Memorandum

Diabetes Technology and Therapeutics publishes Dr. Irl Hirsch’s third annual rant on diabetes care – January 27, 2015

Executive Highlights

  • Diabetes Technology and Therapeutics recently published Dr. Irl Hirsch's (University of Washington, Seattle, WA) third annual rant on the state of diabetes care, titled “Diabetes Care Entering 2015: Ineffective Ranting.”
  • In the piece, Dr. Hirsch expressed frustration with the effects of “grading” physicians, the persistent high costs of diabetes care, and the increasing bureaucratic and administrative burdens placed on physicians.

Diabetes Technology and Therapeutics recently published Dr. Irl Hirsch's (University of Washington, Seattle, WA) third annual rant on the state of diabetes care, titled “Diabetes Care Entering 2015: Ineffective Ranting.” In the piece, Dr. Hirsch commented on the negative impact of “grading” physicians, the high costs of diabetes care, and the increased bureaucratic and administrative burden (including the use of EMRs) on physicians. Notably, Dr. Hirsch’s greatest concern is that the next generation of physicians “won’t be ranting” but will simply accept the status quo as inevitable. He noted that many endocrinologists are already retiring early, while those who stay mostly do so to maintain their health insurance. We are unfortunately not surprised by this sentiment as several recent studies have shown declining job satisfaction among physicians – see our coverage of survey results from The Physicians Foundation and the Academy of Integrative Health and Medicine. Overall, if you’re thinking it’s largely a nightmare (especially an administrative one) to be a doctor treating diabetes today, you’re right, and this piece underscores it well. We have thought for some time that although there are doctors going into diabetes, they are probably not the doctors at the top of the medical school classes for the most part, except for some who have personal connections or amazing mentors and a deep desire to address mounting public health problems. This is a major negative for research and clinical care and is another “crisis” that isn’t currently discussed very much.

  • Dr. Hirsch expressed frustration over evaluation systems that force providers to practice “cookie-cutter” diabetes care rather than considering patients’ individual needs. He argued that “grading” providers solely on whether their patients’ A1c, LDL-cholesterol, and blood pressure fall within recommended ranges does not account for the wide spectrum of patients and conditions seen in clinical practice; Dr. Hirsch said that he himself has ordered tests that he felt were unnecessary in an effort to increase his score. While we would argue that the general concept of “pay for performance” does represent an improvement over the traditional fee-for-service system, we agree that such standardized assessments can easily serve as a barrier to individualized treatment. Clearly, the process of designing physician evaluation systems that incentivize the best possible care for all patients is still very much a work in progress.
  • Dr. Hirsch was especially critical of the high costs of diabetes care, including skyrocketing insulin prices and Medicare’s lack of reimbursement for CGM.
    • As Dr. Hirsch described in a provocative talk at this summer’s Keystone conference, recent price increases have made the cost of insulin prohibitive for many patients, even those with insurance  – according to him, the least expensive vial of Sanofi’s Lantus (insulin glargine) in Seattle is a shocking $399. He also noted that single-source formulary contracts have eliminated many patients’ ability to choose which insulin to use and thwarted traditional marketing of insulin products directly to providers and patients. How pricing dynamics will play out in the coming year is very much an open question, especially in the basal insulin market – as a reminder, Sanofi was forced to accept a significant increase in rebates for Lantus in 2015 in order to secure favorable formulary positioning. The trend toward exclusive contracts does appear likely to continue for the foreseeable future, which will certainly raise the stakes for companies during negotiations with payers (though it could also provide them with leverage to counteract payer pressure once they have won an exclusive contract).
    • In addition, through the story of one of his aging patients, Dr. Hirsch expressed significant frustration with Medicare’s exclusion of CGM coverage. Notably, while he finds it “clear” (and we agree) that hypoglycemia is more debilitating than any downfalls of CGM use for elderly patients, Dr. Hirsch stated that Medicare points to the lack of research on CGM in this population as a reason not to cover the device. We hope to see such studies take place in the near future, as this seems to represent the most likely path to a change in policy given CMS’ emphasis on evidence-based medicine. Both the Senate and the House of Representatives have bills in committee that would establish Medicare coverage of CGM and pave the way for reimbursement of future artificial pancreas technologies – our fingers are crossed for action on these proposals in 2015.
  • Dr. Hirsch touched on the burden of the increased bureaucratic and administrative hurdles for providers created by technology like electronic medical records (EMRs). In his view, such tools have “not resulted in improved medical management as was originally advertised” but have only added more unnecessary work for providers, lengthening the time required to write a prescription or order a lab test. Dr. Hirsch pointed out that the extra burden of EMRs has even pushed some providers to “cut corners” in patient care, (e.g. reporting that medications are correct without properly reviewing them). Dr. Hirsch is clearly not alone in his frustration with EMRs – one attendee at an AHA session on big data described the technology in its current form as a “disaster [with the] potential to ruin the profession.” Dr. Hirsch also lamented the absurd amount of time providers spend negotiating pre-authorizations for non-covered or poorly reimbursed items (an average of 12 minutes per negotiation according to one assessment, which Dr. Hirsch believes is an underestimate). Such bureaucratic hassles are clearly detrimental for patients, and it is a shame in this era of fifteen-minute office visits to see such a substantial chunk of providers’ time diverted away from patient care. We also believe that the current lack of standardization between different EMR systems must be addressed to better streamline patient care and potentially provide a framework for future larger-scale integrated data networks.

-- by Melissa An, Emily Regier, and Kelly Close