‘Baptism by fire:’ Managing diabetes during COVID-19 in Seattle
As COVID-19 spreads across the country, the greater Seattle area has been one of the hardest hit. As of March 20, there were 1,376 confirmed cases and 74 deaths in Washington, according to the state department of health.
On Friday, the federal government approved the state of Washington for a special health care status that could help officials and health care providers respond to the novel coronavirus. According to The Seattle Times, special status under Section 1135 of the Social Security Act will allow the state to waive regulations in order to provide more effective telemedicine and enroll people in Medicaid more quickly, as well as create new treatment facilities.
Irl B. Hirsch, MD, an endocrinologist and professor of medicine at the University of Washington School of Medicine in Seattle, spoke with Healio about how the COVID-19 outbreak is affecting the Seattle area, the problems that come with quickly converting from in-person to telemedicine visits, and how the changes are affecting people with diabetes.
How are you doing?
Hirsch: I’m OK, and I think part of the reason I am doing OK is I am slammed. I haven’t had the time to sit back and pontificate about how our world as we know it is changing. I’m literally at ground zero. This is really hitting us in Seattle. We are seeing people who are affected. We are getting hit hard, but we jumped on it pretty quickly.
There is a wonderful article in The New York Times, and I am still shaken by it, regarding the researchers at the University of Washington involved with the Seattle Flu Study, and how they went around the federal government to prove there was a COVID-19 outbreak in our area. I sometimes make jokes about how difficult the University of Washington institutional review board (IRB) is for clinical trials. Someday when the movie comes out about what happened here in Seattle, the University of Washington, the researchers here and the IRB here, they are going to be the heroes. This could have been a lot worse. They went around the federal government to show the world that we have a big problem.
How has your day-to-day routine changed, and what are you putting in place for patients?
Hirsch: Things are changing by the day here. For one, I’m wearing a sweatshirt and sweatpants.
But to be more serious — and I think this may be a silver lining — we have been wanting to utilize telemedicine and telehealth for years. In fact, before President Obama left office, the Kaiser Family Foundation projected that by 2020, 50% of all evaluation and management visits would be conducted virtually or via telemedicine. Of course, as of 2 or 3 weeks ago, that was not the case. That is because, at least where I live, there was zero reimbursement. Zero.
This new reality is pushing us all to make that change. We are learning via baptism by fire. We are inefficient. In my world right now, what has happened is we are doing all of our visits with telephone — which has had minimal, if any, reimbursement — with an EPIC template, which is extremely inefficient. But I’m doing it because that allows me to get the glucose downloads from the patients before the visits.
Last night, our institution gave us 24 hours to take training on how to use Zoom conferencing for visits. We use Zoom every day in our academic work, but you have to have a special certification to get a Zoom license to conduct telehealth visits where you actually see the patient. The reason for that is the face-to-face contact, which is good for what I do. This is what we were supposed to be doing all along, and I don’t want to get political about this, but I can’t help it. The last data I saw from Gallup, which is about a year old now, shows 14% of people aged 18 to 64 years do not have health insurance. How this will bear out over the next weeks and months, particularly for people with newly diagnosed diabetes, I can’t even predict. There are a lot of people without insurance who will not be able to afford their medical care, and in particular, their insulin.Our option up until now was for patients to get their insulin from Canada, but that option has disappeared. Although some patients may need to be switched to cheaper human insulin, the good news is that, even before this crisis, the insulin companies were changing their rules to make insulin more accessible and affordable.
What needs to change?
Hirsch: My biggest concern in the short term is that we only found out Tuesday of this week that Medicare is going to cover telemedicine visits. What we still do not know — at least, I don’t know — is will these visits count for our patients with diabetes on insulin pumps and continuous glucose monitors to continue using their technology? In the pump world, patients must be seen every 3 months. In the CGM world, its every 6 months. On top of that, all patients on devices are required to get an HbA1c measurement. Labs are open, but a lot of these people either cannot leave their house or don’t want to leave their house. If they are on a CGM, from my point of view, they should not need an HbA1c. I’ve been talking about this for years. All they need is their CGM data, their glycemic management indicator (GMI), and they should be good to go. But that is not the world we live in. We still live in an A1c-centric world.
The silver lining here is maybe this situation will force the people who make the decisions about who gets the technology and how it is obtained, once and for all, make the right one. I hope this forces us to fast forward and make the decisions that otherwise would take the bureaucrats 5 years to make. This is a bad situation, but there may be some good that comes out of it.
The “rules” are changing every day, and people are scared. What do fellow endocrinologists and clinicians — who are not yet seeing what the Seattle area is seeing — need to know?
Hirsch: The big thing is, it makes no sense to go into the clinic. You really can do this in your sweatpants.
The big challenge I have with these telehealth visits are my Medicare patients, especially those with type 1 diabetes. They have a hard time. Here is a very common scenario for me: I have their CGM download, with their Dexcom, typically, but I don’t have their insulin pump download. So, I don’t know their basal rates, and I can’t “see” that. I can’t “see” the insulin.
Many of these patients really struggle with these pump dose changes. They either don’t know how to find the doses on their pumps, or they forgot, or they have trouble seeing. I’m on the phone, trying to make changes with them, but this is something that, normally, the nurses would do with them in clinic. This is something I have been chastised for, in a very friendly way, by my nurses in the past, because typically, I would just make the adjustments for the patient, because it saves time. By making these adjustments in pump settings for the patient, even though I save a huge amount of time, I’m now paying the price for it, because these patients cannot do it on their own. I have to talk them through it, and now we have so many versions of different pumps out there. That is, right now, my biggest problem when I try to do these telemedicine visits.
Now, if I’m dealing with an Amazon millennial with type 1 or type 2 diabetes, and they’re in their 20s or 30s, these visits are fantastic. I get as much out of the diabetes part of it as I would in person. The big problem is, of course, I don’t have the blood pressure, I can’t do an exam, and until I get access to the video part, I can’t even look at the feet, let alone do a foot exam, and then there is the vascular exam. You can’t do any of it.
My hope is that this is short-term, and by doing what we are doing this way, a year from now, or even 6 months from now, this will make us better so we can do even more of our visits virtually. That is a big issue where I live in Seattle, since patients come from such far distances to see me. If I can see a patient once a year for a complete exam and management in the clinic, and do the rest of the visits virtually, I can see more patients and be more efficient, and I can “pick” my patients. For the patient with diabetes aged 75 years on a pump, even if CMS didn’t have the rules, I would likely want to see that person every 3 to 4 months in person. For the majority of well patients, I think this is going to really put us into an era where we were supposed to be 4 or 5 years ago.
What is your message for patients?
Hirsch: Not everyone is going to survive this. That is the scariest part. That said, what JDRF and the American Diabetes Association is saying is true: Someone with well-controlled diabetes is not at increased risk for a bad outcome vs. someone without diabetes. However, someone with poorly controlled diabetes, someone with poorly controlled diabetes and diabetic kidney disease, and other immunosuppressed patients, those are the highest-risk patients. You can’t do anything about your age, and if you’re age 75 years vs. age 25 years, your risk will be higher if you get the disease. My biggest advice to patients is don’t go to the gym, but if the weather is nice, still take your bike ride, continue to do your walks outside. So many of our patients have home exercise bikes or treadmills. With or without diabetes, patients who are well conditioned do better when they do get sick. – by Regina Schaffer
The New York Times. How delays in testing set back the U.S. coronavirus response. Available at: www.nytimes.com/2020/03/10/us/coronavirus-testing-delays.html. Accessed: March 20.
The Seattle Times. Coronavirus daily news updates, March 19. Available at: www.seattletimes.com/seattle-news/health/coronavirus-daily-news-updates-march-19-what-to-know-today-about-covid-19-in-the-seattle-area-washington-state-and-the-nation/. Accessed: March 20.
Disclosures: Hirsch reports he has received research support from Medtronic Diabetes and is a consultant for Abbott Diabetes Care, Bigfoot and Roche.