James T. Kenney, RPh, MBA: It has a huge economic burden on society. And when you think about the complications, microvascular [and] macrovascular, of this disease, that adds significant expense in the cardiovascular space. From the patient’s perspective, it’s also a huge burden because patients are often on multiple medications. Most patients are on 2½, 3 medications to try to control diabetes, also type 2 diabetes. And certainly the insulins are very expensive, and we see that’s a big topic on the news these days. There’s lots of expense, out-of-pocket expense, for patients, and it chews up their deductible and their coinsurance; their co-pays are quite significant. So it makes it challenging to make the patient compliant with therapy because you’ve got to combine all these medications.

Peter Salgo, MD: Let’s parse this out for a minute, because I do want to talk about the burden and the impact on a patient’s life. But now let’s just talk dollars and cents. And to be brutal about it, if you don’t treat diabetes, these patients die earlier. Is it cost-effective to treat them or not? Is the cost of diabetes untreated greater or less than the cost of treating them?

James T. Kenney, RPh, MBA: I think the cost of diabetes is better if you treat it, better controlled if you treat it, because those complications can persist for a long time. So you can have a patient who has a stroke. They could live for many years after the stroke, and you’ve got to pay the cost of treating that patient for a long period of time.

Peter Salgo, MD: What do you say to a patient who says to you, “My doctor just told me I’ve got diabetes. I’ve got to take all these meds, and I can’t afford it.” What do you say?

James T. Kenney, RPh, MBA: Well, you try to help the patient. I mean, we have case managers in the health systems [who] try to work with patients, try to identify co-pay assistance programming. There are certainly lots of generic options in the space. Most patients are going to start with metformin, which is very inexpensive, and we see a lot of other drugs in this category [in which] there are differences between the choices that can be less expensive for a patient. But they also have to try to find a health plan or an insurance design that promotes some of the lower-cost options as well.

Peter Salgo, MD: We were talking about who needs to be screened, and we’ve been talking people with overt diabetes [who] need to be treated. Are there payer criteria for testing these patients, or these prospective patients? Are there ladders that people have to look at before you say, “I’m going to pay for a test for an A1C [glycated hemoglobin] or a fasting blood glucose”?

James T. Kenney, RPh, MBA: I think, for the most part, the screening tests are paid for universally. I don’t think there [are] a lot of restrictions there. A lot of these tests are now conducted in a physician office, [which is] fairly inexpensive [and] part of routine physicals or visits. So not a huge burden to the testing. There may be burdens to get to certain drugs in a certain order, and certain requirements for patients to get to those. But as far as tests and routine screening, I don’t think that plans typically are going to put barriers in place.

Peter Salgo, MD: Do you test everybody? I mean, you’re an endocrinologist. But let’s say [this is] primary care. There’s somebody that person is seeing for the first time. Would it be routine for you to get an A1C and a fasting blood glucose [test]?

Helena W. Rodbard, MD: Well, by the time somebody comes to us, they already have diabetes.

Peter Salgo, MD: But put yourself in the chair of somebody takes all comers.

Helena W. Rodbard, MD: But if I’m going to wear the hat of a primary care physician, depending on the family history, I would certainly put great emphasis on the family history. I would put emphasis on the other topics that we discussed, such as race, depending where they live, depending also whether the woman had gestational diabetes, probably cystic ovary, all the risk factors. But having a first-degree relative is very important. Also elderly people. And I hate to [say that] elderly [are] over the age of 60.

Peter Salgo, MD: Don’t you dare.

Helena W. Rodbard, MD: Sorry.

Peter Salgo, MD: You just lost a chunk of a lottery.

Helena W. Rodbard, MD: Sorry, present company included.

Om P. Ganda, MD: The cost of a moving target.

Helena W. Rodbard, MD: But it’s been shown that 23% of people over the age of 60 have diabetes. So this is a huge, huge burden. And going back to what Jim said, if we are going to put dollars and cents on the economic burden of it, last year it was $327 billion.

Peter Salgo, MD: B?

Helena W. Rodbard, MD: B, billion; it’s a B. And of which $237 billion were [in] costs related to medications, but primarily the complications. And $90 billion was the cost of lost quality of life. And quality of life is something that we should really consider very seriously.

Peter Salgo, MD: Let me throw something out very briefly before we move on. I’m a primary care physician. It costs me virtually nothing to get an A1C and a fasting blood sugar [test]. Even at random. So I’m going to take everybody. I’m going to test everybody, and I don’t care what their family history is, what their age is. What’s so wrong about that?

Om P. Ganda, MD: Yeah, the only other cost you can argue about is the A1C test. Blood glucose is part of the chemistry profile, right?

Peter Salgo, MD: Right.

Om P. Ganda, MD: I think even what we have just discussed, I think [for] people who have [an] even modest increase in the risk of diabetes, [it] is good to get an A1C. And actually you can get it from the same sample. So [there is nothing] more ... required.

Peter Salgo, MD: I guess all that I’m saying is, in this country at this time, pretty much everybody is at some risk for diabetes. You might as well check because it’s cheap.

Helena W. Rodbard, MD: Why not?

Peter Salgo, MD: Why not. So what about the new ADA [American Diabetes Association] and AACE [American Association of Clinical Endocrinologists] guidelines? Do they recommend that?

Helena W. Rodbard, MD: Well, they don’t really recommend you need universal screening. They can’t do that for obvious reasons.

Peter Salgo, MD: No, no, what’s so obvious, why not?

Helena W. Rodbard, MD: Well, they can’t recommend it because there is a dollar implication when you compare dollars and cents.

Peter Salgo, MD: But he just said it’s cheap.

James T. Kenney, RPh, MBA: Well, I think from the [insurance company’s] perspective, yeah, why wouldn’t you want to identify these patients? Because certainly if you have a patient with disease that’s not being treated, then they’re already on the road to complications, which are going to cost the health system money.

Om P. Ganda, MD: And in a practical way, if you add up all the risk factors that you talk about in the ADA or AACE…or any guideline, it will add up to about 60% of the people above the age of 40 who need screening.

Peter Salgo, MD: That’s my point.

Om P. Ganda, MD: So why not screen all the people at the right age group with the right ethnic background?