The Case for “Outsourcing” Diabetes Care

Abstract

Diabetes has a profound effect on the health of our population as well as on our economy. Diabetic retinopathy is the leading cause of blindness in people between 20 and 74 years of age (1). Diabetic nephropathy is the leading cause of patients undergoing dialysis for end-stage renal disease (2). Diabetic peripheral neuropathy is the underlying cause of nontraumatic lower-extremity amputations in diabetic patients (3). More than half of lower-extremity amputations occur in people with diabetes (4) who at that time constituted only 4.5% of the population (5). The prevalence of coronary artery disease is twofold higher in men with diabetes and fourfold higher in women with diabetes compared with appropriate nondiabetic control subjects (6). Strokes are two to three times more common in people with diabetes than in those without the disease (7). Peripheral vascular disease is also much more common in diabetic patients compared with nondiabetic individuals (8). The total cost of caring for people with diabetes in this country in 1992 (106 billion dollars) represented 15% of the total health care budget (720 billion dollars) (5). In a more recent study, the American Diabetes Association (ADA) study found that in 1997 the specific (direct) costs for diabetes care was 44 billion dollars with another 54 billion dollars lost to the economy through indirect costs (i.e., short- and long-term disability and losses secondary to premature mortality) (9). Medicare spent 26.5% of its budget on diabetic patients (5). The excess costs for diabetes in Kaiser-Permanente in Northern California amounted to $3,494 per patient per year (10). Much of these increased costs for diabetes were for related complications. There were progressively increasing costs associated with worsening diabetic control in patients with either diabetes alone or with hypertension and heart disease (11). Increased glycated hemoglobin levels predicted higher rates of …

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