Is diabetes management next?

In 49 days Americans will head to the polls for what many view as one of the most important elections in our nation’s history. An election which will take place during an unprecedented pandemic which has shaken this country and quite frankly created an even greater political divide. Social distancing, wearing a facemask and the simple act of washing your hands have all become hot button political issues. Worse in our opinion has become the politicization of science.

Ironically the average American is now getting a taste of what we have watched for the last 20 years, the painstakingly methodical clinical trial process. As companies race to develop a COVID vaccine this process which normally takes years is being condensed into months. This is like trying to run a marathon with the speed of a sprinter. This isn’t just unprecedented it could well prove to be dangerous. The facts are, and we even hate to use the term facts these days, we still have much to learn about COVID.

What concerns us here is could diabetes management become another hot button political issue. Diabetes is not just a healthcare epidemic it is also a financial plague. As America ages the diabetes epidemic has the potential to bankrupt programs like Medicare. It is well known that many of the costly complications that come as a result of poorly controlled diabetes disproportionately impacts older Americans. A patient population which is growing by the day.

Making matters worse is the continued focus not on outcomes but the toys in the toy chest. Sure everyone talks about improving patient outcomes but the data shows that even with a plethora of new drugs and way cool whiz bang devices more than two thirds of patients aren’t under good control. It’s equally true that never before has the patient had so many options to get help if they want help. There are thousands of apps, web sites and employer sponsored programs designed to help patients better manage their diabetes.

Still with all these great drugs, amazing devices and access to information outcomes have barley improved from when we first began writing Diabetic Investor some 20 years ago.

Some believe that the reason we have not seen an improvement in outcomes is lack of patient access. That our healthcare system is in disarray creating a huge disparity between the haves and the have nots. Many of these people are advocating a single payor system to level the playing field believing that given access to all the drugs and devices we’d see an improvement in outcomes. Others believe that drugs such as insulin have become a basic right and should be given away for free.

The debate over the “high” out of pocket cost if insulin is a perfect illustration of how diabetes management could become politicalized. For years many regaled about this issue complaining loudly that patients were dying because they could not afford the medication that keeps them alive. It was not until this issue became political that was action taken. Today thanks to pressure brought by patient advocacy groups the politicians acted. While we applaud these efforts and the results achieved lost in this debate was outcomes. Insulin may now be more affordable but that does not mean nor is there any evidence to support the theory that greater patient access leads to better patient outcomes.

Could CGM become the next insulin? What about hybrid closed loop insulin delivery systems? Crazy maybe but then again maybe not. As everyone knows we consider CGM the most transformational technology in diabetes history. Thanks to CGM and the data it provides we now have an inside view of diabetes. Old standards to measure good control such as HbA1c are being reexamined and new one’s such as time in range (TIR) are becoming just as important.

Thanks to systems like the Control IQ and 670g we are seeing dramatic improvements in patient outcomes.

Yet as amazing as this technology is it is not cheap. Yes CGM is becoming more affordable and the playing field for insulin pump reimbursement appears to be leveling but even with these positive developments social media is filed with patients complaining how expensive these systems are. Could this be the beginning of an effort to bear political pressure? Emboldened by their success with insulin could patient advocacy groups target CGM or hybrid closed insulin delivery systems? Could we be headed for price controls?

Now before we go any further let us state for the record that there is no question our healthcare system is in serious need of reform. The question, a question which has been around since we began writing Diabetic Investor, is what should this reform look like. What happens for example if as we advocate that patients are incentivized for achieving better outcomes. Does this mean that patients who fail to achieve better outcomes are penalized? And just who becomes the judge of what is and what is not good control?

That last question may seem silly but thanks to technology we now know that a patient can have a “good” HbA1c and still not be under good control due to adverse TIR. We have also learned that the simple adage that an HbA1c of 7 or below is good control does not necessarily apply to all patients. Research has shown that for some patients this HbA1c target is unrealistic and could actually be dangerous.

There are huge business implications here. Will diabetes management become what the race to develop a COVID vaccine has become with the government investing billions of taxpayer money. A process many see as contaminated due to the politicization of the FDA and CDC. Most reasonable people believe we should follow the science which sounds great until the very science we are basing everything on is being questioned at each and every turn. Is it any wonder that most polls show that a high percentage of people will wait to get vaccinated or not get vaccinated at all.

The big difference between COVID and diabetes is that hopefully whatever vaccine(s) are developed for COVID will put this pandemic to rest. Diabetes on the other hand is a chronic disease for which there is no cure. Diabetes must be managed 24 hours per day 365 days a year with no days off. Therein lies the biggest problem of all a problem which is lost in all this talk about whiz bang way cool. A problem which is bigger than the cost of any drug or device. A problem which even with greater access to drugs and devices will not be solved. While no one talks about this the patient with diabetes does bear some responsibility for outcomes.

We’ve said it before and will say it again you could give away everything a patient needs to manage their diabetes for free and we would still not see improvements in outcomes. Improvements in outcomes isn’t about the toys in the toy chest or the drugs in the medicine cabinet. Improvements come from playing with the toys and taking the drugs. It comes from the patient doing their part and this is far too often ignored in this debate.

We have seen many elections in our time here and know only one thing for certain that this wonderful democracy of ours works because people vote. So no matter what your view no matter which party or person you support do us all a favor and vote. As Momma Kliff said many times elections are like decisions they have consequences and you lose your right to complain about the outcome if you don’t decide, if you don’t vote.