Expert Blog

Diabetes Care 2014: We're Losing Ground

Irl B. Hirsch, MD

Recently I started a tradition of looking back over my last clinic day of the year and reflecting on our efforts to improve the care of patients with diabetes. Just about a year ago, considering my experiences of 2012, I ranted in print about our broken systems.1 Now, as I look back on my last clinic day of 2013, I find that not only has there been no improvement, we are in fact losing ground.

My detailed complaint, Diabetes Care Entering 2014: More Ranting, just appeared in the February 2014 issue of Diabetes Technology & Therapeutics. The publisher has kindly made the entire article available free online through the end of April. I want to share some highlights with colleagues here on

Startling price hikes for insulin: At pharmacies near our clinic in Seattle, the price for one vial of insulin glargine, for example, averages $206. All forms of insulin have gotten costlier. In April 2012, I was complaining about prices increasing about 120% over the preceding seven years. Now, just in the past 19 months we have seen an additional increase of more than 50%.

High cost affects treatment: I am now told by my primary care colleagues that some patients are not started on insulin because of cost. This is a first.

Back to insulins of the 1980s: On my last clinic of 2013, I saw a woman whose insurance company had dramatically raised her co-payment for insulin analogs and encouraged her to instead use less costly NPH and regular insulin. It made me realize that for patients who were diagnosed with their diabetes and for physicians who finished their training before the late 1990s and early 2000s, we need a massive education effort on how to use our insulins of the 1980s. In the past month, I’ve seen two patients on insulin pumps come in using regular insulin. Our education efforts will require us to re-learn how to use this longer-acting prandial insulin in pumps.

Inadequate coverage: On that last day, I also saw a woman who, despite repeated life-threatening episodes of hypoglycemia, has been denied coverage for a continuous glucose monitor that would minimize her risks. Just the week before, she had suffered a generalized seizure resulting in numerous bruises and hematomas. We will keep trying to get her a monitor, but I would not be surprised if she is another mortality statistic from hypoglycemia in 2014.

See the full article for further ranting about such issues as paperwork, illogical decisions, and unqualified evaluators. But now I would like to invite colleagues who are facing these and other challenges to weigh in.

What do you rant about? I welcome your thoughts on how to cope and perhaps how to create hope for a better end-of-year report 12 months from now.

Please add your comments below.

1. Hirsch IB. Healthcare reform in diabetes: more ranting about a broken system. Diabetes Technol Ther 2013;15:212–213.