Diabetes Insurance

Why You Are Not Getting Aggressive Treatment

We all know that diabetes complications are caused by uncontrolled blood sugars. Most of us assume it only makes sense that HMOs and PPOs would want to prevent diabetes complications in their clients by helping them keep their blood sugars normal. But many are asking why this isn't happening.

All of the tools, like blood sugar meters, insulin pumps, and very convincing research results, have been available for 20 years, with the indisputable DCCT research results being reported in 1993. Yet everyone in the diabetes field knows good control has not happened. Several factors contribute to this slow pace toward progress in diabetes. As in crime, in health care you follow the money:

  1. A client who has diabetes costs the insurer 3.4 times as much as the average client. 
  2. HMOs set up programs that save money. A good diabetes program that draws more clients with diabetes costs them money immediately. Dumbing down in diabetes really pays.
  3. Prevention does not pay. Return on investment for most insurors has a window of opportunity of one or two years. If a new diabetes program cannot pay for itself within this period, executives in that health care system will not fund the program, no matter how beneficial it may be in the long-term. Preventing certain complications, like foot ulcers in those at immediate risk, will certainly pay off within this time frame. Unfortunately, most complication prevention programs have no hope of paying for themselves in this short time frame.
  4. Health care systems have a reduced financial incentive to prevent certain complications like renal disease. Although diabetes is the major (and unneccessary) cause for kidney dialysis and transplants, these costs are largely picked up by Medicare and Medicaid. Because this cost can be passed through to another payor, preventive care takes a lower priority.

What can you do?

  1. Talk to your Human Resources Department, especially if employed at one of the larger companies. These are the folks who decide what companies can offer you health care each year. They have a lot of influence over what gets covered.
  2. Talk to your congressman about reforming health care delivery regarding chronic diseases and true preventive health care. We don't need research nearly as much as we need provision of responsible health care delivery that emphasizes real prevention.
  3. Demand outcomes based health care where the health care provider does not get paid unless HbA1c and cholesterol levels are being lowered, microalbumin levels and eye screening is done yearly in at least 80% of their clients, and fewer referrals are required to dialysis and transplant programs.
  4. Demand time-leveraged insurance coverage. For instance if Blue Cross or one of the HMOs was providing insurance coverage for a person for 20 of their 40 years, they will become responsible for half of that person's health expenses should they require dialysis or coronary bypass.

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