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Chronic Disease Management Part 4

Stanley Feld M.D.,FACP,MACE

Now that you understand the Type 2 Diabetes Mellitus disease process and what you have to learn about your imaginary disease, the strategy for treatment should be simple to understand.

The goal is to decrease the increasing resistance to insulin as you age, gain weight, do less exercise or increase your stress. The blood sugar increases cause a further increase in insulin resistance. By decreasing insulin resistance the result is to decrease the burden on the pancreas to produce insulin. We have to eliminate the causes of insulin resistance, namely, weight gain, stress and the increasing blood sugar. Additionally, exercise increases the effective number of insulin receptors and decreases insulin resistance. If this strategy was simple to execute there would be much less need for the powerful medications developed over the last few years to decrease insulin resistance. A survey done by the American Association of Clinical Endocrinologists (AACE) of its members a few years ago showed that most Type 2 Diabetics were on at least 3 oral medications. The average cost per year of each medication is about $1700.00. If the patient was spending his own money and understood that weight loss, decrease in stress and increase in exercise could help restore insulin sensitivity and decrease blood sugars. The result would be that much of the medication costs could be decreased markedly in most patients. Patient motivation with the appropriate coordinated education about Type 2 Diabetes and the appropriate follow-up by the Diabetic Education Team (DET) would be high.

Another critical self management tool is home glucose monitoring. Patients can now monitor the effect exercise, weight loss, and stress reduction has on their blood sugar. They can also monitor the effect of the various medications on their blood sugars at various times of day. If patients understood how the various medications worked and learned how to spot problems they could make adjustment between visit to normalize the blood glucose level after email consultation with the physicians and their diabetes education center. However, this consultation time spent between visits should be compensated in order to motivate the physicians to expend the time and energy to set up and execute such a system. The new system has to be driven by the patient and his control over his healthcare dollar (Consumer Driven Healthcare).

I have outlined a system of care for Type 2 Diabetes Mellitus. I will review the power of chronic disease management in other chronic diseases.

If our society really wants to fix the healthcare system these various systems of care must be developed, promoted, and funded. The government, insurance industry, and health policy makers are starting to develop an interest in doing the right thing. However, this potentially means their losing power over the consumer and his ability to drive the system in a real market healthcare economy.

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