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Bad Blood

In the Treatment of Diabetes, Success Often Does Not Pay

By IAN URBINA

Published: January 11, 2006

With much optimism, Beth Israel Medical Center in Manhattan opened its new diabetes center in March 1999. Miss America, Nicole Johnson Baker, herself a diabetic, showed up for promotional pictures, wearing her insulin pump.

Third of four articles:
The Business of Care

Second Article in the Series: Living at an Epicenter of Diabetes, Defiance and Despair (January 10, 2006)

First Article in the Series: Diabetes and Its Awful Toll Quietly Emerge as a Crisis (Jan. 9, 2006)

Bad Blood: Diabetes in New York

In one photo, she posed with a man dressed as a giant foot - a comical if dark reminder of the roughly 2,000 largely avoidable diabetes-related amputations in New York City each year. Doctors, alarmed by the cost and rapid growth of the disease, were getting serious.

At four hospitals across the city, they set up centers that featured a new model of treatment. They would be boot camps for diabetics, who struggle daily to reduce the sugar levels in their blood. The centers would teach them to check those levels, count calories and exercise with discipline, while undergoing prolonged monitoring by teams of specialists.

But seven years later, even as the number of New Yorkers with Type 2 diabetes has nearly doubled, three of the four centers, including Beth Israel's, have closed.

They did not shut down because they had failed their patients. They closed because they had failed to make money. They were victims of the byzantine world of American health care, in which the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications.

Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000.

Patients have trouble securing a reimbursement for a $75 visit to the nutritionist who counsels them on controlling their diabetes. Insurers do not balk, however, at paying $315 for a single session of dialysis, which treats one of the disease's serious complications.

Not surprising, as the epidemic of Type 2 diabetes has grown, more than 100 dialysis centers have opened in the city.

"It's almost as though the system encourages people to get sick and then people get paid to treat them," said Dr. Matthew E. Fink, a former president of Beth Israel.

Ten months after the hospital's center was founded, it had hemorrhaged more than $1.1 million. And the hospital gave its director, Dr. Gerald Bernstein, three and a half months to direct its patients elsewhere.

The center's demise, its founders and other experts say, is evidence of a medical system so focused on acute illnesses that it is struggling to respond to diabetes, a chronic disease that looms as the largest health crisis facing the city.

America's high-tech, pharmaceutical-driven system may excel at treating serious short-term illnesses like coronary blockages, experts say, but it is flailing when it comes to Type 2 diabetes, a condition that builds over time and cannot be solved by surgery or a few weeks of taking pills.

Type 2 , the subject of this series, has been linked to obesity and inactivity, as well as to heredity. (Type 1, which comprises only 5 percent to 10 percent of cases, is not associated with behavior, and is believed to stem almost entirely from genetic factors.)

Instead of receiving comprehensive treatment, New York's Type 2 diabetics often suffer under substandard care.

They do not test their blood as often as they should because they cannot afford the equipment. Patients wait months to see endocrinologists - who provide critical diabetes care - because lower pay has drawn too few doctors to the specialty. And insurers limit diabetes benefits for fear they will draw the sickest, most expensive patients to their rolls.

Dr. Diana K. Berger, who directs the diabetes prevention program for the City Department of Health and Mental Hygiene, said the bias against effective care for chronic illnesses could be seen in the new popularity of another high-profit quick fix: bariatric surgery, which shrinks stomach size and has been shown to be effective at helping to control diabetes.

"If a hospital charges, and can get reimbursed by insurance, $50,000 for a bariatric surgery that takes just 40 minutes," she said, "or it can get reimbursed $20 for the same amount of time spent with a nutritionist, where do you think priorities will be?"

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