Seventh Annual Diabetes Technology Meeting (San Francisco, October 25th - 27th)
We will be back next issue with more from the Diabetes Technology meeting - in the meantime, we describe below our impression of the keynote talk from Dr. Richard Kahn, Chief Scientific and Medical Officer of the ADA.
To start, Dr. Kahn provided a fascinating history of diabetes care, highlighting that the cost and complexity of treating diabetes has increased. First there was only insulin. Then, in the 1950s/1960s, oral drugs were developed and diabetes care was no longer a simple proposition. In 1964, test strips came about, and in the 1970s the A1c test was invented. Our advisory board pointed out that the A1c test was actually invented in the 60s!! Since the 1970s there has been a "blizzard" of new discoveries, resulting in more data, risks, costs, and complexities. Kahn claimed the medical industry established enormous marketing budgets, "causing patients to clamor for the latest technology." Wow! What's that all about? Last time I checked, my diabetes equipment was helping me to live a far better, more healthy life, one that kept me out of emergency rooms and in the thick of life.
Dr. Kahn continued by explaining that new developments were often justified by trials he implied were sub-par. There were almost no limits or constraints to the use of new diabetes technology, he claimed. We would agree more evidence should be produced to show the value of technology; on the other hand, we also believe many trials are difficult to execute in a "real world" environment. It was surprising to us that Dr. Kahn didn't mention that patients do have fewer complications today than they did in the 1950s, that they live longer, and that they have, at least to some extent, a higher quality of life due to better blood glucose monitors, insulin delivery systems, and better, more stable drugs and better insulin.
By contrast, we thought Dr. David Klonoff said it best at the conference when he noted that decades ago, his waiting rooms were full of patients with the worst complications (amputations, blindness) and today, on average, he sees far fewer patients in the worst conditions. We certainly have a long way to go, but we credit diabetes technology as being instrumental in the developed world for reducing complications and hope that self-glucose monitoring in particular becomes much more widely available in developing countries so they can see these improvements too. We also hope more improvements are in store - to be sure, Dr. Kahn is right that outcomes must improve much further.
Per Dr. Kahn, as a result of new tools and complexities, the cost of healthcare in the US soared from a small percent of GDP in the 1970s to 16 percent of GDP in 2006 - this amounts to about $7,100 on healthcare per person per year. America does not get its money's worth, he said. Americans spend more per capita than in any other country, even though health outcomes lag behind many other countries. We would certainly agree that America is not the best health system globally in some respects - but largely it is reimbursement woes (absence of payments for education, for physician care, for drugs, and for technology) that need to be addressed. Specifically, the lack of payments to healthcare providers to work comprehensively with patients who are chronically ill is untenable in our view and we hope the ADA continues to advocate on behalf of better payments for healthcare providers - and better payments for drugs and devices to improve care and improve lives.
Diabetes care contributes significantly to America's healthcare costs. Dr. Kahn emphasized that diabetes costs Medicare a third of its entire budget. Self-monitoring costs taxpayers over $1 billion "even though there hasn't been a single randomized, control trial demonstrating benefit." In spite of tremendous spending, the quality of diabetes care in America leaves much to be desired, he said. As noted, we would certainly agree that the quality of diabetes care in the US could be dramatically improved but we would cite systemic problems as a bigger culprit than the cost of new technology. We believe that offering patients enabling technology such as blood glucose monitors, pumps, and continuous monitors will allow patients to better communicate with their healthcare providers and to learn to take the best care of themselves.
Looking to the future, Dr. Kahn believes that technology will need to bring simplicity rather than complexity, and will need to cut costs rather than increase costs. We certainly applaud Dr. Kahn's views on this front! As health care costs rise faster than inflation, accountability (value provided per dollar spent) becomes more important, he says. We absolutely agree with him on this point and believe most patients and healthcare providers would! As more health care costs are shifted to the patient, Dr. Kahn stressed that patients will begin wondering why new technologies increase costs rather than reduce costs, and the patient will begin looking for better value. In the future, diabetes technology will need to be more effective, timely, safer, patient centered, efficient, and equitable (these are so called "systems of care" improvements). We strongly support these goals - as well as the goal of reimbursement!
Compliance is certainly an issue. Today, Dr. Kahn said that over 70% of diabetes patients don't take their diabetes medications properly, and a technology that could improve patient compliance would improve outcomes tremendously. We also strongly agree with this. Technology should identify and reduce errors, rather than add ways to make errors. Technology that could improve patient adherence would be a tremendous breakthrough. Kahn also said that gadgets that add complexity would receive more scrutiny than gadgets that simplify diabetes care. Where we differ with Dr. Kahn is where he said that there would be a new equilibrium favoring improvements in systems of care advances as opposed to new fancy and expensive technology. We certainly believe medication adherence could and must be improved significantly - but not reimbursing new drugs and technology is not the way to get there - rather, we should think about what education is needed in tandem with what tools - this would differ by patient, of course. Dr. Kahn also didn't acknowledge that sometimes side effects are the reason people don't continue to take their medicine. Blaming that on the patient is counter-productive at best. Improving reimbursement for doctors and educators would be an excellent start to enhancing care. Diabetes is complicated and patients deserve more time with their healthcare professionals.
During Q&A, Dr. Kahn joked that the most cost effective solution in terms of healthcare expense would be to urge every American to begin smoking at age 15. This was not met with much appreciation from what we could tell - he clearly did not have the most welcoming audience, for obvious reasons. We know others also interpreted Dr. Kahn's words as saying diabetes technology wasn't really of value. We certainly hope we are wrong about that, for the sake of all of us that already have some reimbursement for tools - and for the sake of those that are still trying to garner reimbursement for valuable tools.
Overall, we are concerned that Dr. Kahn's views may become a platform and that they will have negative implications for pump and continuous glucose monitoring reimbursement in particular. We certainly believe the right evidence should be produced to demonstrate value of diabetes technology - we also think from a patient perspective it's unfortunate that one of the ADA's highest staff members made some statements that made some feel that technology like insulin pumps and continuous monitoring (and to some extent even self blood glucose monitoring) were threatened or shouldn't be valued. If that is the case, this shows very little, if any, value to patients, families, healthcare providers, payors, or average Americans. We look to ADA for leadership on these important fronts and hope that it will advocate for improved cost control and new products and technology and reimbursement for products and healthcare providers - then, we would feel we were moving in a very positive direction.