Chronic disease management: Drug shareholders�?goldmine
by Alan Cassels
The job description of your average physician keeps getting bigger. If you are sick, you go to the doctor. If you are worried that you might be getting sick, you go to the doctor. If you aren’t sick and want assurances how to stay that way, you go to the doctor. In the paradigm of modern medical care we’ve set up, a doctor is your first, or primary, contact with the system. That’s why we call their services “primary care.�?
One way that medical authorities around the world are trying to improve the world for primary care physicians has been the creation and embrace of chronic disease management (CDM) to help physicians manage patients with long-term, unremitting diseases such as asthma, arthritis and diabetes.
CDM has its champions and detractors, yet curiously, it almost never makes the news. Until recently. In early January, the Vancouver Sun seized on some remarks related to CDM, made by former BC deputy minister of health, Dr. Penny Ballem. By most accounts, a hard working, competent and long serving deputy minister, she quit the Campbell government in 2006, citing the BC Liberals inability to set “quality targets�?with doctors.
Given that most truth gets disfigured when chewed on by media hounds, and this story is likely no exception, what caught my attention was the following quote attributed to her: “Only about 40 percent of diabetics in BC were getting good care.�?This is described as “guideline-based optimal care,�?a practice where physicians systematically monitored and managed the care of their diabetic patients. Calling the situation in BC “atrocious,�?with media-grabbing candor rarely seen displayed by health bureaucrats, Ballem said that such inattentive care was responsible for “killing people.�?/FONT>
What’s really going on? The range of services that physicians are asked to provide their diabetic patients includes checking the level of sugar in the blood, the level of protein in the urine (to see how well your kidneys function) and eye function (elevated blood sugar damages the retinal blood vessels). If only about 40 percent of docs in BC routinely do these tests for their diabetic patients, is this really a bad thing?
Canadian diabetes guidelines beat a pretty steady drum, encouraging our doctors to carry out intensive testing and monitoring of their patients�?blood sugar, and then encouraging them to help the patients monitor themselves (a practice called SMBG or self-monitoring of blood glucose).
If you wonder how big an issue SMBG is, you should know that blood glucose strips, which diabetics use as many as eight times a day cost about a buck each. In fact, they are the fastest growing item in Pharmacare’s formulary; in Canada we spend more than $300 million per year on blood test strips. Ninety percent of those strips are for type-2 diabetics. (Remember from my January column that type-2 diabetes is a “disease�?largely, but not completely, controllable by diet and exercise and most people require social, not medical, interventions to prevent their diabetes from killing them.)
Despite the steady drum pumping out the SMBG paradigm, some researchers say that all this blood-checking activity actually does very little to improve patients�?health outcomes. Testing your blood this frequently is like trying to lose weight by stepping on the bathroom scale eight times a day. Such testing could even lead diabetics in the opposite direction, where they would end up taking prescribed drugs that could be harmful or of marginal efficacy, and otherwise turning them into worry warts, obsessing about their blood sugar that naturally fluctuates throughout the day, anyway.
A recent presentation by an Alberta researcher captured the inanity of aggressive SMBG as part of a debate in which he argued: “Frequent glucose monitoring is a waste of time in the vast majority of people with type-2 diabetes.�?In this debate, he blew the lid off most arguments made for getting people to test and retest their blood sugars. Citing the Cochrane database of systematic reviews, 2006 (www .cochrane.org), he said that there is “�?no valid randomized trial evidence that SMBG reduces either the number or severity of symptomatic episodes of hypoglycemia (or hyperglycemia).�?
To add to this severe indictment of SMBG, he points out that getting people to test and retest their blood sugars did not improve peoples�?quality of life, and was expensive and even potentially harmful in that it increases patients�?rates of depression, stress and worry.
What is happening here?
While the psychological impact of diabetes mongering is surely the subject of a future column, suffice to say I smell a rat in the whole move towards the “disease management�?approach, not because the guidelines may be promoting stuff that isn’t based on evidence, but because those guidelines tend to see patients and their body parts in isolation. The person in the doctor’s office becomes a glucose level or a blood pressure reading or a set of peak flows �?primary care by numbers.
We’ve seen other examples where so-called “evidence-based�?practice guidelines for chronic disease �?hypertension, Alzheimer’s disease, etc �?become corrupted, shaped by committees stacked with experts whose dependence on Pharma largesse is de rigueur, as long as it’s “declared.�?/FONT>
If you follow the money, you’ll find that those who are gunning for profits �?drug, device and insulin manufacturers �?will have their own people at the table to ensure the guidelines reflect a treatment paradigm that leads to maximal, instead of rational, consumption of their products. No offence. After all, business is business.
The BC Ministry of Health defines Chronic Disease Management (CDM) as “�?an approach to health care that emphasizes helping individuals maintain independence and keep as healthy as possible…�?and BC doctors agree with the prime importance of treating diabetes. A September 2001 BC Ministry of Health survey of BC doctors found that diabetes was their top choice as a candidate for CDM.
The key elements of CDM seem somewhat commonsensical: measuring performance, developing physicians�?skills, collaborating with other health professionals, creating patient registries and monitoring patient performance. Despite the ministry’s talk of strategies to explore “private/public partnerships with the pharmaceutical industry,�?to fund CDM �?as if that’s the ticket to solving the sustainability of healthcare problem �?how, exactly, does Big Pharma view Chronic Disease Management?
In a nutshell, it’s a goldmine. In fact, managed care, and by extension Big Pharma, helped invent CDM. If you look back far enough, you’ll find that disease management as a strategy was unveiled, not to a group of doctors, but rather at a meeting of stock market investors. In November 1994, Raymond Gilmartin, then president and CEO of Merck (makers of Vioxx), told a gathering of financial bigwigs at the New York Society of Securities Analysts: “To us, disease management means treating diseases more effectively, primarily by using pharmaceuticals more effectively.�?
Listen and you can hear the chorus of drug industry shareholders rejoicing.
Disease management was clearly a well-planned, strategic response to demands by health care payers in the US, who, in the early 1990s, needed to rein-in exploding prescription drug costs; the drug industry’s response to keep profits growing was to expand methods to increase sales. Pharma’s well-funded propaganda, notoriously short on good evidence, promoted the idea that higher drug use would offset other medical costs. The argument was that the more drugs we could put people on, the less those patients would be inhabiting expensive hospital beds, and hence, more savings to the healthcare system.
To increase those sales, the brilliant idea was born that, instead of just pushing drugs, drug companies needed to retool themselves as key players in disease management and convince executives they were really working towards the holistic care of the patient. The first diseases fed to the disease management mill in the mid-1990s were diabetes, asthma and hypertension; today, there are over 100 diseases or conditions treated with some form of disease management. In the US, and by proxy Canada, too, it’s a big and growing business. In 1997 in the US, just as the disease management movement was gathering steam, revenues were almost US $80 million. Eight years later in 2005, they had reached $1.2 billion.
Remember what the ministry said about the goals of CDM? “To help individuals maintain independence.�?Ponder that thought for a while and consider whether disease managers would want to put themselves out of business if they were truly successful in making people “independent.�?The truth is when you look closely at diabetes treatment protocols and guidelines, they are tooled for greater dependence on drugs, devices and insulins. There’s no real attempt to provide good, comparative information about treatment options for patients, or to discuss with them in clear, unbiased language the natural history of diabetes or the likelihood of treatment success, or to advise them of the enormous costs and side effects related to drugs and insulin.
Ironically, the whole process of “disease management�?seems to be about turning ordinary people into patients, an essentially disempowering fact of life. Is it possible BC doctors know this, and that’s why they’ve largely rejected the offensive diabetes mongering enshrined in the guidelines?
Few doctors may have the temerity to admit this, but I am sure there are many out there who despair at the sheer futility of the whole venture and find it distasteful to be told to follow a diabetes cookbook to treat their patients. I wonder if they fret about the enormous level of useless drugs and insulin being pushed onto their diabetic patients. Do they fear becoming so lost in the minutiae of blood sugar, they sometimes forget there’s a patient attached to those numbers? Do they long for some freedom to go beyond the drugs-testing-insulin paradigm being pushed onto them and their patients?
What should we do when physicians are being pressured by a system to try to improve the percentage of their diabetics that get “good care�?when they may fundamentally disagree with what constitutes “good?�?
Doctors and patients, you have a story to tell. I’d like to hear from you.
Alan Cassels is co-author of Selling Sickness and a drug policy researcher at the University of Victoria. He is also the founder of Media Doctor Canada (www .mediadoctor.ca), which evaluates reporting of medical treatments in Canada’s media.
From February /07 CommonGround.ca magazine
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