Walter M. Bortz II


Diabetes Wellness News
June 2008: Volume 15, Number 6
Something Else That I Didn't Learn in Med School

When I was a med student at the University of Pennsylvania 50 some years ago, I'm sure that all of us there thought that we were the smartest things on earth. After all, for weeks and months we were being coached and coaxed by brilliant scientists who were intent on increasing the size of our brains.

The longer I am removed from this challenging time of life, the more I recognize how little we really knew, how shallow was our real competence. Sure, we learned about insulin and islets of Langerhans and hypoglycemia, a little about diet, virtually nothing about behavior, and absolutely zero about economics. It almost seems like what we were instructed about was inversely related to what really matters in the big world.

Almost everything we were taught has to do with treatment - nothing about prevention. Of course, remember that most of the diabetes we were concerned about then was Type 1, and even now our insight about prevention of Type 1 is sparse. Type 2 was scarcely on our radar screens in any of its now familiar guises.

But the further I am removed from the medical school curriculum and live in the real world, the more I recognize the dearth of my education about the economic units of this terrible disease. Now it is one of my major interests but I have had no training in it.

Everyone recognizes of course that doctors are notoriously ignorant of all things financial, and this truth certainly permeates the topic of the economic costs of diabetes.

So it was an immediate "sit-up-straight-and-pay-attention" moment when I grasped the major article in the March 2008 issue of Diabetes Care entitled "Economic Costs of Diabetes in the US in 2007." The report was prepared for the American Diabetes Association by the esteemed consulting firm, The Lewin Group, of Falls Church, Virginia.

The authors surveyed a wide collection of national health care statistics and costs including data from the CDC, the Bureau of Labor Statistics, Medicare and Medicaid services, Social Security, etc. All of the figures were related to the medical consumer price index. The compilation is wonderfully broad, providing numbers by age, sex, ethnicity, insurance status, disability figures, health resource use, and associated conditions.

Several gross statistics stand out, such as 17.5 million people being listed in the 2007 figures as diagnosed with the diabetes. This figure is derived from the answer to the question: Have you been told by your doctor that you have diabetes? The 17.5 million case figure amounts to 5.6% of the total population. Another 2.2% -- nine million - are estimated to be undiagnosed, leading to a grand total of 26.5 million Americans currently with diabetes. And tomorrow…?

Beyond those with diabetes is hidden the additional huge number of those with pre-diabetes, and millions more with the condition that I have termed pre-diabetes - those who are overweight and under-exercised, but whose fasting blood sugar levels have not yet begun to increase.

The numbers produced are staggering by themselves, and all the commentators remark that every estimate is an underestimate.

The costs of these bloated figures are represented in various ways. Among them: the days of productive activities that are lost due to absenteeism, disability, and premature mortality. These translate tot 15 million days attributable to work absence and 120 million days to reduced performance at work; 6 million days of reduced productivity for those not in the workforce, 6 million days from permanent disability, and 107 millions days from mortality - yielding a total productivity loss numbering in the mega-billion-dollar range.

Further, it is estimated that people with diabetes will retire 2.6 years earlier than those without diabetes.

All of these numbers are fascinating to me… frightening to me, but they are only the statistics that generate the dollar costs- where the real terror lies. The Lewin Group authors generate the sum total of $174 billion as the expenses due to diabetes in 2007. But virtually in the next sentence they confess that these numbers are a gross underestimate. But, acknowledging the single number of $174 billion for a moment - this represents 8% of all national medical care expenses. (The authors elsewhere project that the real percentage is closer to 10%.)

Beyond these gross figures is the evidence that placing the diagnosis of diabetes on a person's chart is accompanied by an additional expenditure of $6,649 per person, per year on average, which then comes to $11,744 total.

And with all projections tending to be much higher, these figures are certain to skyrocket further… scary stuff.

Having laid out the data as above inevitably prompts an editorial comment. A recent fine article in the New York Review Books concerns an essay about cancer generated by the editor of the Lancet, a leading British medical journal.

The point of the report derives from the fact that, aside from a few notable exceptions, the survival rate for all forms of cancer has not improved substantially in over 50 years, despite huge increases in expenditure. The author lays this ugly anomaly to the fact that almost all of the cancer monies are spent on often ineffectual treatment strategies, and almost nothing on prevention.

He further asserts that most cancers are truly preventable; but we have lacked the vigor and commitment in addressing this approach, emphasizing again the dominance of treatment-dedicated dollars over prevention.

The relevance of this observation to the issue of diabetes and its economic and human costs is glaring. The ultimate questions are: What is the cost benefit of the hundreds of billions of dollars currently consumed by diabetes? Are the dollars correctly targeted? Can we do better?

I hope the current medical students are given the instruction that will prime their interest in the economic costs of diabetes, of which I learned absolutely nothing what seems like only a few years ago when I was at Penn.

Copyright 2006-20172019 Walter M. Bortz II, M.D.