Treatment of Diabetes, Success Often Does Not Pay

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January 11, 2006

Bad Blood

In the Treatment of Diabetes, Success Often Does Not Pay

By IAN URBINA

 

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.

 

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? "

 

Back in the Pantsuit

 

Calorie by calorie, the staff of Beth Israel's center tried to turn

diabetic lives around from their base of operations: a classroom and

three adjoining offices on the seventh floor of Fierman Hall, a

hospital building on East 17th Street.

 

The stark, white-walled classroom did not look like much. But it was

functional and clean and several times a week, a dozen or so people

would crowd around a rectangular table that was meant for eight,

listening attentively, staff members said.

 

Claudia Slavin, the center's dietitian, remembers asking the patients

to stand, one by one.

 

" Tell me what your waking blood sugar was, " she told them, " and then

try to explain why it is high or low. "

 

People whose sugars soar damage themselves irreparably, even if the

consequences are not felt for 10 or 20 years. Unchecked, diabetes can

lead to kidney failure, blindness, heart disease, amputations - a

challenging slate for any single physician with a busy caseload to manage.

 

One patient, Ella M. Hammond, a retired school administrator, recalled

standing up in the classroom one day in 1999.

 

" Has anyone noticed what's different about me? " Ms. Hammond asked.

 

Blank stares.

 

" Now, come on, " she said, ruffling the fabric of a black gabardine

pantsuit she had not worn since slimmer days, years earlier.

 

" Don't y'all notice 20 pounds when it goes away? " she asked.

 

Ms. Slavin, one of four full-time staff members who worked at the

center, remembers laughing. There were worse reasons for an

interruption than a success story.

 

Like many Type 2 diabetics, Ms. Hammond had been warned repeatedly by

her primary care doctor that her weight was too high, her lifestyle

too inactive and her diet too rich. And then she had been shown the

door, until her next appointment a year later.

 

" The center was a totally different experience, " Ms. Hammond said.

" What they did worked because they taught me how to deal with the

disease, and then they forced me to do it. "

 

Two hours a day, twice a week for five weeks, Ms. Hammond learned how

to manage her disease. How the pancreas works to create insulin, a

hormone needed to process sugar. Why it is important to leave four

hours between meals so insulin can finish breaking down the sugar. She

counted the grams of carbohydrates in a bag of Ruffles salt and

vinegar potato chips, her favorite, and traded vegetarian recipes.

 

After ignoring her condition for 20 years, Ms. Hammond, 63, began to

ride a bicycle twice a week and mastered a special sauce, " more garlic

than butter, " that made asparagus palatable.

 

She also learned how to decipher the reading on her A1c test, a

periodic blood-sugar measurement that is a crucial yardstick of

whether a person's diabetes is under control.

 

" I was just happy to finally know what that number really meant, " she

said.

 

Many doctors who treat diabetics say they have long been frustrated

because they feel they are struggling single-handedly to reverse a

disease with the gale force of popular culture behind it.

 

Type 2 diabetes grows hand in glove with obesity, and America is

becoming fatter. Undoubtedly, many of these diabetics are often their

own worst enemies. Some do not exercise. Others view salad as a

foreign substance and, like smokers, often see complications as a

distant threat.

 

To fix Type 2 diabetes, experts agree, you have to fix people. Change

lifestyles. Adjust thinking. Get diabetics to give up sweets and prick

their fingers to test their blood several times a day.

 

It is a tall order for the primary care doctors who are the sole

health care providers for 90 percent of diabetics.

 

Too tall, many doctors say. When office visits typically last as

little as eight minutes, doctors say there is no time to retool

patients so they can adopt an entirely new approach to food and life.

 

" Think of it this way, " said Dr. Berger. " An average person spends

less than .03 percent of their entire life meeting with a clinician.

The rest of the time they're being bombarded with all the societal

influences that make this disease so common. "

 

As a result, primary care doctors often have a fatalistic attitude

about controlling the disease. They monitor patients less closely than

specialists, studies show.

 

For those under specialty care, there is often little coordination of

treatment, and patients end up Ping-Ponging between their appointments

with little sense of their prognosis or of how to take control of

their condition.

 

Consequently, ignorance prevails. Of 12,000 obese people in a 1999

federal study, more than half said they were never told to curb their

weight.

 

Fewer than 40 percent of those with newly diagnosed diabetes receive

any follow-up, according to another study. In New York City, officials

say, nearly 9 out of 10 diabetics do not know their A1c scores, that

most fundamental of statistics.

 

In fact, without symptoms or pain, most Type 2 diabetics find it hard

to believe they are truly sick until it is too late to avoid the

complications that can overwhelm them. The city comptroller recently

found that even in neighborhoods with accessible and adequate health

care, most diabetics suffer serious complications that could have been

prevented.

 

This grim reality persuaded hospital officials in the 1990's to try

something different. The new centers would provide the tricks for

changing behavior and the methods of tracking complications that were

lacking from most care.

 

Instead of having rushed conversations with harried primary care

physicians, patients would discuss their weights and habits for months

with a team of diabetes educators, and have their conditions tracked

by a panel of endocrinologists, ophthalmologists and podiatrists.

 

" The entire country was watching, " said Dr. Bernstein, director of the

Beth Israel center, who was then president of the American Diabetes

Association.

 

By all apparent measures, the aggressive strategy worked. Five months

into the program, more than 60 percent of the center's patients who

were tested had their blood sugar under control. Close to half the

patients who were measured had already lost weight. Competing

hospitals directed patients to the program.

 

" For the first time in my 23 years of diabetes work I felt like we had

momentum, " said Jane Seley, the center's nurse practitioner. " And it

wasn't backwards momentum. "

 

Failure for Profit

 

From the outset, everyone knew diabetes centers were financially risky

ventures. That is why Beth Israel took a distinctive approach before

sinking $1.5 million into its plan.

 

Instead of being top-heavy with endocrinologists, who are expensive

specialists, Beth Israel relied more on nutritionists and diabetes

educators with lower salaries, said Dr. Fink, the hospital's former

president.

 

The other centers that opened took similar precautions.

 

The St. Luke's-Joslin diabetes center, on the Upper West Side, tried

lowering doctors' salaries, hiring dietitians only part time and being

aggressive about getting reimbursed by insurers, said Dr. Xavier

Pi-Sunyer, who ran the center.

 

Mount Sinai Hospital's diabetes center hired an accounting firm to

calculate just how many bypass surgeries, kidney transplants and other

profitable procedures the center would have to send to the hospital to

offset the cost of keeping the center running, said Dr. Andrew

Drexler, the center's director.

 

Nonetheless, both of these centers closed for financial reasons within

five years of opening.

 

In hindsight, the financial flaws were hardly mysterious, experts say.

Chronic care is simply not as profitable as acute care because

insurers, and consumers, do not want to pay as much for care that is

not urgent, according to Dr. Arnold Milstein, medical director of the

Pacific Business Group on Health.

 

By the time a situation is acute, when dialysis and amputations are

necessary, the insurer, which has been gambling on never being asked

to cover procedures that far down the road, has little choice but to

cover them, if only to avoid lawsuits, analysts said.

 

Patients are also more inclined to pay high prices when severe health

consequences are imminent. When the danger is distant, perhaps

uncertain, as with chronic conditions, there is less willingness to

pay, which undercuts prices and profits, Dr. Milstein explained.

 

" There is a lesser sense of alarm associated with slow-moving threats,

so prices and profits for chronic and preventive care remain low, " he

said. " Doctors, insurers and hospitals can command much higher prices

and profit margins for a bypass surgery that a patient needs today

than they can for nutrition counseling likely to prevent a bypass

tomorrow. "

 

Ms. Seley said the belief was that however marginal the centers might

be financially, they would bring in business.

 

" Diabetes centers are for hospitals what discounted two-liter bottles

of Coke are to grocery stores, " she said. " They are not profitable but

they're sold to get dedicated customers, and with the hospitals the

hope is to get customers who will come back for the big moneymaking

surgeries. "

 

Indeed, former officials of the Beth Israel center said they

anticipated that operating costs would be underwritten by the

amputations and dialysis that some of their diabetic patients would

end up needing anyway, despite the center's best efforts. " In other

words, our financial success in part depended on our medical failure, "

Ms. Slavin said.

 

The other option was to have a Russ Berrie.

 

Mr. Berrie, a toymaker from the Bronx, made a fortune in the 1980's

through the wild popularity of a product he sold, the Troll doll, a

three-inch plastic monster with a puff of fluorescent hair. Mr. Berrie

took more than $20 million of his doll money and used it to finance

the diabetes center at Columbia University Medical Center in memory of

his mother, Naomi, who had died of the disease. The center was also

helped by a million-dollar grant from a company that makes diabetes

drugs and equipment.

 

Even with its stable of generous donors, even with more than 10,000

patients filing through the doors each year, the Columbia center

struggles financially, said Dr. Robin Goland, a co-director. That, she

said, is because the center runs a deficit of at least $50 for each

patient it sees.

 

Without wealthy benefactors, Beth Israel's center had an even tougher

time surviving its financial strains.

 

Ms. Slavin said the center often scheduled patients for multiple

visits with doctors and educators on the same day because it needed to

take advantage of the limited time it had with its patients. But every

time a Medicaid patient went to a diabetes education class, and then

saw a specialist, the center lost money, she said. Medicaid, the

government insurance program for the poor, will pay for only one

service a day under its rules.

 

The center also lost money, its former staff members said, every time

a nurse called a patient at home to check on his diet or contacted a

physician to relate a patient's progress. Both calls are considered

essential to getting people to change their habits. But medical

professionals, unlike lawyers and accountants, cannot bill for phone

time, so more money was lost.

 

And the insurance reimbursement for an hourlong diabetes class did not

come close to covering the cost. Most insurers paid less than $25 for

a class, said Denise Rivera, the secretary for the center.

 

" That wasn't even enough to pay for what it cost to have me to do the

paperwork to get the reimbursement, " she said.

 

Beth Israel was not alone in this predicament. Dr. C. Ronald Kahn,

president and director of the Joslin Diabetes Center in Boston, the

nation's largest such center, with 23 affiliates around the country,

said that for every dollar spent on care, the Joslin centers lost 35

cents. They close the gap, but just barely, with philanthropy, he said.

 

" So you have the institutions, which are doing much of the work in

dealing with this major health epidemic, depending on charity, " he

said. " In the long run, this is definitely not a tenable system. "

 

Plastic Strips and Red Tape

 

Sidney Schonfeld was not a patient at Beth Israel, but he ran into his

own set of financial obstacles in trying to manage his disease.

 

" Controlling my condition isn't that hard, " said Mr. Schonfeld, 82, a

retired businessman from Washington Heights. " The hard part are the

things outside my control, like getting the test strips and the

medicines. "

 

Test strips are not complicated pieces of medical equipment. They are

inch-long pieces of plastic with tiny metal tabs that diabetics use to

measure the sugar in their blood. After pricking their finger,

diabetics place a drop of blood on the strip and then insert it into

the side of a handheld meter that analyzes their sugar levels.

 

Each strip costs only about 75 cents, but many diabetics are poor and,

over the course of a year, those who test their blood frequently, as

instructed, will spend more than $500 on strips.

 

Mr. Schonfeld, like many diabetics, is supposed to test his blood at

least twice a day so he can make adjustments to his diet and

medications that can ward off serious complications. But many insurers

cover only one strip per day unless a patient obtains written

justification from a doctor. Even with letters from his doctor, Mr.

Schonfeld has had a tough time getting insurers to pay for his strips,

his doctor and nurse said.

 

" Fighting the disease is only half of this job, " said Mr. Schonfeld's

doctor, Dr. Goland. She held up a manila folder thick with letters

that she had sent to his insurer explaining Mr. Schonfeld's case. Mr.

Schonfeld had his own pile of letters: the rejection notices he got back.

 

Dr. Goland says that Mr. Schonfeld has good reason to be vigilant. His

mother lost her left foot to Type 2 diabetes. She died several months

later after gangrene spread to her right. Mr. Schonfeld's six uncles

and aunts on his mother's side had the disease. Three of them

underwent amputations. His son, Gary, is also diabetic.

 

" You can't get a more textbook high-risk case than Sidney, " Dr. Goland

said.

 

Though the health care system asks diabetics to become rigorously

involved in daily management of their conditions, red tape and the

cost of drugs and supplies put self-management out of reach for many

patients. As a result, many diabetics either do without or pay out of

their own pockets. Some resort to other means to get their supplies.

 

In Indiana, hospital workers organized Diabetes Bingo Night last May

to collect money for strips and supplies. In California, F.B.I agents

found that diabetics were buying stolen strips on eBay. Last year, the

agents charged a couple with mail fraud and accused them of having

sold $2.5 million worth of stolen test strips and supplies.

 

In East Harlem, doctors at Mount Sinai were mystified by a number of

cases in 2002: patients came into the hospital asserting that they had

been testing themselves daily and were sure that their blood sugar was

under control. Hospital tests, however, showed just the opposite.

 

" We finally figured out, " said Dr. Carol R. Horowitz, an assistant

professor at the Mount Sinai School of Medicine, " that patients who

could not afford the strips for their blood monitor were buying

cheaper strips that were incompatible and that were giving false reads. "

 

At least they knew they had the disease. A third of diabetics do not,

in part because doctors do not screen as often as they should, studies

show. Since symptoms do not appear for 7 to 10 years on average, the

effects of the elevated sugars begin to build and become irreversible.

 

Mr. Schonfeld has known about his diabetes for more than 20 years and

prides himself on keeping it in check.

 

" I've seen what it can do, " he said. " So I know better than to ignore it. "

 

When Dr. Goland told him to limit the chocolate mousse and

frankfurters, he did.

 

When she told him to start walking two miles a day, he did that, too.

But her instructions to test his blood at least twice a day were not

as easy to follow.

 

Mr. Schonfeld runs out of strips even though he tries to plan ahead by

ordering extras, said Kathy Person, his nurse. " The insurance reps say

they don't want the strips to end up on the black market, so they

don't let people preorder extras, " she said.

 

The Naomi Berrie Diabetes Center has a full-time staff member who

tries to do the clerical work associated with insurance coverage.

" Still, it's a struggle to keep up with the paperwork, " Dr. Goland said.

 

Some doctors simply do not have time and patients are left to haggle

with insurers - usually unsuccessfully - on their own.

 

Although a recent federal study found that an increasing number of

health insurers cover strips, few cover more than one a day, according

to strip manufacturers. In fact, a study last year by Georgetown

University found that insurance restrictions on strips and other

services for diabetics were reducing the quality of care.

 

" I was a businessman for more than 40 years, " said Mr. Schonfeld, a

former food importer. " What I just don't understand is how these

insurance companies can operate the way they do and keep their customers. "

 

Sick Patient? Expensive Patient

 

As it turns out, keeping customers who are diabetic is not the goal of

most health insurance companies, experts said. Avoiding diabetics is

actually more the point.

 

Understanding why, the experts said, requires an appreciation of one

of the crucial obstacles to better diabetes care.

 

Most insurers do not operate the way Mr. Schonfeld did in the import

business, luring additional customers by advertising a good product at

a fair price. Were they to operate in that fashion, health plans

looking to grow might advertise better coverage for diabetics, such as

a wide choice of blood-sugar monitors.

 

But in the insurance business - and virtually all businesses based on

risk - the point is not to attract the most customers but rather the

best ones. As businesses, not charities, insurers need to attract

healthy customers, not sick ones, said David Knutson, a former

insurance executive who studies the industry's economics for the Park

Nicollet Institute, a health research organization in Minneapolis.

 

As a result, experts say, insurance executives usually think twice

before bolstering their diabetes benefits, for fear they will attract

the chronically ill.

 

In a 2003 survey, 87 percent of health insurance actuaries queried by

Mr. Knutson said that if they were to improve coverage with richer

drug benefits or easier access to specialists, they would incur

financial problems by attracting the sickest, most expensive patients.

 

" Insurers are as eager to attract the chronically ill as banks are

interested in loaning to the unemployed, " Mr. Knutson said. " The

chances of losing money are simply too high. "

 

Insurers are not alone in these concerns. Large employers, many of

which devise and finance their own employee health plans, know that

their allotted reserves are jeopardized if too much of their work

force is seriously ill. Last year, for example, a Wal-Mart executive

suggested in an internal memo that the company could reduce costs by

discouraging unhealthy people from applying for work.

 

Even when insurers are simply third-party administrators, processing

claims but not covering the actual medical expenses, they try to keep

claims down by attracting healthier patients to their plans, Mr.

Knutson said.

 

Similarly, coverage for Medicaid recipients, though underwritten by

the government, can be subject to the same private-sector pressures.

More than 70 percent of Medicaid recipients in New York now receive

their health care through private health maintenance organizations

that operate under government contract. These H.M.O.'s get the same

annual flat fee from the government, regardless of whether the patient

is robustly healthy or chronically ill, thus creating an incentive to

attract the healthiest customers.

 

For insurers, the high cost of attracting the sick is far from a

hypothetical problem, said David V. Axene, president of Axene Health

Partners, a consulting firm that advises these companies. For each

additional session of nutritional counseling, he said, an insurer must

account for the likely cost of luring sick patients away from its

competitors.

 

Mr. Axene cited an example from several years ago when, he said, an

insurer became puzzled about why a provider network that it had set up

at a Boston hospital was consistently over budget. Mr. Axene's company

found that two-thirds of the hospital's diabetics had chosen to enroll

in that network over others.

 

The reason? The insurer had mistakenly listed an endocrinologist on

its network's primary care physician list, he said.

 

" These patients no longer needed to get a referral to see the

endocrinologist, and with one visit they could get their general and

their diabetes needs filled, " Mr. Axene said. Within months, the

network had redrafted its lists, dropping the endocrinologist, he said.

 

Mohit Ghose, a spokesman for America's Health Insurance Plans, an

industry trade association, said insurers were working to improve

chronic care coverage. Many have created disease management programs

to track their sickest patients and pay bonuses to doctors who show

results in treating the chronically ill.

 

" Is there still a long way to go? Yes, definitely, " Mr. Ghose said.

" But we're on the right track. "

 

Some preventive measures would, at first glance, seem sure money

savers for health insurers since they might eliminate or forestall

expensive diabetes complications down the road. But many insurers do

not think that way. They figure that complications are often so far

into the future, insurance analysts say, that many people will have

already switched jobs or insurers, or have even died, by the time they

hit. As a result, any savings from preventive measures will only go to

their competitors anyway, analysts say.

 

In fact, experts say, people generally change their health insurance

about every six years.

 

" It's perverse, " Mr. Knutson said. " But it's the reality of there

being a weak business case for quality when it comes to handling

chronic care. "

 

'Jerry, We Need to Talk'

 

It usually took Dr. Bernstein seven minutes to walk from his office in

Fierman Hall to the hospital president's office across 17th Street. On

Jan. 4, 2000, he had a bounce in his step, and it took him half that

time, he recalled.

 

He had a good story to tell, and graphs and tables to back it up. The

Beth Israel center was an unqualified medical success. In fact,

patient loads were growing by 20 percent each month as its reputation

spread.

 

When he arrived, Dr. Fink, then the hospital's president, asked the

three other executives to take their seats. Dr. Bernstein began

talking before he had reached his chair.

 

" Things are really coming along well, " he said as he handed out a

spreadsheet. " Patients are starting to turn their lives around. "

 

Pausing, Dr. Bernstein looked around the table. He was struck by an

awkward silence.

 

" Jerry, we need to talk about what is happening at the hospital, " Dr.

Fink said. " We're going to have to close your program. "

 

Dr. Bernstein cannot say which was more jarring: the news or the way

it arrived.

 

Numb, he kept his composure for 25 minutes, he said. The

administrators explained that the hospital was running a deficit. The

diabetes program was not helping matters.

 

" It was really not about the medicine but the business, " Dr. Fink said

recently about the meeting. " That didn't make it any easier to deliver

the news, especially since I had been one of the main advocates behind

getting the center started. "

 

After the meeting, as Dr. Bernstein walked back to his office, he

wondered where he would direct the program's 300 or so patients.

Still, he remained sympathetic to the hospital's plight.

 

" I was not of the belief that we should save the center only to end up

losing the hospital, " he said.

 

For many of the patients, the news was a second strike of lightning.

They had come to Dr. Bernstein only after being cut loose by the

closing of the St Luke's diabetes center earlier that year. Now they

were being cut loose again, to drift back to a life of limited care

options: understaffed and overwhelmed clinics; general practitioners

with too little time; a city with about 100 overbooked diabetes

educators surrounded by 800,000 patients; and a shortage of

endocrinologists, the specialists who are often critical providers of

diabetes care.

 

Since endocrinology is one of the lower-paying specialties, there is a

national shortage of such doctors. In New York, with its armies of

diabetics, patients must often wait months for an appointment with one

of fewer than 200 endocrinologists. The poorest patients face the

biggest problem, as only a fraction of the specialists accept Medicaid.

 

Once the center had closed, Dr. Bernstein continued to teach at Beth

Israel, but he began to devote more and more time to a side project.

He was working on an inhaler that delivers insulin in the form of a

mist. The product is being developed by Generex, and it is designed to

appeal to patients who are reluctant to use insulin because they do

not like the idea of injections or needles.

 

But the device will probably cost about 15 percent more than

traditional insulin and is likely to be too expensive for many of the

poorest diabetics, who are often the patients who need it most because

their illness is most severe.

 

" The center was a way to really make a dent in this epidemic, " Dr.

Bernstein said. " The inhaler is a promising breakthrough. But it's

mostly a business opportunity. "

 

Other pharmaceutical innovations are likely to soften the toll of

diabetes for many patients in coming years, doctors said. With an

average diabetic spending more than $2,500 per year on drugs and

equipment, pharmaceutical companies have good reason to focus their

attention on the more than $10 billion market in controlling the

disease's complications.

 

But there is only so much the drugs can do, they add, if they are not

accompanied by the sort of changes in patient habits that the centers

fostered through education and monitoring.

 

Health economists suggest that if these preventive measures were

practiced on a wide scale, complications from diabetes would be

largely eliminated and the American medical system, and by extension

taxpayers, could save as much as $30 billion over 10 years. The

experts disagree on what such an effort would cost. (How much

nutrition counseling does it take to wean the average person from

French fries?) Nonetheless, many of them believe the cost would be

largely offset by the savings.

 

Dr. Bernstein says the lone hope on the horizon is a restructured

reimbursement system that puts the business of chronic care on a more

competitive footing with acute care. Experts say this restructuring

could start if government insurance programs like Medicaid began

paying more for preventive efforts like education, a move that the

private sector would be likely to follow.

 

" Until we address the financing and the reimbursement structure, this

disease is going to rage out of control, " Dr. Bernstein said.

 

Not everyone believes the centers were the best answer to diabetes

care. Even with their demise, many hospitals, clinics and

endocrinology practices say they are providing cost-effective, quality

treatment.

 

" The care we provide now is on the par with what was offered before, "

said Dr. Leonid Poretsky, who became director of Beth Israel's

endocrinology division after the diabetes program closed. " The main

difference is that we are financially viable because half of our

patients are not diabetic. "

 

These facilities, though, often find themselves in the same position

the centers did: financing prevention efforts with profits from the

very kidney transplants and amputations that preventive care is meant

to deter.

 

It is tough to convince a former patient like Ms. Hammond that the

closing of the Beth Israel center was anything but a mistake. She had

started to make critical changes in her lifestyle after just a few

weeks there. She did not find out it had closed, she said, until

several months after the doors had shut, when she called looking to

sign up for a refresher class. She was starting to fall back into old

habits.

 

" I needed reminding, " she said.

 

With the center gone, Ms. Hammond said she has had to try to muddle

through. She goes to the podiatrist once a year, but she said she

could not remember the last time she visited an eye doctor. She has

gained about 40 pounds.

 

Some days she wakes up and her blood sugar is high. Other mornings she

doesn't bother to check, she said.

 

" I couldn't get to where I was before, " she said.

 

Two years ago, she said, she took a last look at that favorite

gabardine pantsuit she had once modeled for her class. Then, she said,

she gave it to her cousin.