The other side of the coin

The other side of the coin

“As a busy surgeon, I have serious concerns about the race to consolidate America’s hospitals because of the risk that very large organizations may govern without valuing the wisdom of their front-line employees. Already many doctors are frustrated by the electronic medical records, strategic planning and hospital processes that they feel have marginalized their medical insights into their own patients.”

This quote comes from Dr. Marty Makary who penned an excellent piece in today’s Wall Street Journal entitled; “The ObamaCare Effect: Hospital Monopolies”. Although Dr. Makary was not specifically referring to anything diabetes related his comments apply directly to diabetes and the continuing push towards interconnected diabetes management.

After talking with several endocrinologists and primary care physicians Diabetic Investor can state emphatically that these people feel the same way as Dr. Makary when it comes to managing their patients with diabetes.  Many see this consolidation of hospital and medical practices as interfering with how they manage their patients with diabetes. Yes they see the business rational for this consolidation yet agree with Dr. Makary in that unless some changes are made it will be patients who ultimately suffer.

As we have been noting in the future its likely physicians will receive even more detailed instructions for how they should be managing their patients with diabetes. That their performance will be more closely watched as technology makes this easier than ever. As outcomes factor into how physicians are compensated this technology which is supposed to help them can become a double edged sword. Some have expressed concern that they could be forced to dump non-compliant patients or patients who for one reason or another are difficult to manage.

Yes the metrics for measuring good control are well accepted but as recent research has shown good control is also subjective. Just by way of example research has shown that the risks of tight glycemic control may outweigh the benefits of achieving an HbA1c of 7 or below. That for certain patient populations the target HbA1c should be closer to 7.5. Physicians worry that this quest to achieve tight glycemic control may well result in unacceptable level of hypoglycemic events.

They also worry that as payors become even more concerned with costs they won’t be able to prescribe the drugs these patients need to achieve control. In many respects this is already happening as more and more payors are instating higher co-payments or instituting counter intuitive reimbursement policies. Many would like to prescribe a certain drug only to discover that due to the patients coverage this drug is either not covered or if used requires a co-payment which the patient cannot afford.

Diabetes is perhaps one of the few disease states where outcomes are directly tied to patient compliance. As we noted many times managing diabetes requires work, that in addition to all the other things a patient worries about they have the additional job of managing their diabetes. A job made more difficult given all the external factors that impact outcomes, factors which often times are not controlled by the patient.

Underlying all this is another unspoken but very real concern for the physician, as interconnected diabetes management (IDM) could seriously impact a physician’s livelihood.  The fact is IDM when used as intended would minimize the role the physician plays. That income generating events such as office visits or blood work would become less frequent. The fact is with regular glucose monitoring it’s easy to determine the patients HbA1c, it also becomes easier to determine whether the patient’s medication regimen is working or not. Technology makes it possible for a third party such as Certified Diabetes Educator to intervene electronically with patient an intervention which in the old days would require a visit to the physician’s office.

A possible solution to keep physicians in the loop would be to compensate them for non-face to face communications such as emails or text messages. While some payors allow this others do not or place restrictions on the amounts physicians are allowed to submit for reimbursement.

This changing reimbursement landscape is actually a reason more physician groups are consolidating selling their practices to larger practices or hospital groups. Under such an arrangement the physician transforms from being an independent contractor to an employee.

The most perplexing question just might be exactly what role will the physician play as we move closer to IDM becoming the standard of care. As we have noted before the real battle looming on the horizon is just who gets paid for managing the patient. Will it be the physician, the pharmacist, CDE or a software algorithm?

The reality is as much as IDM has the potential to change diabetes management for the better, there are still several hurdles to overcome before IDM moves from the fringes to everyday usage.