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Monday, January 21, 2008

Unmanaged Care

For all the talk about managed care, it seems that managing care is something we have yet to do.

I’ve been vaguely aware of that for some time, but recent experience has brought it into sharper focus.

Last summer my father’s genes finally asserted themselves and I was diagnosed diabetic. Fortunately, it is a mild case, easily treated with diet and medication. I take a pill every morning and nstead of watching calories, I watch carbs.

My care has been provided by a primary care physician, a diet counselor and a nurse diabetic counselor. The dietician and the nurse know each other because they work out of the same office suite in South Shore Hospital. But neither of them knows my primary care physician and, to the best of my knowledge, has had any communication with her. Visits to the physician and the nurse counselor seem to deal with pretty much the same subject matter – weight, blood pressure, blood sugar levels, foot care, eye care, etc.

I read somewhere that there are 15 million diabetics in the U.S. That would be about five per cent of the population.

If the population served by South Shore Hospital and its medical staff is 100,000 (a conservative estimate, I think), then they would be serving 5,000 diabetics. That offers an opportunity, I think, for somebody to think about how the cost and outcomes of diabetic care might be optimized.

So far as I can tell, no one has done that. But, of course, even if they did, there would be the problem of implementing any conclusions reached. The medical staff consists mainly of private practice physicians who are effectively accountable to nobody for what they do in their offices, which is where diabetics get most of their care.

In theory, organizations like Kaiser, Mayo and Ford with their full-time medical staffs could do it, but they don’t impose the necessary discipline on their physicians, either.

If I’m wrong about that, I hope somebody will tell me. But if I’m not, we ought to be talking about unmanaged care rather than about managed care.

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