[Congressional Record Volume 140, Number 65 (Monday, May 23, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: May 23, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                        IMPROVING DIABETES CARE

                                 ______


                          HON. EDOLPHUS TOWNS

                              of new york

                    in the house of representatives

                          Monday, May 23, 1994

  Mr. TOWNS. Mr. Speaker, all of us recognize the problems Americans 
with diabetes have in obtaining affordable, quality, health care. This 
is particularly true for African-Americans, Hispanics, and Native 
Americans, who are more likely to have diabetes than other Americans 
and who are underserved by today's health care system.
  Mr. Speaker, we also recognize that diabetes is a costly disease, 
both to those with the disease and to the health care system overall. 
Two recent studies, the first by the National Institutes of Health 
[NIH] and the second Lewin-VHI, demonstrate that aggressive and 
consistent management of the disease significantly enhances the health 
of the people with diabetes and that improving diabetes care is 
absolutely necessary if we are to control health care spending.
  Mr. Speaker, last year NIH completed the landmark diabetes control 
and complications trial [DCCT], with the results published in the 
September 30, 1993, issue of the New England Journal of Medicine. The 
NIH study demonstrated that tight control of blood sugar levels can 
significantly reduce the risk and progression of complications 
associated with diabetes, including blindness, kidney disease, and 
amputation. Aggressive and consistent management of diabetes is best 
achieved through blood-sugar control, which includes monitoring blood-
sugar levels, exercise, controlled diet, and regular insulin injections 
with a team of health care providers. Today, few individuals with 
diabetes receive the aggressive and consistent management found 
effective in the NIH study.
  The Lewin-VHI study revealed that the 5-percent of Americans who have 
diabetes account for one of every seven health care dollars spent. The 
study also found that 42 percent of total diabetes health care costs 
was paid by Medicare and Medicaid--1992. The study's results were 
published in the April 1994 issue of the Journal of Clinical 
Endocrinology and Metabolism. The study was sponsored by America's 
leading diabetes provider, Diabetes Treatment Center of America, which 
has over 70 diabetes centers in hospitals across the United States.
  Mr. Speaker, the NIH study proved that we can improve the lives of 
people with diabetes though aggressive management of the disease before 
complications develop. The Lewin-VHI study showed that improving care 
for people with diabetes is necessary to control overall health care 
costs. National health care reform must address the problem of 
Americans who are underserved by the current system and ensure all 
Americans with diabetes are provided with the kind of health care 
proven effective by the NIH study.
  I respectfully submit an April 13, 1994, Boston Globe column by Tom 
Oliphant entitled ``A case study in the health care: What's right, 
what's wrong and what's needed'' to be included in the Congressional 
Record. The article deftly explains the importance of the NIH and 
Lewin-VHI studies in the context of national health care reform. I also 
submit the abstracts of the articles published in the New England 
Journal of Medicine and the Journal of Clinical Endocrinology and 
Metabolism.
                                  ____


   [From the Journal of Clinical Endocrinology and Metabolism, 1994]

    Health Care Expenditures for People with Diabetes Mellitus, 1992

    (By Robert J. Rubin, William M. Altman, and Daniel N. Mendelson)


                                abstract

       The purpose of this report is to estimate diabetes 
     prevalence and annual health care costs for people with 
     diabetes in 1992, compare average annual costs for diabetes 
     and nondiabetes, and estimate the portion of total U.S. 
     health care expenditures incurred by people with the disease. 
     Data from the 1987 National Medical Expenditure Survey were 
     used to estimate diabetes prevalence and health care 
     expenditures for diabetes in 1992. Diabetics were identified 
     based on self-reports of a physician diagnosis of diabetes, a 
     history of taking diabetic medications, or an encounter with 
     the health care system specifically related to diabetes. 
     Identified diabetics were classified as confirmed if they had 
     a history of taking diabetic medications, had a diabetes-
     specific encounter with the health care system, or purchased 
     diabetic equipment. Estimates of diabetes prevalence and 
     health care expenditures were calculated separately for 
     identified and confirmed diabetics using the National Medical 
     Expenditure Survey database. Total health care expenditures 
     included costs associated with inpatient hospital care, 
     outpatient hospital care, office visits to a physician or 
     other provider, emergency room visits, home health care, 
     prescription drugs, dental care, and durable medical 
     equipment purchases. We estimate that per-capita annual 
     health care expenditures in 1992 were more than three times 
     greater for diabetics ($9,493) than for nondiabetics 
     ($2,604). Per-capita expenditures for confirmed diabetics 
     ($11,157) were more than four times greater than for 
     nondiabetics. In 1992, diabetics constituted 4.5% of the U.S. 
     population but accounted for 14.6% of total U.S. health care 
     expenditures ($105 billion). Confirmed diabetics constituted 
     3.1% of the U.S. population but accounted for 11.9% of total 
     U.S. health care expenditures. ($85 billion). This study 
     found that health care expenditures for people with diabetes 
     constituted about one in seven health care dollars spent in 
     1992. Health care reform and insurers should take note of 
     these findings and structure benefit packages to promote care 
     likely to reduce the costs of caring for diabetics.
                                  ____


       [From the New England Journal of Medicine, Sept. 30, 1993]

 The Effect of Intensive Treatment of Diabetes on the Development and 
 Progression of Long-Term Complications in Insulin-Dependent Diabetes 
                                Mellitus

    (By The Diabetes Control and Complications Trial Research Group)

       Abstract--Background. Long-term micro-vascular 
     and neurologic complications cause major morbidity and 
     mortality in patients with insulin-dependent diabetes 
     mellitus (IDDM). We examined whether intensive treatment with 
     the goal of maintaining blood glucose concentrations close to 
     the normal range could decrease the frequency and severity of 
     these complications.
       Methods. A total of 1441 patients with IDDM--726 with no 
     retinopathy at base line (the primary-prevention cohort) and 
     715 with mild retinopathy (the secondary-intervention cohort) 
     were randomly assigned to intensive therapy administered 
     either with an external insulin pump or by three or more 
     daily insulin injections and guided by frequent blood glucose 
     monitoring or to conventional therapy with one or two daily 
     insulin injections. The patients were followed for a mean of 
     6.5 years, and the appearance and progression of retinopathy 
     and other complications were assessed regularly.
       Results. In the primary-prevention cohort, intensive 
     therapy reduced the adjusted mean risk for the development of 
     retinopathy by 76 percent (95 percent confidence interval, 62 
     to 85 percent), as compared with conventional therapy. In the 
     secondary-intervention cohort, intensive therapy slowed the 
     progression of retinopathy by 54 percent (95 percent 
     confidence interval, 39 to 66 percent) and reduced the 
     development of proliferative or severe nonproliferative 
     retinopathy by 47 percent (95 percent confidence interval, 14 
     to 67 percent). In the two cohorts combined, intensive 
     therapy reduced the occurrence of microalbuminuria (urinary 
     albumin excretion of 40 mg per 24 hours) by 39 
     percent (95 percent confidence interval, 21 to 52 percent), 
     that of albuminuria (urinary albumin excretion of 
     300 mg per 24 hours) by 54 percent (95 percent 
     confidence interval, 19 to 74 percent), and that of clinical 
     neuropathy by 60 percent (95 percent confidence interval, 38 
     to 74 percent). The chief adverse event associated with 
     intensive therapy was a two-to-threefold increase in severe 
     hypoglycemia.
       Conclusions. Intensive therapy effectively delays the onset 
     and slows the progression of diabetic retinopathy, 
     nephropathy, and neuropathy in patients with IDDM. (N Engl J 
     Med 1993:329:977-86.)
                                  ____


                 [From the Boston Globe, Apr. 13, 1994]

  A Case Study in Health Care: What's Right, What's Wrong, and What's 
                                 Needed

                          (By Thomas Oliphant)

       Ann Young and Joyce Psalidas, nearing 40 and first cousins, 
     were each diagnosed with diabetes at age 11 when they were 
     kids in suburban Atlanta.
       After more than a quarter-century of more traffic with the 
     country's health care system than most Americans have in a 
     lifetime, they personify what's right with the beast, what's 
     wrong with it and what's needed to change it.
       What's right with it is science and medicine and doctors 
     and nurses who have made it possible to control a chronic 
     disease affecting nearly one in 20 Americans.
       What's wrong with it is that the best and most efficient 
     care is available only haphazardly, with immense human and 
     financial consequences.
       And what's needed--in human as well as economic terms--is 
     private health insurance that covers everyone with basic 
     benefits, including intensive therapy for diabetics.
       Over 27 years, Joyce Psalidas' more or less conventional 
     treatment has cost nearly $75,000 and has included 51 days in 
     the hospital and 11 outpatient visits.
       Over the same period, Ann Young's treatment has cost barely 
     $40,000 and has involved just five days in the hospital and 
     four outpatient visits.
       From first diagnosis, Psalidas had a daily insulin shot and 
     urine test but nonetheless experienced a host of eye and 
     kidney complications. From her first diagnosis, Young visited 
     her doctor more often, had her diet and exercise routine 
     monitored and took insulin more frequently as needed to 
     maintain a more nearly normal blood sugar level.
       Young, a nurse, has benefited from comprehensive insurance 
     coverage at work, from her own knowledge and from good luck. 
     Psalidas, who has used more intensive therapy for the last 10 
     years, has often had to pay out of her pocket (she's an 
     educator) and to scheme her way into studies at research 
     hospitals.
       The two women were brought here yesterday by Young's 
     employer, Diabetes Treatment Centers of America, part of 
     American Healthcorp Inc., to make a point that cuts to the 
     core of this year's health care debate.
       As the company's CEO, Jim Deal, summed up, ``When you 
     improve the quality of care, the cost of care goes down.'' To 
     make the point just as dramatically, the company released a 
     study it commissioned from Lewin-VHI, the firm whose broader 
     work on the health insurance issue is widely accorded 
     definitive status.
       Diabetes is more than the No. 4 killer among diseases, 
     according to the research just published in the Journal of 
     Clinical Endocrinology and Metabolism. The national cost of 
     health care for diabetics in 1992 was a stunning $106.2 
     billion, more than 60 percent of it in the form of inpatient 
     hospital treatment.
       That compares with a total national health care bill of 
     $615.3 billion the same year, less than half of it from 
     hospitals.
       In English, this means diabetes is to health care what 
     health care is to the over-all economy; it also means that 
     caring for 4.5 percent of the population produces nearly 15 
     percent of the costs, more than 40 percent of which are paid 
     through Medicare and Medicaid.
       In medicine, it has been shown a zillion times that the 
     more you monitor blood sugar, the more timely the use of 
     medicine and the more aggressive the other aspects of a 
     diabetic's therapy, the less frequent are the complications. 
     And monitoring blood sugar levels is easy.
       What a famous study released last year by the National 
     Institutes of Health showed is that when diabetics' blood 
     sugar levels are close to normal, the risk of kidney disease 
     drops by 56 percent, of nerve disease by 60 percent and of 
     eye disease by 76 percent.
       Ann Young and Joyce Psalidas are both resourceful women, 
     but Young has also been fortunate, and there is no logical 
     reason why her experience--rather than her cousin's--
     shouldn't be a model for the country.
       Managed care works and it pays. When people don't have good 
     insurance that promotes intelligent care, people suffer, and 
     the country pays through the nose.
       Slowly, Congress is summoning the will to marry universal 
     coverage and managed care along President Clinton's outlined 
     lines. The idea that this is controversial is absurd, and 
     Joyce Psalidas is this weeks Exhibit A.

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