Said Better Than I Might Say It?

This comes from "Clinical Endocrinology News", one of the monthly "newspapers" I receive and read. You would need to register to access the link to the article, but the following excerpts are important points that must be considered:

I made the decision to restrict my practice to diabetes from the start. There may come a day where I'll have to reconsider that.

The following editorial (in red), written by Dr. I. Hirsch, a Professor of Medicine at the University of Washington in Seattle, for Clinical Endocrinology News, nicely explains why:


Most clinical endocrinologists acknowledge their greatest challenge is appropriate reimbursement for their expertise, particularly in the area of intensive insulin therapy. The added time commitment with these patients, in addition to the additional training, does not fit any business model.

The American College of Endocrinology (ACE) could help to solve this problem by supporting a new certification concept, we could call it DACE, for “Diabetologist of the American College of Endocrinology.”

Current reimbursement practices are rendering state-of-the-art diabetes care virtually impossible. Simply put, we need more than the typical 15-20 minutes allotted for return visits in order to adequately teach and counsel our diabetes patients how to self-manage their disease.

Too many endocrinologists are getting bogged down with complicated patients without sufficient resources to manage them efficiently. Since the system rewards volume rather than quality of services, many of us have begun opting out of treating complicated diabetes patients, especially those requiring insulin therapy, pumps, or wanting to pursue continuous glucose monitoring.

Fundamentally, the system is broken. It's just not possible for board-certified endocrinologists to see everyone with diabetes. But that doesn't mean we should close our practices down to this population due to lack of systems support. But sadly, that's what some of us have done.

Others in our specialty have opted for other less-than-ideal approaches, such as working in a closed-system managed care arrangement in which primary care physicians manage 95% or more of the patients with diabetes while endocrinologists only managed nondiabetes endocrinopathies. Others have completely stopped taking new diabetes referrals. Still others approach diabetes management the same way they approach Medicaid patients: rationing the numbers in order to sustain financial survival.

It is inappropriate to manage chronic diabetes therapy within the same dysfunctional care model that is based on acute treatments. Yet, that's what we've been doing. We continue to be underappreciated by payers for our services, and to spend an ever more time fighting for our patients to be reimbursed for their needs when no one is fighting for us.

What's needed right now is a better understanding of the burden of diabetes among all stakeholders: patients, providers, and certainly payers. Government and payers need a better appreciation of all we do that results in good diabetes care. It is far more complicated than simply measuring hemoglobin A1c, yet that's what health plans grade us on.


Many patients tell us we provide "better" or "more extensive" or "more complete" care than other practices they have experienced. Imagine the feeling I had upon receiving the following note a while back -- I don't think I could put it into words. The salutation and closing are cropped out of the letter copy to maintain confidentiality. Click on the letter copy to enlarge, then on your "Back" button to return to this post:

However, it's difficult to predict how long we'll be able to "hold out" while we're being reimbursed the same, per patient encounter, as the physician recently described to me by one of our patients:

"Yeah, I think he schedules about 6 people an hour. I've never been taken back for my appointment less than an hour late and, if he spends 5 minutes in the room, that's a lot. Basically, I get my blood pressure checked and, if I have a complaint, it's almost like he's annoyed that he has to take an extra minute. I never hear about any of my test results and we know he never sends anything to you."