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Diabetes - but not as the Government knows it
Mary is a diabetic. Should I sign her up to the Government's proposed scheme?
Mary is 66 and she has had diabetes for three years and her last Hba1c was 6. Surely she would be an excellent candidate for the new Government scheme. Her glucose is obviously well controlled so we definitely should be in front financially by looking after her.
A total of $250 for allied health professionals from the Medicare Local should be plenty. Shouldn’t it?
Mary is a bit overweight, however – her BMI is 38.9, which makes her morbidly obese. Perhaps she could see the dietician on a regular basis as part of her allied health support - every three months would be beneficial.
Mary also has psoriasis and she has psoriatic damage to her fingernails and toenails. The small joints of her hands and feet are affected as well. She has psoriasis of her scalp and, when she flares up, it is present on her arms and back. With her diabetes and the psoriatic arthritis, she would definitely benefit from seeing the podiatrist regularly – perhaps every three months?
I also forgot to mention that Mary has had bilateral hip replacements (the left one has been done twice already). This is probably contributing to her difficulty with exercise. So, given her psoriatic arthritis, obesity and diabetes, she would definitely benefit from some assistance with exercise. An exercise physiologist would also help. Maybe every three months would be good – at least until she gets on her feet and has a program that she can follow.
Mary would find a diabetic educator very useful. Even though her Hba1c is in the right range, it would be valuable for her to understand her condition better. She needs to know how to monitor her diabetes and how and when to use a glucometer correctly. Thankfully she is only on oral therapy. Perhaps two visits per year would be good to get her started.
Mary is a non-smoker, but was not able to give up until after the third total hip replacement. By this time she had already suffered lung damage and has COPD.
Probably as a result of her smoking, diabetes, obesity and hyperlipidaemia, Mary had a NSTEMI a few years ago - so we need to keep an eye on her blood pressure and cholesterol, as well as her blood sugar.
Mary also has Stage III chronic kidney disease with evidence of microalbuminuria. In light of the hypertension and the diabetes and the renal failure, I commenced an ACE inhibitor that initially improved the blood pressure and the proteinuria, but became intolerable because of her cough.
I had to change her over to an A2RA and now her blood pressure is well controlled. Thankfully, she is not showing any signs of diabetic retinopathy and is still only seeing her ophthalmologist every two years.
Mary also sees her ENT specialist on a regular basis. Some time ago, she developed otosclerosis in both ears and has had at least a dozen ear operations to try to restore some sort of hearing. She copes pretty well with her bone conduction hearing aid.
I almost forgot to mention that Mary has had terrible problems with dental caries. Fortunately, she was eligible for dental services under Medicare because of her complexity. Previously, financial pressures meant she could not afford to see her family dentist or look after her teeth properly.
Sometimes, all of these illnesses can get Mary down. At last count, her regular medication list numbered 30 different items. She usually reaches the safety net in February each year. This year, things have been particularly difficult so we enlisted the help of a psychologist to try to help Mary deal with her health issues as well as her family and financial issues. These visits have been of great benefit to her with at least one person being able to spend a bit of extra time with her.
So, let’s go back to the beginning of this true story. Should I sign Mary up to the new Government diabetes plan?
What about her Medicare safety net? What about her access to her dentist? Mary would not be better off under the Government plan.
She would, however, be better off under the AMA’s alternative plan (see it at www.ama.com.au), which offers less red tape and better access to allied health support.
When looking at the Government’s proposal, you can’t help but paraphrase a famous Ship's Doctor - “It's diabetes care, Minister, but not as we know it!”
Let’s build on what works. We don’t have to reinvent the wheel.
Dr Steve Hambleton is Vice-President of the AMA. This article first appeared in Medical Observer on 22 June 2010.
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