When I first saw her, she was about 60 years old, and she was not well. She had not had health insurance for some time, and she had not seen a doctor. She was chronically tired, losing weight, and had frequent urination that interfered with her sleep. Her hemoglobin A1c was 12.1, triglycerides 457, LDL cholesterol was 150, and her blood pressure was 162/102. She was in great danger. It was not because she did not care about her health, it was because she could not afford healthcare and did not know about other resource that could have helped her.
She was very attentive as we discussed her problem. She understood the need to take her medications regularly and within a few days she was already feeling better. Within a couple of months, she had achieved optimal medical therapy (OMT). The top number on her pressure was under 130 and she was on an ACE inhibitor. Her LDL cholesterol was under 100 on atorvastatin. Her hemoglobin A1c was under 8 on metformin, she had never smoked, and she was taking aspirin. She was very excited about her accomplishments and feeling better again.
The practice I was in did not have a population health tool, and so when she stopped coming to her appointments, I did not know. She had a good understanding of the importance of regular care, but she lost her insurance again and she thought that meant she could not get care. She did not contact us and I did not know she was gone. Months passed. When I saw her again, she was not even close to being on optimal medical therapy. Even worse, she had a very large diabetic foot ulcer. She had been on hyperbaric oxygen chamber treatment and wound care at one of the local hospitals. That course of treatment cost someone $60,000.
For patients with chronic illnesses like diabetes, a population health computer tool identifies patients who are in your practice but have never been seen, have not had a visit within 6 months, or a test within a specific window of time. It identifies patients who are not at goal for their pressure, sugar, or cholesterol. It is invaluable in making certain that patients receive the right care, in the right setting, at the right time.
Because disadvantaged patients like this without insurance do not get the care they need, they develop horrendous complications like foot ulcer, which is in part due to microvascular disease. Disease to the large arteries in the leg is only part of the story. Microvascular disease is also a critical factor in diabetic damage to the eyes, kidneys, and heart. Optimal medical therapy for type 2 diabetes improves microvascular function. Patients on OMT for their type 2 diabetes have one third as many amputations, one third as many go blind, one sixth as many go on dialysis, and one fourth as many have heart attacks.
Disadvantaged, poor, and minority patients tend to have these problems much more often than the rest of us. Optimal medical therapy is not widely available even to those who can afford it. Because the disadvantaged can not get care early, they develop very expensive complications that we will pay for. We cover everyone if their kidneys fail and they need dialysis. We don’t provide primary care visits and the thirty dollars worth of generic medication that would avoid these catastrophes. It is a systems problem. That is part of the reason Europeans live longer for half the money. They focus on primary care and everyone has access. A population health tool and access to care are an essential elements of the new system. That would have served this patient much better and saved us all a lot of money.