importance of this is in a minute.
In April, Karla, my physician assistant, saw a new patient who came in for a visit. He had moved to Illinois from out of state, and based on his medication list, we knew this patient was going to need careful monitoring. He was on a significant amount of narcotics and anxiety drugs. Karla came to me for guidance, and we decided that based on the sheer amount of narcotic he was taking (80+ milligrams a day), he would need to get his prescriptions through a pain management physician. So, we gave him some names, asked him to let us know when he secured an appointment with the pain specialist, and sent him on his way.
He called 2 weeks later, saying he was going out of state and was afraid of running out of medicines. He said he had an appointment with the pain management doctor for when he returned. So, I refilled his medicines, but just one time, and made it clear to the patient I wouldn't refill them again.
This past week, we received a fax from a local big-box pharmacy, with a list of prescriptions filled by the above patient, from 5 different physicians in the last 12 weeks. Narcotics, anxiety drugs, sleep medicines. And there was my name, scattered amongst the other physicians who were prescribing for him. The pharmacy was notifying us they wouldn't fill any further prescriptions for the patient, because he was getting the same medicine from multiple prescribers.
The list which was faxed to us is from the Illinois Prescription Monitoring Program. Controlled medicines, like narcotics, are reported by pharmacies to the state, which then posts the information on a website for prescribers and pharmacists. It's a fantastic resource. 34 states have a monitoring program like this, but Florida does not.
We checked this database the moment the patient left our office. The database didn't show any controlled substance prescriptions for him, because he misspelled his last name on his registration forms. ON PURPOSE. He knew we were going to check the database. The fax from the pharmacy listed the patients birth date and name, but his last name was spelled differently. We actually addressed the spelling issue when he checked in, because his wife's insurance card had a different spelling on it. In addition, the patient conveniently had forgotten his driver's license, so we couldn't double-check his information against a legitimate form of ID.
We got a call from the pain management physician on Friday that the patient failed to show up for his appointment. I will be discharging the patient from our practice next week.
Chronic pain is a problem for millions of people. Narcotics are a mainstay of managing their pain. The difference between compliant patients and the addict I describe above is that compliant patients are exactly that. They keep appointments. They allow the doctors to count their medicines. They sign narcotic contracts. They don't take advantage of the physician.
Two or three times a year we get new patients like this. A few years ago, we had no way to check if we were being played by patients seeking inappropriate prescriptions. The IPMP has changed the game. Physicians can remain compassionate, without thinking every patient requesting a strong pain medicine is a drug seeker. If we are suspicious, we can easily check to see if they are listed, and if their name doesn't come up, we can take care of them without concern.
Prescription monitoring programs should be in place in all 50 states. There is no reason why physicians and pharmacies shouldn't have the ability to check for patients who abuse medicines. The problem is, we aren't utilizing these resources like we should. If we checked these databases on each and every patient, it would be a significant deterrent to stop this type of behavior. If we could make it harder for them to get their fix, then maybe, with the grace of God, we could help them climb out of the hole of addiction.
In April, Karla, my physician assistant, saw a new patient who came in for a visit. He had moved to Illinois from out of state, and based on his medication list, we knew this patient was going to need careful monitoring. He was on a significant amount of narcotics and anxiety drugs. Karla came to me for guidance, and we decided that based on the sheer amount of narcotic he was taking (80+ milligrams a day), he would need to get his prescriptions through a pain management physician. So, we gave him some names, asked him to let us know when he secured an appointment with the pain specialist, and sent him on his way.
He called 2 weeks later, saying he was going out of state and was afraid of running out of medicines. He said he had an appointment with the pain management doctor for when he returned. So, I refilled his medicines, but just one time, and made it clear to the patient I wouldn't refill them again.
This past week, we received a fax from a local big-box pharmacy, with a list of prescriptions filled by the above patient, from 5 different physicians in the last 12 weeks. Narcotics, anxiety drugs, sleep medicines. And there was my name, scattered amongst the other physicians who were prescribing for him. The pharmacy was notifying us they wouldn't fill any further prescriptions for the patient, because he was getting the same medicine from multiple prescribers.
The list which was faxed to us is from the Illinois Prescription Monitoring Program. Controlled medicines, like narcotics, are reported by pharmacies to the state, which then posts the information on a website for prescribers and pharmacists. It's a fantastic resource. 34 states have a monitoring program like this, but Florida does not.
We checked this database the moment the patient left our office. The database didn't show any controlled substance prescriptions for him, because he misspelled his last name on his registration forms. ON PURPOSE. He knew we were going to check the database. The fax from the pharmacy listed the patients birth date and name, but his last name was spelled differently. We actually addressed the spelling issue when he checked in, because his wife's insurance card had a different spelling on it. In addition, the patient conveniently had forgotten his driver's license, so we couldn't double-check his information against a legitimate form of ID.
We got a call from the pain management physician on Friday that the patient failed to show up for his appointment. I will be discharging the patient from our practice next week.
Chronic pain is a problem for millions of people. Narcotics are a mainstay of managing their pain. The difference between compliant patients and the addict I describe above is that compliant patients are exactly that. They keep appointments. They allow the doctors to count their medicines. They sign narcotic contracts. They don't take advantage of the physician.
Two or three times a year we get new patients like this. A few years ago, we had no way to check if we were being played by patients seeking inappropriate prescriptions. The IPMP has changed the game. Physicians can remain compassionate, without thinking every patient requesting a strong pain medicine is a drug seeker. If we are suspicious, we can easily check to see if they are listed, and if their name doesn't come up, we can take care of them without concern.
Prescription monitoring programs should be in place in all 50 states. There is no reason why physicians and pharmacies shouldn't have the ability to check for patients who abuse medicines. The problem is, we aren't utilizing these resources like we should. If we checked these databases on each and every patient, it would be a significant deterrent to stop this type of behavior. If we could make it harder for them to get their fix, then maybe, with the grace of God, we could help them climb out of the hole of addiction.
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