Stanley Feld M.D.,FACP,MACE
I am a retired Dallas Clinical Endocrinologist who has no financial vested interest in this new report. I also was the chairman of the American Association Clinical Guidelines on the Treatment of Type 2 Diabetes Mellitus: A System of Care Of Intensive Self-Management of Diabetes Mellitus.
I am disheartened the lack of science that is presented as scientific information in this new study of claims data for Type 2 Diabetes Mellitus.
An article about the report was published in the Dallas Morning News on Thursday September 12, 2009. The article demonstrates how well intended people can be mislead by data that has little scientific or social scientific validity.
Misleading data can lead to inaccurate conclusions. Inaccurate conclusions lead to incorrect healthcare policies.
The federal and state governments as well as private industry rely heavily on medical claims data to make healthcare policy decisions. Medical claims data are derived from healthcare insurance industry’s computer systems. Claims data relate variables to each other and produce data.
The study reported in the Dallas Morning News relates the diagnosis of Type 2 Diabetes Mellitus to the average cost per Type2 Diabetic patient per year in five cities in Texas. There are many defect in the claims data because they do not consider the many confounding variables that might affect the conclusions (variables that can influence the data in one direction or another). Accurate conclusions cannot be derived from the data.
Healthcare policy makers have used similar inaccurate claims data to formulate healthcare policy for years. Inaccurate conclusions lead to incorrect healthcare policy. The new healthcare policy in turn distorts the dysfunctional healthcare system even further.
Well intended corporations want to help employees improve their health and healthcare coverage. However, they adopt incorrect policies that fail to achieve their goals and increases their healthcare costs.
“Dallas-area doctors charge more to treat patients with the most common form of diabetes than doctors in any other Texas city, according to a report set for release Thursday.”
“Doctors here charge an average of $6,992 annually per patient with Type 2 diabetes, compared with $2,079 in Austin, $3,067 in El Paso, $1,578 in Fort Worth and $2,226 in Houston. “
Let us assume these claims data are correct. The implication is in Dallas physicians charge more for the treatment of Type 2 Diabetes Mellitus than in the other major cities in Texas and do not do a better job of caring for Type 2 Diabetic patients. If you are going to get Type 2 Diabetes Mellitus don’t get it in Dallas, get it in El Paso.
What is wrong with these claims data? What are the confounding variables and their effect on the conclusion?
1. Physicians in Dallas see Type 2 Diabetics more frequently and do more tests than physicians in other cities.
What is wrong with these claims data and what are the confounding variables.
One confounding variable could be that Clinical Endocrinologists in Dallas have been teaching Primary Care Physicians how to practice evidence based medicine for Diabetes Mellitus for years
Best practices for Type 2 Diabetes Mellitus dictates that patients are followed up 4 times a year.
HbA1c levels which measure the blood sugar control over 3 months should be done four times a year. A minimum of twice a year is acceptable in some guidelines. These criteria are adopted by the NCQA. NCQA will be President Obama “expert guideline panel.
Patients with Type 2 Diabetes Mellitus in the other cities might not see physicians as frequently. Some physicians see Diabetics once a year because the Diabetic is told they have a touch of Diabetes and follow up is not that important. Type 2 Diabetics are usually not symptomatic even if they are walking around with a high blood sugar.
However, high blood sugar levels cause micro and macro vascular disease leading to the complications of diabetes such as eye disease and blindness, kidney disease and renal dialysis, neuropathy or nerve disease, leg amputations and heart disease. High blood sugars increase cholesterol and LDL (bad cholesterol), low HDL (good cholesterol) and subsequent heart attacks.
All of these complications need to be monitored according to guidelines. Effective treatment intervention can stop the progression and even reverse the onset of complications.
- The claims data might indicate that the physicians in other cities do not take care of patients with Type 2 Diabetes Mellitus as well as physicians in Dallas.
- It might also mean that despite physicians in Dallas following up patients and practicing evidence based medicine patients do not comply with treatment recommendations resulting in expensive complication.
Physicians can do tests, see patients often, prescribe the correct medication and diet and patients still gain weight and have very high blood sugars and cholesterol levels. Patients must be responsible for their care between doctor visits.
3. In Dallas there might be more Obesity, Type 2 Diabetes, heart attacks and renal dialysis leading to a higher cost per patient per year than other cities despite physician effort.
None of this data is reflected in the claims data collected and compared. This is great deficiency of claims data.
We have claims data about physicians in Dallas. They do a higher percentage of HbA1c’s than physicians in other cities. They probably do a greater number also.
The implication is Dallas physicians should have a lower cost than other cities because a higher percentage of HbA1c’s. Patients should be better controlled and have less complications.
The HbA1c is simply a marker of blood sugar control. It does not decrease the complication rate. It should not be a measure of quality of care. If done once a year rather than four times a year it will decrease the cost of care. Lowering the HbAic should be the measurement of the quality of care. It will reduce the complication rate of Type 2 Diabetes. Claims data does not measure the improvement in HbA1c levels.
The complications of Type 2 Diabetes Mellitus consumes 80% of the healthcare dollars spent on Type 2 diabetes.
4. The majority of Type 2 Diabetes Mellitus is discovered in the CCU after a male has a myocardial infarction. These patients are expensive patients. They are included in the diabetes claims data.
5. Physicians in El Paso might not code for Type 2 Diabetes Mellitus in a patient with a myocardial infarction. We do not know this from claims data.
Claims data tell us nothing about the care of the patients. Yet health policy makers assume studies are valid. The only thing valid about this new report is that it was done. Claims data confuses health care policy makers and leads to wrong conclusions about the quality of care. .
"This confirms what we already know from other recent studies that medical charges in Dallas are among the highest in the country," said Marianne Fazen, executive director of the Dallas Fort Worth Business Group on Health.”
“The state average is $3,399 per patient with
Type 2 diabetes, the form of diabetes that occurs when insulin the body produces doesn’t work well enough to process sugar into energy. “
The treatment of Type 2 Diabetes Mellitus is a team sport. The physician should be the coach and the patient is the player. The patient has to be taught to be a professor of diabetes care. Physicians have to measure patients’ progress and help patients make adjustments to their care.
This new report is worthless. It does not shed any light on what needs to be done to prevent the complications of Type 2 Diabetes Mellitus nor improve the quality of diabetes care in Texas.
Once we abandon the notion that claims data can tell us something about quality of care we will start making progress to improve quality of care.