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A Little Number-A Lot of Cost

Numbers mean a lot in health care. They form the difference between good and bad. For example,

Blood pressure above 140 / 90 bad, blood pressure 120/80 good.

High denisity cholesterol 250 bad, low density cholesterol 100 good

But numbers also determine treatments, spending and can even shape a patient’s life style.

Here is an example: In diabetes care there is a number called the glycated hemoglobin or HbA1c. It is a measure of a patient’s blood sugar over a 1-3 month period. It can give a useful long term picture about a patient’s diabetic health.

Normally you could say “HBA1c above 7%, bad, HbA1c below 7% good.” There is debate is that number should be below 6.5% .   The American Diabetes Association recommends keeping the A1c below 7% for type 2 diabetics.   The American Association of Clinical Endocrinologist recommends keeping the A1c level below 6.5%.   So what’s the big deal with ½ percentage point? Well, it turns out, a lot matters.

Well first, a little background.

Diabetes is a disease of the pancreas, the organ that produces insulin which helps to get glucose or sugar into the cells of the body. If you don’t produce enough insulin your blood glucose goes up and your A1c goes up as well.   In the past, you controlled diabetes by giving insulin to those people who produced no insulin, called type 1 diabetes or you gave oral medications to those who produced some but not enough insulin; this is called type II diabetes.

A1c, also called glycated hemoglobin, is a measure of level of glucose in the blood over a 3 month period. It has become a gold standard to diagnose and manage diabetes.   It is generally accepted that when you are diagnosed with diabetes if your A1c is too high it will cause long term damage to the small blood vessels of the heart, and kidney and eye. There is also a correlation with stroke and heart attack.

Now the important part— mainly concerning type II diabetics–some oral medications do not do a good enough job controlling diabetes. In other words, you could be on one medication and still have an A1c above 7%. If this is the case your health care provider may prescribe a second pill or even the use of insulin.

So for the same condition you could be on 2 or more oral medications and on multiple daily injections of insulin, along with finger sticks to monitor your blood glucose. The first oral medication they give for diabetes is usually metformin—an old effective, cheap medication. If you have to give another oral mediation in addition to metformin then you run into what I have termed The Economic Order of Patient Treatments

The Economic Order of Patient Treatments

(the further down the list, the more expensive the treatments.)


Old Oral Meds/Patches and some Older Self Injectable Meds

  1. New Oral Meds
  2. Older Self Injectiable Meds
  3. New Self Injectable Meds and some Newer Oral Medications
  4. Home IV meds
  5. Office IV meds
  6. Medications given in Hospitals and EDs
  7. Treatments given on the Moon and in the International Space Station   (not yet developed but this is a vision for the future


There is a corollary to The Economic Order of Patient Treatments–just because they are more expensive does not mean they are more effective or that they are even necessary.

F we apply this order to diabetic treatment—If you have a doctor who wants to get you A1c below 6.5% and you are at 7.1% and on metformin, he will put you on a second or a third newer oral medication and possible insulin. This could raise up the cost of treatments 30 to 40 times. Daily metformin at $14 per month. Daily insulin injections with test strips are up wards of $500 per month and the new oral medications can cost $200 per month.


The cost is not the only factor.   There is a risk of too low of a blood sugar. This can cause damage immediately while the benefits of insulin treatment are usually in the future.     This decision has many factors. For many younger people who face a life time dealing with diabetes such strict control may be worth it. For older folks it may not be worth the cost.   In whatever the case, the cost should be discussed openly and honestly.

So ask, as your clinician—is that extra ½% worth the cost?



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