Sicker Than Sicko

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I’ve never liked Michael Moore’s movies much, but Sicko is way better than anything he’s done before. He really exposes the madness of our medical system. He does this partly with some horror stories about people who couldn’t get help. But, more importantly, he shows how they do it better in England, Canada, and France.

All these countries spend far less on health care than the U.S. does (40% to 70% as much), but they cover everybody and have much better health. Even Cuba, a very poor country that spends 4 cents on health per person for every $1 we spend, has similar life expectancy and health outcomes.

Other countries’ health-care systems are better because they a) cover everyone for basic care, and b) focus more on prevention and basic care and less on expensive treatments of advanced disease. This has the effect of helping people stay healthier, which saves a lot of money and improves quality of life. The U.S. system, in contrast, doesn’t pay much for prevention or wellness, but spends billions treating advanced complications and keeping very sick people barely alive.

I write about the failings of American medicine in my book Diabetes: Sugar-coated Crisis—who gets it, who profits, and how to stop it (New Society, 2006). I explain how our $2,000,000,000,000 medical system may actually do more harm than good. One example relevant to Diabetes Self-Management readers: In the 1990’s, four diabetes treatment centers operated in Manhattan, teaching and supporting self-management. All had excellent results in controlling blood glucose and preventing complications. Their patients were living good lives. Clinically, they were a great success.

They all closed within ten years. Why? Because insurance paid so little for these prevention services that the clinics all lost money. The only time they could get paid was when they failed. When someone needed an amputation or laser eye surgery, they made money, but when people stayed well, they operated at a loss. So they had to stop.

Meanwhile, in this same time period, nearly 50 dialysis centers opened in New York. Almost all of their patients were people with one of the worst complications of diabetes: kidney failure. Many had very low qualities of life, but they were kept alive. Insurers paid for the service, and the dialysis companies made nice profits.

Who Pays for Self-Management?
This is what happens when you have a medical system based on profit. Drug companies and other profitable, high-tech ventures take over more and more of the system. Low-tech interventions like self-management support struggle to stay alive.

For example, Medicare pays for 10 hours of diabetes self-management training (DSMT) in the first year after diagnosis and two hours per year after that, and they don’t pay much. (Most private insurers have similar or even less generous benefits.) As a result, says American Association of Diabetes Educators past president Virginia Zamudio, most people with diabetes don’t have access to DSMT at all.

You would think that insurers would be happy to help people manage diabetes, since the cost of complications is so high. But instead, according to health economics expert Thomas Bodenheimer, M.D., insurers often provide minimal services for people with diabetes, because they want to encourage you to take your business elsewhere. Some insurers are more blunt about it—they won’t sign people with diabetes up at all, or they raise the rates impossibly high. An American Diabetes Association study found that some insurers raised premiums 37.5% for an eight-person business if just one worker had diabetes.

The medical system can hurt people with diabetes in other ways, too, as I’ll discuss in my next blog entry. I’ll also talk about what we can do to protect ourselves and change the system. One group that is working to make the system better is New Health Partnerships. NHP brings providers and patients together to develop better ways to support self-management and to figure out how to make it work economically for everyone.

Please tell me: What have been your experiences with the medical system? How has it helped you and hurt you? What ideas do you have for changing it? And if you haven’t seen Sicko, I encourage you to see it. It’s actually about a lot more than health care. Let me know what you think of it.

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