Cost Burden of Diabetes in the Bronx
Co-morbidities associated with diabetes add to the cost of managing the disease. The annual cost for diabetic care in NYS totals approximately $12.8 billion (NYSDOH, 2009) including direct medical costs of $8.7 billion and loss-of-productivity costs of $4.7 billion. For the Bronx, the expense for diabetes care has an approximate total cost of $503 million or $342.2 million for medical costs and $160.8 million in loss-of-productivity costs (ADA, 2012). The ADA estimates that on average, about $1 out of every $10 spent on health care in the Bronx can be attributed to diabetic care. The largest portion of these expenditures stems from inpatient hospital costs (50%), costs for medication and testing supplies (33%), and doctors’ office visits (9%); the remaining 10% was attributable to ancillary costs, such as transportation (ADA, 2007).
According to the Public Health Association of NYC (PHANYC) (2007), an estimated $4.5 billion was spent annually for the care of 700,000 diabetes patients citywide. This included more than $2.3 billion to treat inpatient hospitalizations because of complications, such as ketoacidosis, hyperosmolarity, and diabetic coma, which could have been prevented by the patient with a proper self-management support structure. A 2007 NYSDOH survey, which was administered from 1997 to 2004, reported that approximately 85% of diabetic patients living in the Bronx, who responded to the survey, did not have their HbA1c or LDL levels checked at all between 2001 and 2004. It has been estimated that approximately 40% of people diagnosed with diabetes have not achieved HbA1c goal of 7 or less, and consequently have been classified as having uncontrolled diabetes (Hoerger, Gregg, Segel, and Saadine, 2008). Subsequently, this has led to greater numbers of hospitalizations for chemical imbalances, disease-related complications, and treatments for associated co-morbidities. This reveals the importance of the need to increase enrollment into the diabetes disease management program at Gotham. The uninsured and underinsured in The Bronx community with diabetes if not enrolled into the program are more likely to have an uncontrolled blood sugar level. They are then more likely to develop diabetes complications which are often more difficult and expensive to manage. Additionally, an uncontrolled blood sugar level in a diabetes patient is very likely to lead to repeated admission into the emergency unit due to diabetic ketoacidosis and other metabolic complications. It has been estimated that a patient with diagnosed diabetes and no complications, such as chronic foot ulcers, had care costs of approximately $1,600 a year, while a patient with disease complications could expect to spend approximately $40,000 annually (PHANYC, 2007). For the reporting period of 2001 to 2004, the Bronx had an average of 47.5% hospitalization rate per 100,000 diagnosed cases of diabetes .This was greater than the national average of 32% for uncontrolled diabetes cases (NYSDOH, 2007). The greatest rate of hospitalizations was amongst the poor neighborhoods in the Bronx and across NYC (Exhibit 5).
One of the major implicating factors for the poor statistical finding as it relates to diabetes [what does this mean?] in the Bronx is underutilization of diabetes management services, especially by the uninsured and underserved in the community. While lack of health insurance is a possible factor responsible for lack of access to the needed diabetes care, it should be noted that there still remains underutilization of diabetes care even for the diabetes programs offered at no cost. So while these programs are available, the underserved in the Bronx community are either not aware of these programs or do not see the need for them. It is worthy of note that most of the figures that define diabetes profile statistics amongst the inhabitants of the Bronx community were obtained Pre ACA/ACO implementation. However, it is expected that with the passage of the ACA along with Gotham hospital reconfiguring its existing diabetes management unit to comply with the ACO guidelines, these figures are expected to improve. The change in this figure for better or for worse will validate the success of the ACO. As at the time of writing this paper, there still remains insufficient data to be used for comparative analysis pre and post ACO.
Socioeconomic factors and racial diversity in The Bronx community play a major role in the low utilization of health services provided at Gotham hospital. [why? You need to provide support for such statements and should be careful about sweeping generalizations – the Bronx is similar to many other urban areas]. The group hypothesizes that post ACA/ACO, utilization of the diabetes program at Gotham hospital is likely to remain low if the current existing structure is not expanded to reach out to the underinsured and uninsured in the Bronx community. [There are so many other outreach and structural opportunities I do not suggest your focus be on local coordinators, exclusively. Who are they in terms of training? Data that supports their impact on improving control of diabetes? There are many effective approaches out there and you later comment on their effectiveness so you need to explore them.] This can be done through the use of local coordinators to reach out to the community and increase enrollment and participation of this target population to the diabetes care services available at Gotham hospital. The local coordinator who shares the same socio-cultural and racial characteristics and relates at a personal level with the underserved is more likely to persuade these group on the need to utilize the services provided at Gotham. [They still need to show up and keep appointments]