Diabetes is one of the great health crises of our time. Unfortunately, it does not affect everyone equally, not merely in terms of the disease’s severity but the financial stress it places on the patient. Signs that patients’ financial means lead to differing abilities to cope with the effects of the disease are starting to be documented around the world. In a 2014 study based in Massachusetts, one of the few US states with universal healthcare, Dr Seth Berkowitz, of Boston’s Massachusetts General Hospital, highlighted that overall, 39.1% of patients in the study reported at least one material need insecurity.
“Difficulty affording food, cost-related medication underuse, housing instability and energy insecurity, poor diabetes control (as measured by factors including haemoglobin A1c, low-density lipoprotein cholesterol level or blood pressure) was seen in 46% of patients.” The report concluded that “the efforts of patients and clinicians are insufficient in situations where patients could not afford basic needs.”
Identifying the problem
Difficulties in maintaining the more costly lifestyle required to combat diabetes affects patients globally, regardless of healthcare and social services systems. A Taiwanese study published by researchers in the journal Diabetes Care in November 2012 concluded that “poverty is associated not only with higher diabetes incidence but also with the inequality of diabetes care in a north-east Asian population, despite universal health coverage,” and that “lack of access to healthcare has been considered an important risk factor for the consequences of diabetes among the socioeconomically deprived.”
In the UK, “the least affluent section of society are two and a half times more likely to have diabetes at any age than the average income person,” according to data published by the charity Diabetes UK from research undertaken in conjunction with the National Health Service. The report goes on to state, “once they have the condition, those in the most deprived homes are twice as likely to develop complications of diabetes [compared with] those in the least deprived.”
We spoke to assistant professor at the University of Michigan’s School of Public Health Minal Patel, who has identified some worrying patterns. Her most recent work looks at socioeconomic problems and diabetes, analysing American diabetes sufferers’ issues with out-of-pocket expenses for illness management and the resulting financial stress.
“The purpose of this study was to look at different aspects of financial burden, those related to diabetes and other social determinants, to see how it affects cost-related non-adherence.”
“We used a national dataset to examine factors that are correlated with costrelated non-adherence, related to general financial stress, food insecurity and health-related factors, as well as different factors that fall under ‘solutions’ and how they may mitigate those behaviours.”
Diabetes requires complex management in a variety of ways and food insecurity – the state of being without reliable access to a sufficient quantity of affordable, nutritious food – has a severe impact on successful disease management. A specific and very complex diet is needed to manage diabetes, which makes food access, specifically healthy food access, a crucial factor.
Patel’s research found that “half of the adults with diabetes perceived financial stress, and a fifth reported financial insecurity with healthcare and food insecurity. Talking to a healthcare provider about low-cost options may be protective against cost-related non-adherence (CRN) in some situations. Improving screening and communication to identify CRN and to increase transparency of lowcost options that patients are pursuing may [act as a] safeguard [against] the health consequences of cutting back on treatment.”
The rising price of healthcare
Examining the social impacts of the disease and how they are affected by financial stress is a fairly new way of analysing diabetes. Patel has identified a number of socioeconomic factors that she believes contribute to and exacerbate the condition.
“Definitely in the US, the price of healthcare for people, specifically the price of pharmaceuticals plus the cost of seeing a doctor, is much higher than in any other country in the world. Our health insurance system has been going through many reforms over the past six years, but the trend is that people are [increasingly] responsible for paying for their healthcare.”
Aware that more studies are beginning to map patient nonadherence to treatments, Patel gave her thoughts on the kind of strategies for mitigating the financial burden of the disease that she would like to see being further investigated.
“We saw that people who talked to their doctor were less likely to engage in [non-adherence] behaviours,” such as skipping medicine, she explains. “But that in itself is complex because I don’t think we’ve really figured out how to have those conversations between doctor and patient in a productive way yet.
“A cost-related conversation could potentially be very long and drawn-out and take away from other crucial aspects of the visit, but there are things we can do in terms of triaging to other people in the care team to address these issues.”
Cost-effective solutions
Patel believes that more research is needed. “I want to think of solutions,” she says. “We know this is a problem [that] is difficult to talk about, but it is a significant issue that affects the ability of people to manage their health, especially in the context of rising healthcare costs being shifted onto consumers.” For Patel, the problem calls for a multifaceted solution that goes beyond the public policy perspective. The approach needs to account for how healthcare professionals can help at an individual level, and offer counsel so that “patients can continue to manage their health in the face of broad financial issues that may or may not be related to health specifically,” Patel suggests.
A big part of achieving this in an effective manner is being aware of the infrastructure for social services, connecting people to those resources and informing them of their options.
How this is done depends on the healthcare delivery setting, explains Patel. “You may have a designated care person on your care team responsible for the issues; you may have protocol to address your patient, especially if the mission of your delivery system is to provide low-cost care,” she explains. “Some people may know of no solution and may be pointing people to seek it out on their own. So it really depends on what the delivery system is, the capacity and the infrastructure to actually handle this – all of which vary.”
“Obviously, finances affect people in a lot of different ways but we’re moving more towards documenting its impact on health and when people have to make trade-offs. There are a lot of opportunities to really look at different ways of addressing those social determinants in a clinical care setting.”
Due to the high number of type 2 diabetes sufferers, reliable data and a wide-reaching plan to combat the challenges faced by patients are essential. One strategy is standardised data collection that incorporates patient-level measures of social determinants of health. The analysis of any resulting data would be able to ensure that policies and practices are allocating resources properly in order to mitigate any impact socioeconomic disparities may have on management of the condition.
A number of successful healthcare schemes show that a good way of combatting issues is upfront communication, which includes patient screening and counselling, as well as training doctors to help their patients to access affordable options. With further research and implementation of appropriate strategies, the problems faced by more vulnerable patients will hopefully be addressed.
