Interview with Anne Albright
Hedrick Smith: Were in San Francisco, talking to Ann Albright, Health Specialist and former President of the American Diabetes Association for the Western States. Tell me, how big a health problem is diabetes?
Ann Albright: Diabetes is an enormous health problem in this country. Unfortunately, its one thats not as recognized as it should be. Weve got about 16 million people in this country that have diabetes, and about a third of those people dont know they have it. Its also an enormous problem in this country because of the devastating complications that can accompany diabetes.
The number one cause of blindness is because of diabetes. Its the number one cause of kidney failure in this country. And its the number one cause of amputations of the leg and foot. And its also a huge contributor to heart disease and stroke. And, unfortunately, our country does not make the connection between diabetes and all of those serious complications.
Hedrick Smith: What do we spend, as a country, on care for a diabetes patients?
Ann Albright: Weve just described the human cost to diabetes. The financial cost of diabetes is astronomical. Approximately one in seven health care dollars is spent on diabetes. And approximately one in four Medicare dollars is spent on diabetes. A good portion of those costs are because of caring for people in the end-stage complications.
Hedrick Smith: What does that mean in dollar and cents terms? How much money are we talking about here?
Ann Albright: Thats approximately 40 to 45 billion dollars [that] was spent on diabetes, and that would be [by] agencies like Medicare, the VA, Medicaid, those federal agencies that pay for health care.
Hedrick Smith: Could we cut that cost if we were smarter about the way we took care of diabetes patients?
Ann Albright: Theres no question we could cut costs related to diabetes care. We used to not be able to make that statement. I think that in these last few years, we have come to know very clearly that we can do a lot to prevent or, at the very least, postpone the complications of diabetes - and those are the most costly aspects.
We now know that good blood glucose control, blood sugar control is very important to preventing or postponing those complications. But that means that people need to get access to those tools. They need to understand how to use the tools to care for their diabetes and they need to be given instructions and support on how to use those - and to take an interest in their disease.
Hedrick Smith: How big a problem is diabetes for people who are uninsured? There are now 43, 44 million people in America who are uninsured. Are they a huge expense? Are they at huge risk?
Ann Albright: Diabetes disproportionately affects certain populations that are oftentimes the ones that may have problems with health insurance. Diabetes disproportionately impacts those of African-American, Asian and Pacific Island or Hispanic/Latino and Native American descent. So many times, those populations also seem to have a disproportionate share of the uninsured. So, in that regard, diabetes is, no question, an issue for that population.
Hedrick Smith: Let me ask you about your own personal experience. Are you a diabetic?
Ann Albright: I do have diabetes. I have had diabetes for 32 years. Im happy to say, Im still here and still doing well. Its been an interesting trip of 32 years with diabetes. I was a little girl when I was diagnosed and its a real adjustment for you and your family. Thirty-two plus years ago we didnt have the tools that we have now. We did not have the needle or the monitor that we use to test our own blood sugar every day. I grew up with a rack of test tubes in my bathroom, as a little girl, testing urine to check what my sugar was. I tell people thats why I went into science; Im comfortable around test tubes.
And we didnt have insulin pumps. We had fewer kinds of insulin. Fine needles were not as fine as they are now. We didnt have that level of knowledge that we have now. We didnt realize the magnitude of the problem that diabetes is and what blood sugar does to the complications.
Hedrick Smith: Whats it like to be a diabetic? What do you have to adjust to? Whats life like?
Ann Albright: Well, we have to adjust to a lot of things with diabetes. It impacts every area of your life - every area. You have to think about what you eat. You have to think about what youre going to do when youre a kid on the playground. You have to think about when you go to sleep at night, if youre going to be safe and that your insulin will be doing what it should be doing for you. Theres some risks to taking insulin. As a young person or as a person with a diabetes, you have to manage all of those things. You have to manage the fact that you have a disease that could take your eyesight or your limbs or your kidneys. So there is a lot of fear involved with diabetes.
I was very fortunate that my mom is a nurse and we grew up in diabetes together. Later she became a diabetes educator. She helped me to understand as little girl that this disease was never going to be my friend, that it was something I was always going to have to learn about and try to do the very best I could to take care of myself, to learn all I could, and to use that information.
She helped me adjust and to develop a philosophy about living with the disease. You have to come to terms with it. It doesnt mean that youve given up or that youve given into the disease. Quite frankly, in my opinion, it means the opposite. It means you have taken charge and youre going to do your best to, to stay on top of things.
Until we find a cure we have to take good care of ourselves and we have to manage it every day. You have to pay attention to, as I said earlier, food and physical activity, stress in your life, managing a schedule. The things that everybody else takes for granted.
Hedrick Smith: This is chronic. Its not like coming over to the hospital because of an accident or something happens even in the acute problem, this is one thats with you.
Ann Albright: This is with you every day, no vacation, no breaks. You have to deal with it every day. And you have to adjust to that mentality, and you have to be willing to try to stay as positive as you can and to realize that none of us have any guarantees. There are no guarantees for any of us, but you want to do all you can to stack the deck in your favor. So you want to pay attention to your blood sugar and pay attention to your food and pay attention to all of those things.
Hedrick Smith: You mentioned that medical science and technology have come up with a number of devices that make life more manageable. Like what?
Ann Albright: I think one of the first tools developed that was a big lifesaver was a blood glucose meter. It tells you that you have a code here, and the code matches whats on the bottle of strips. Then it tells you to insert the strip. Blood has to be on the strip for about 45 seconds. And at the end of that time, it will tell me what my blood sugar is.
Hedrick Smith: When your blood sugar is too high, what does the insulin do?
Ann Albright: Insulin is a hormone that is produced by an organ in your body called the pancreas. It sits near your stomach. When you eat, your pancreas squirts out some insulin. It takes the sugar thats in the blood stream out of that blood stream into the cell[s] where it can be processed.
Having sugar floating around in your bloodstream is not helpful. It needs to get out of the bloodstream into the cell[s] where it can be processed and used for energy. For those of us that have a deficiency in our insulin, the bottom line is, we dont have insulin. We dont have enough or its not working properly. We cant take that sugar out of the blood stream and get it into the cell[s]. So, essentially, our cells are starving.
Hedrick Smith: How much does it cost for a diabetes patient to begin with? And is that covered by health plans?
Ann Albright: Many, many more health plans now are covering it. In certain states in the country, there are now 37 that have passed legislation in which they are covering these supplies and diabetes education. Thats not always been the case, particularly for patients who have Type II diabetes that do not use insulin.
Many times that form of diabetes is viewed as being less serious and somehow those patients dont get to have these supplies, and thats a mistake. They may not need to test as often as someone like me does, [but] everybody with diabetes should be able to check their blood sugar.
Because of doing this, I now can see what my blood sugar is. I can make decisions on how to gauge my insulin. I can know whether or not the dosage that I took and what I ate and what my exercise is like, is going to help keep my body healthy. And by having these tools, my - our - everyones hope, certainly mine and my familys hope - is that I will never lose my kidneys and never lose my eyesight and never have an amputation - which will cost volumes more than what these supplies will cost.
Hedrick Smith: So this is preventive care - up front?
Ann Albright: Absolutely preventive care.
Hedrick Smith: Now what about the insulin pump? How much does that cost? Is that covered by your health plan?
Ann Albright: An insulin pump is about a $5,000 item. In my case, yes, my insulin pump was covered by my health plan, but that took a little bit of work to get it to be covered. I was eligible for the pump, except that when they looked at where I lived, that I was considered to live too far away from the hospital site to have it covered. The insulin pump was in the same category of whats called, "durable medical." Devices like insulin pumps, crutches, wheelchairs - all those things are covered under whats called "durable medical."
The insulin pump was in the same category as other kinds of infusion pumps that somebody might need if they were on home tube feedings or some sort of other kind of medication infusion that usually [is for the] more home bound. And the insulin pump somehow got into that category of devices.
And so when they saw that I was requesting an insulin pump and where I lived, they said, "Oh, if the pump malfunctions, youd have to have a health care professional come out and help you manage your diabetes." I said, "No, I wouldnt. Id go back to the syringes and that would be what I would do to manage it. No health care professional would have to come and help me."
Through a process of working with my physician and diabetes educators we were able to change the policy within the health care system to get them to cover insulin pumps wherever your geography was.
This is life support for me, but its not the same kind of thing that if it malfunctioned, my oxygen would be gone or my tube feed. So, after talking with my physician and diabetes educators we wrote to the health plan and we questioned that policy. And we demonstrated why it should not be in that category of supplies. And they agreed to cover the pump.
Hedrick Smith: How important is an insulin pump?
Ann Albright: From my perspective, in my lifestyle, with the way I try to manage my diabetes, its very important. Its not a cure, but definitely allows me to have flexibility in my life, and when you live a chronic disease, its really important.
Hedrick Smith: What about somebody who is in a Kaiser plan and under group coverage would qualify for an insulin pump, the employer cancels Kaiser, [and the employee] now takes Kaiser as an individual patient, but doesnt qualify for the pump under the [individual] Kaiser plan? Whats your response to that? Is that logical to you?
Ann Albright: People need to be able to take good care of themselves - particularly if she had been on a pump and she were managing her diabetes well on a pump, its in the best interest of health plans to help people with diabetes take good care of themselves because it will be less costly in the long run.
I would be very upset if that happened. I would be devastated. I would probably try to find some way to manage getting back on the pump and being able to afford the supplies, but I think that people have demonstrated that theyre doing well on a pump or it can improve their care - that they should be given that option for the best care.
Hedrick Smith: Youre a health professional as well as a patient, so you see lots of different health plans and lots of different systems. How would you compare the Kaiser Permanente handling of diabetes patients like yourself, with that of competitive plans?
Ann Albright: I think that what Kaiser does have going for it is [that] the staff model allows you to have information about you as a patient in a more easily contained location. They know more about you. They know more about your care. They can better manage you and they have the opportunity to have some more continuity in your care because youre able to be tracked more easily within that system. I think thats more of a challenge for other methods of delivering health care. Its more difficult to access data, to follow patients, and to make sure that theyre getting the right kinds of check-ups and the right kinds of services.
I think that those things are important to do as a consumer, but you need to make sure that you are working with your health care professionals and that youre doing it because you are clear that its in your best interests and your health care professional is helping you to understand whats in your best interest.
I think there are lots of choices of things that people could be on. And I dont think that I need to be on every single, solitary thing thats out there. I think I need to look at whats out there, whats in my best interest as somebody with diabetes and make sure Im getting those things.
Hedrick Smith: Im hearing two different things. One, Im hearing that if youre a patient, particularly if you have a chronic illness, you have got to fight for yourself. The second thing Im hearing is that within the Kaiser system, that if you do fight for yourself and you make a case, they will respond and change. So Id like you to address what your lessons from your experience are.
Ann Albright: I think without question, when you live with a chronic disease, you need to learn as much as you can about your disease and be your [own] advocate. You have to learn about your disease so that you can be in a good situation to fight, if need be, for the things that you need for your health.
And I think that, yes, in my situation, Kaiser has been responsive. When I have come with a case and made that case, I have had success in getting them to see that I wasnt being unreasonable in what I was asking for.
Hedrick Smith: Youve been with Kaiser Permanente for roughly 30 years. You had plenty other choices, why have you stuck with Kaiser?
Ann Albright: I have stuck with Kaiser because of the fact that if you understand the system and you know what you need to obtain, they are quite amenable to obtaining what it is you need. I think that I have been able to get the supplies and the services that I needed to take good care of myself as somebody with diabetes.
Hedrick Smith: Do you have the best care you can get?
Ann Albright: I think I do. I think that there are probably some things with care that I would do differently. I mean, thats true in any situation. But I think if you are an active participant in your care, you have good communication with your health care professionals, you can get very good care.
Hedrick Smith: If you had two or three things that were absolutely critical in delivering what you thought was the best care, in this system, Kaiser Permanente, what are they?
Ann Albright: Access to the necessary supplies and medications. So, access to those blood glucose monitors and, if necessary, the pump. And the appropriate medicines. I think that the other very important thing is access to information and education about your diabetes. And I think that Kaiser has some variability on their education component. Because I am a health care professional, I did not need to access that as much as other patients would need to, and theres some variability in access and opportunity for those sorts of classes within Kaiser. I think that varies to some degree, but it still can be obtained within the system.
So, I think access to knowledge and information about how to live with your disease and access to the supplies and equipment that you need to take good care of yourself are absolutely critical.
Hedrick Smith: You have been fortunate because youve managed your disease well and youve been healthy and active. As the President of the Western States American Diabetes Association, you must have seen diabetes patients who were not as fortunate - people [who] had complications. From the standpoint of a diabetes patient who develops complications, are there advantages to being in a system which is coordinated and closed and works as a group as opposed to being in a more open system? Or is it the other way around?
Ann Albright: I think that coordination of care the more complicated your case gets is very important. I think the potential for coordinated care is likely to be greater in a closed system because of the opportunity to access more common information.
Hedrick Smith: If youre thinking of it from the standpoint of the health plan, whats the attitude at Kaiser? How do you feel about it, as a patient?
Ann Albright: From somebody who lives with a chronic disease, Im thrilled that a plan will take a long-term look. Its a contradiction for people with diabetes not to have a health plan take a more long-term look. We understand if someone leaves your plan, you wont benefit from it. Its absolutely important to remember that others will come and if theyve gotten shoddy care somewhere else, they now become your problem. So there has to be this, this willingness to look more long term, particularly with a disease like diabetes.
Hedrick Smith: What was the mentality, the decisionmaking in the health plans at that point, before this last two year period? What were the health plans thinking, deciding, doing? What were patients experiencing?
Ann Albright: I think that the mentality when I first entered this arena, four years ago, was, "They are probably going to leave our plan, why should we make this investment?" They were not willing to acknowledge that the investment was worth making. And so, decisions that would require that long-term mentality were often times not being made.
As weve learned more about diabetes, as weve begun to help people understand the long term costs and the fact that people are leaving the plan, but theyre going somewhere, that they have to be cared for more as a group. A number of health plans and medical groups are coming together to try to look at those issues.
Kaiser is ahead of the game in that arena because of the fact that the closed system has allowed them to have much better data much earlier in the game to make decisions and have in front of them the hard numbers that will demonstrate whether or not these things are going to be effective down the road. And I did make a long term commitment to this health plan because, to date, Ive been very satisfied with what Ive been getting.
Theres a large number of health plans and medical groups that have come together because of exactly what we were just talking about, this understanding that we cant have multiple measures and multiple ways of measuring good care. We need to be using a similar score card when were deciding on whose making the mark and who isnt. And so as a group, the industry is trying to come together, understanding they are competitors, but beginning to understand - particularly in areas like chronic illnesses, such as diabetes - that they need to come to the table and talk to each other because they will, indeed, be sharing this population of patients that can be very costly in the long term.
Hedrick Smith: So from your perspective as a health professional, as well as a patient, how well has managed care delivered on its promises? Preventive care, coordinated care, long term care?
Ann Albright: Well, I think in the answer to how well managed care has delivered on three important areas--the preventive care and the coordinated are and long term care--that prior to managed care coming on the scene, we werent doing very well. We are moving from a fairly low-level position to an improved position. I think we have moved, but the numbers are still abysmal - certainly for diabetes. We still have very low rates of eye exams. Very low rates of foot exams. And very low rates of an exam that looks at your blood sugar control. We still have a long way to go, but there has been some improvement - but I think were quite a ways away from where we need to be - a very long ways away from where we need to be still.
Hedrick Smith: As youre working with these rapidly growing HMOs with hundreds of thousands of clients here, as you work with these new, growing HMOs, what are the most difficult frustrations and obstacles that you face?
Ann Albright: I think the most difficult frustrations and barriers that we face in working with the newer HMO style care, is the difficulty that they have in tracking their patients, following their patients, monitoring them because the format is that a plan can contract with a variety of medical groups. Its just easier to communicate information when its all contained within a single environment. Its much easier to follow patients, to make sure that theyre getting the kind of care that they need when theyre not getting certain tests done or that there are things that are lacking.
Hedrick Smith: What a lot of patients, what a lot of customers think is they want a wide open system where they can pick the doctor here and a doctor there and a laboratory here and a specialist over there. What youre saying is thats a disadvantage for dealing with chronically ill people?
Ann Albright: It very much can be a disadvantage. Medical relationships are very important relationships that you develop with your on-going provider. So, its important to identify someone who youre able to develop a relationship with. And I would challenge audiences to ask themselves how often have you changed health care? Or are you changing health care? I think that you really want to look at who are you trying to develop a relationship with in your health care system.
Hedrick Smith: Looking at your experience, overall, on a scale of 1 to 10, how would you rate Kaiser Permanente for your care?
Ann Albright: I would probably give them an eight or a nine in my situation. I have had, I think, very good care from Kaiser. Ive been able to access the things that I need. The situations where I have had to be more assertive to get what I needed, I was able to do that. And I think thats why I would still give them an eight or a nine because I know, no matter what health care system Im in, its not always going to be a smooth road, and youre still going to have to have some situations where you assert yourself and question the decisions that are being made. But because I was able to get those decisions made - and obviously in my favor - it makes me have a higher rating, but I think they were not unreasonable requests and that they were willing to listen.
Hedrick Smith: If you compare Kaiser with the rest of the market are they ahead? Do they have a model? Is there a disease management at work, with admitted variations in how its implemented as compared with competitors? Or is everybody doing about the same and there are variations everywhere?
Ann Albright: Well, I think thats one of those questions Id say, sort of both. I think that there is variation everywhere. I think that more plans are trying to pay attention to how to have a more coordinated system and disease management. Some, in fact, are paying companies who are disease management companies to come in and manage a particular disease process. And they probably have fairly well integrated care.
The challenge is, how are they able to identify their patients with diabetes in order to deliver that care? Kaiser is able to more readily identify their patients and get them into the system of coordinated care - or whatever semblance of coordinated care exists at that site.
I think there are some lynchpins or some critical pieces that have to be in place in order to have a disease management model: You have to identify the people who need the service, in order to give them access to the service.
Hedrick Smith: And why does Kaiser do this well? What is it about Kaisers either approach or philosophy that has it finding the patients sooner?
Ann Albright: Kaiser has a registry. They have identified their patients with diabetes. Because of their model of health care that they [use], because theyre this more enclosed model, they are able to get this information from their patients and have a registry and theyre able to access it from all these sites all over the place. Theyre able to use that information to do a better job of identifying their patients.
Now, once theyre identified, not every patient is getting this coordinated care, but I think that they are setting up certain standards that theyre trying to follow. They are trying to remind people in a variety of ways what services they need to access. What Im not seeing, what I have not experienced is anybody telling me, "Oh, its time for your hemoglobin A1C," or, "Its time for your kidney function test." Thats still on me to come in and access that, but once you get into the system, youll get a reminder about certain things.
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