Specialist Physician/Endocrinologist and Principal Physician, and Executive Chairman of the Centre for Diabetes and Endocrinology (CDE), Dr Larry Distiller, explains what’s needed to effectively manage diabetes.
The diabetes tsunami is here. Unless we meet it head on with appropriate management, this condition is single-handedly set to break the healthcare system, if not the entire economy, in the next decade.
Managing the costs
At this time of year when many schemes are announcing their benefits packages for 2018, and people with diabetes are mulling over their medical aid options, it is important to review what programmes are in place for the management of diabetes. Unfortunately, diabetes is often treated ‘on the cheap’ to save costs in the short term.
A patient not seeing a nurse and registered dietitian costs less than someone who does. While no care may look cheaper than good care in the short term, we know that this is definitely not the case in the longer term. If we look at UK data, we see that complications of uncontrolled diabetes account for most of the overall costs of the condition (80%) while treatment and management only accounts for 8%.
It is regrettable that diabetes is often not ‘treatable’ due to the cost barriers for the patient. Just because you have medical aid, does not guarantee that you will automatically receive care.
When you consider that diabetes remains the most common cause of blindness in the Western World, the leading cause of kidney failure, dialysis and transplantation and the most common factor in lower limb amputations, this lack of care becomes significant. It is linked closely to the other well-known risk factors for heart disease and death, namely high blood pressure, high cholesterol and obesity and is also a major cause of acute hospitalisation.
Good management of diabetes has the potential to reduce acute hospitalisation rates for diabetes by 85%, eye complications and renal failure by 60% and amputation rates by over 80%. The potential cost savings run into billions of rands.
The problem is that diabetes, despite its prevalence, is both an expensive and difficult condition to treat. It requires ongoing, in-depth management, education, monitoring and constant review and intensification of medication, with many patients eventually requiring insulin for control. And, as complications develop, the cost of management goes up incrementally and exponentially.
The need for new care models
Against the backdrop of increasingly scarce and costly healthcare resourcing, and escalating, but preventable, costs of admissions for diabetes and complications of poor diabetes care, it is imperative that the healthcare sector urgently seeks integrated approaches to preventative, community-based diabetes care.
We are clearly lacking critical research funding and resources to improve healthcare and treatment and there is an urgent need for more education and a change in the way diabetes is managed and funded in South Africa.
The real challenge is finding a way of reducing costs without impacting quality care. We appreciate that medical schemes are under enormous pressure to manage their costs, but it is concerning when the focus moves to cost-saving rather than greater patient service utilisation and improved clinical outcomes. We need to start being far more proactive in treating and promoting patient health, particularly when one considers economic studies from the US showing that in people with diabetes, inpatient hospital care accounts for 43% of the total medical costs of diabetes and that poor long-term clinical outcomes increase the cost burden of managing diabetes by up to 250%.
Diabetes management programmes
Over the last 23 years, CDE Diabetes Management Programmes have resulted in a significant overall reduction in all acute diabetes-related hospital admissions. We have seen a reduction as high as 40% in all-cause hospital admissions and a 20% reduction in the length of hospital stays. This can only be good for funders who choose to utilise our services.
One of the challenges in the past was that these programmes were largely confined to Medical Scheme Members on the top end options. We have been working hard to ensure that CDE Programmes of care can now be customised to ensure that scheme members on lower-benefit options are not excluded and that education platforms are extended.
The bottom line is that the most important person in the management of diabetes is the person living with diabetes. The majority of diabetes care is self-administered. The best results are without doubt where there is co-ordinated and continuous support for patients by a team of properly skilled doctors and allied health professionals in a defined programme of care.