Their Best SHOT
TWENTY-EIGHT-YEAR-OLD Jack Perkins has lifestyle choices middle-class people take for granted. From his home in Valencia, it’s walking distance to both a Whole Foods and a Vons supermarket.
He exercises daily -- lifting weights in his condo’s workout room or jogging through safe, quiet, meandering streets. “It’s almost like it’s designed for runners and walkers,” he says.
Maria Sahagun’s Huntington Park home has bars on the windows and doors, and the 61-year-old doesn’t venture far on foot.
Her neighborhood has a hefty supply of mom-and-pop food markets where the variety of chips and sodas vastly exceeds that of fruits and vegetables.
Robberies in her neighborhood are 75% higher than the county average, so she walks on busy Pacific Boulevard only in daylight, and never alone.
Perkins, who has health insurance, and Sahagun, who does not, both have diabetes. He has Type 1, and since childhood his pancreas has not been able to make insulin; she has Type 2, and can no longer make enough insulin nor properly respond to it. For each, the disease means using insulin, medications, diet and exercise to do the work the pancreas cannot do.
Diabetes is afflicting more people, at younger and younger ages, sending doctors, insurers and public health officials into a tizzy as the epidemic threatens to overwhelm the healthcare delivery system. The annual cost of healthcare for an adult with diabetes is more than $13,000, and rates of Type 2 have risen sharply in the wake of the upsurge in obesity in this country.
A bold experiment is unfolding in Los Angeles County that may serve as a lesson for the nation as it battles the epidemic.
Experts know that the cost of care could be much lower if patients could take simple measures to control their disease and avoid complications: nerve damage, amputations, heart disease, blindness, even death. But surveys show that many, even those with adequate health insurance, do not get that care, which is costly and labor intensive, demanding daily attention from patients and timely responsiveness from doctors.
Poverty creates additional obstacles, such as finding fresh vegetables or a safe place to exercise. Study after study shows that low-income people have less access to healthcare and a greater risk of getting sick and dying prematurely.
But in an odd twist to the usual healthcare disparity story, more than 1,000 L.A. residents in low-income areas, most of them uninsured or on MediCal, are getting the gold standard of aggressive diabetes management -- better, even, than many with insurance who live in ritzy ZIP codes.
The care is taking place at clinics in East L.A. and South L.A., two communities with the highest rates of diabetes in the county, as well as three other outlying clinics. A team of L.A. doctors is participating in the experiment, training nurse practitioners, pharmacists, social workers and community educators to intervene in a way that doctors cannot do.
They’re offering frequent patient checkups to monitor the disease, and teaching patients to track blood sugar, get out and take a walk, cut out the doughnuts, all the things they need to do to keep complications at bay.
They are reaching people with uncontrolled disease in some of the county’s poorest pockets.
“The county patients [in the program] receive care that is as good, and probably better, as anywhere in the country,” says Dr. Mayer B. Davidson, endocrinology professor at Charles Drew Medical Center and UCLA.
Davidson and others hope that if such a program is multiplied across L.A., and if similar programs are adopted across the country, the approach could slash the soaring cost of treating diabetes and save thousands of hearts, eyes, feet and lives -- of the insured and comfortably well-off as well as the poor.
There are signs that it’s working. Studies so far show that patients in the program have improved blood sugar and have had fewer emergency room visits and hospitalizations.
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Local pioneers
The intensive program is a response from local academic and public health experts to the crisis ahead. One of those experts, Dr. Anne Peters, professor at USC’s Keck School of Medicine and an endocrinologist who specializes in diabetes, works both sides of the disease’s socioeconomic divide.
Peters has a Beverly Hills practice where she sees insured patients, including Perkins, and offers an intensive program not usually available to even those with good health coverage. She has cared for many of her private patients for years. “I know them so well,” she says. “It’s the old model of having a doctor who takes care of you your whole life.”
But she also has a second job: supervising teams of workers on the same intensive model at five clinics including the Edward Roybal Health Center in East L.A., and the Hubert Humphrey Health Center in South L.A.
Sahagun, a patient at Roybal, is part of the experiment.
She has had diabetes since she was in her 20s, and for decades thought of it benignly as a “touch of sugar.”
But over the years, she saw her weight go up to 250 pounds, was hospitalized several times, and had to stop driving because of neuropathy, a consequence of the disease that led to pain in her legs and numbness in her feet. “I’m afraid I’ll step on the wrong pedal,” she says.
Her parents both have diabetes. Her father recently died after a stroke, and her mother has lost a toe to gangrene. Last year, Sahagun was referred to the county program because her disease was uncontrolled. “It took me more than 20 years to take it seriously,” she says.
And yet it is very serious. Uncontrolled, it results in a buildup of sugar in the blood and, over time, damage to the eyes, kidneys, nerves and heart. Three in five diabetic patients suffer from at least one significant complication, according to research presented in April.
Those numbers could worsen because diabetes is striking more people at younger ages. Type 2 diabetes used to be unheard of in children. Now, because of the rise in childhood obesity, more than 200,000 children and teens younger than 20 have the disease, according to the Centers for Disease Control and Prevention.
“It’s like a tsunami coming,” says Dr. Francine R. Kaufman, head of the division of endocrinology and metabolism at Childrens Hospital Los Angeles and professor of pediatrics at USC’s Keck School of Medicine.
There are an estimated 20 million diabetics today, 18 million with Type 2, and the Centers for Disease Control and Prevention now projects that 1 in 3 children born in 2000 will develop diabetes in their lifetime. When Type 2 diabetes hits a middle-aged person, the consequences of uncontrolled disease show up 20 to 30 years later as heart attacks, strokes, blindness, kidney failure, amputations and death.
When the disease strikes younger adults and children, it’s anybody’s dismal guess what will happen. The number of children hospitalized, already suffering from complications from Type 2 diabetes, increased by 200% between 1997 and 2003, according to data presented Saturday at a pediatrics meeting.
“I have colleagues who tell me that they have actually lost patients in their 20s to heart attacks,” says Dr. Larry Deeb, pediatric endocrinologist and president of the American Diabetes Assn.
Reducing complications is key to protecting patients and controlling costs. It’s not rocket science: lose weight, watch your diet, exercise, monitor blood sugar, blood pressure and cholesterol, take your medications, have regular eye and foot exams.
But often, these simple things aren’t done. When the federal Agency for Healthcare Research and Quality looked at national rates of recommended diabetes interventions between 2000 and 2002, they found that only about half of patients received the blood glucose test and foot and eye exams called for in treatment guidelines. Only 40% had their blood glucose levels under good control; half had cholesterol levels controlled; and 70% had their blood pressure controlled.
And, of course, Americans prove again and again that it’s difficult to eat right, exercise, take medications on schedule and follow doctors’ orders.
For diabetics, the consequences are gruesome.
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Doctors needed
Even fully insured patients rarely get the hands-on medical attention it takes to properly control diabetes. All but about 5% of diabetics are seen by primary care doctors, who are rushed and have varying degrees of expertise in the disease.
Some insurers, such as Kaiser Permanente, have adopted an intensive team approach to diabetes management, but such programs are uncommon. “It’s not happening much in the real world out there,” Davidson says.
The reason, he says, is the convoluted bottom line of America’s fragmented health care system, which pays more to amputate a foot than to prevent amputations, or to treat heart attacks than to prevent them.
Peters’ practice is an exception. She’s a private practice doctor who spends as much time with her patients as they need. Her practice follows a team model, with a staff of nutritionists, educators, nurses and nurse practitioners to advise and prod patients via face-to-face discussions, phone calls and e-mails.
“I personally believe that anyone can take good care of their diabetes, no matter who they are or what their level of education,” she says. “But they need a team, or at least a guide.”
Perkins of Valencia is one of Peters’ insured, Westside patients. He was diagnosed with Type 1 diabetes at the age of 13, and it took time to learn his body’s unique reaction to food, exercise and doses of insulin.
As a child, he spent an initial week in the hospital, getting educated on the disease and learning to give himself shots. “I didn’t want to be doing all that,” he says. But he did, for the most part, except for a couple of rebellious years in college.
Now, as Peters’ patient, he gets constant reminders of how he has to live. He has learned to count carbohydrates and anticipate the amount his blood sugar will rise with a meal.
He’s learned what working out does to his body (he lifts weights three times a week, runs 10 miles a week, and plays basketball three times a week.) “If I lift weights on a Monday night, it’s going to help my blood sugar the whole next day. I’ll need less insulin,” he says.
He’s thinking like a pancreas.
So successful has Peters’ method been, that six years ago, she launched a pilot program for the county, supervising a team of professionals trained to educate, monitor and, when necessary, nag. The program took off in four other county centers in 2005.
The treatment team members make phone calls, hold classes, help patients change their diets, prescriptions or medication doses. They will even visit patients’ homes to keep treatment on track.
Community members who speak the same language and share the same culture and who have successfully controlled their diabetes are recruited to teach classes and help coordinate care for newcomers to diabetes management. The idea is to allow specialist physicians to become consultants to community-savvy teams who offer up a steady drumbeat of medical attention and lifestyle education.
“It makes more sense to reach out to people where they live 24/7, and not think that a visit every three months to a provider is where all the care happens,” says Dr. Jeffrey Guterman, medical director of the L.A. County Department of Health Services.
Before being accepted, patients in the county program sign an agreement that they will keep appointments and follow medical instructions. If they fail to comply, they’re out.
Because funding is limited, patients can stay with the program only 6 to 9 months, but the expectation is that they can learn to control their disease in that time, then go back to a primary care physician. Those county doctors are ready, having been trained in how to manage diabetes patients.
“They explain to you a lot of things,” Sahagun says. “I’ve learned to eat more vegetables, chicken, fish. They teach you how to examine your feet, how your eyesight can change.”
She’s gone to education programs with others with diabetes. “We talk,” she says. “Some people talk about how they can’t handle it. I say that we have to eat what they tell us to eat. We can’t eat all the stuff we’re accustomed to. Chips. Sodas.
“I still eat Mexican food, but I don’t fry tacos. My mother taught us to use lard when we cook. No more.”
Early studies suggest that the program works. A report in the April 2006 American Journal of Managed Care looked at how a key blood sugar test, called A1c, was controlled in 367 patients in the L.A. County program the year before and the year after they entered the program.
The A1c guideline was met by only 28% of participants when they were under traditional medical care. After a year in the program, 60% of patients met the blood sugar level goal.
A second study published in February in the journal Diabetes Care found that diabetic patients in the program reduced their use of emergency rooms by half and cut down on hospitalizations. Total hospital charges dropped that year for the 331 patients studied to $24,630, from $129,176 the year before.
The program still treats only a fraction of underserved patients with diabetes. It is expected to expand after a recent state grant of $54 million was awarded to the county to treat chronic diseases.
For insured patients, the upfront costs of such care to practitioners are high, and America’s patchwork quilt of payment systems offer few incentives to do diabetes care right.
Peters, for one, does not break even from her intensive approach in private practice: In fact, she says, she loses about $250,000 a year caring for these patients and keeps her private practice going only through donations from grateful, wealthy diabetic patients to a foundation she has started.
The health insurance benefits that her Westside patients have cover visits -- generally about every three months. They don’t cover extra visits to change medications or search out the reason blood sugar has fallen out of control. They don’t cover time spent analyzing complex blood glucose printouts, insulin pump data or teaching patients to adjust insulin and drug doses.
Nor do they cover time for long discussions, phone calls, e-mails or the nutritionist, educators and nurses she employs to advise and prod patients.
Most plans pay physicians a set rate per patient, regardless of how much care they provide. The incentive for doctors has been to treat people quickly.
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Patients on track
On a recent afternoon, Perkins is having his quarterly exam with Peters. He’s a conscientious patient, has the drill down, and usually only needs to check in every three months or so.
She’s looking at his lab results, and smiling. “Normal kidneys, normal everything,” she tells him. “I’m thrilled.”
Perkins says it has gotten easier to keep his disease well controlled since he switched from shots to an insulin pump, a small device strapped to his leg with a thin, plastic catheter that delivers insulin in a steady, preprogrammed dose.
On the other side of town a few days later, at Roybal Health Center, Peters squats on the floor in front of Sahagun, looking over her most recent lab results. She studies the computer printout, and calculates adjustments, then coaches Sahagun on the meds she must take.
Sahagun leaves the center with prescriptions and instructions.
“You get used to it,” she says.
As well as not cooking with lard anymore, she’s already eating fewer sweets and trying to walk on her treadmill or in the neighborhood every other day.
It’s a start. She’ll be back for her next checkup in a month.
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