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In 1999, two additional initiatives were added to Ontario's ...

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    In 1999, two additional initiatives were added to Ontario's ... In 1999, two additional initiatives were added to Ontario's ... Document Transcript

    • Canadian Diabetes Association Submission to the The Honourable Greg Sorbara Minister of Finance 2005 B UDGET C ONSULTATION February 2005 Canadian Diabetes Association Suite 1400 – 522 University Avenue Toronto Ontario M5G 2R5 Phone: (416) 363-0177 Fax: 416 408-7117 Web: www.diabetes.ca
    • An Enhanced Ontario Diabetes Strategy: T AKING THE L EAD IN D IABETES P REVENTION , M ANAGEMENT & R ESEARCH ! Diabetes is a chronic disease that cannot be cured, only prevented or managed. It has now reached epidemic proportions in Ontario, in Canada and around the world. Today, 706,500 Ontarians, or 7.5% live with diabetes1 and an estimated 300,000 Ontarians do not know that they have diabetes. Being overweight, inactive and over 40 increases your risk of type 2 diabetes. As the number of baby- boomers in Ontario reach retirement, the prevalence of diabetes will jump significantly in the province. Recent academic research estimates a 76.5% increase in the numbers living with diabetes by 2016.2 Of greater concern however is the proportion of children and adolescents who are overweight. The proportion in Ontario has tripled in the past 30 years, and the evidence clearly indicates that overweight children tend to become overweight adults therefore at increased risk of developing type 2 diabetes in their lifetime. Both type 1 and type 2 diabetes can lead to serious, long-term and costly complications, including heart disease, stroke, kidney disease, blindness, and amputation. Additionally, infectious diseases such as SARS, influenza, and pneumonia affect people living with a chronic disease such as diabetes, more virulently than others. But, there is some good news! ♦ Active living and healthy eating have been strongly linked to prevention or delay of the development of type 2 diabetes. ♦ Outcomes for those living with type 1 or type 2 diabetes can be improved by early diagnosis and prompt, aggressive treatment. ♦ Good diabetes management and tight control of blood pressure and glucose levels can help delay or prevent costly complications of diabetes. Population health approaches and healthy living strategies emphasizing healthier lifestyles and good nutrition for all Canadians will contribute to the prevention of many chronic diseases including type 2 diabetes. However, these prevention strategies will not address the needs and challenges of Ontarians already living with type 1 or type 2 diabetes. A comprehensive, integrated, dedicated and multi-sectoral strategy to support people in the effective management of their diabetes is also needed in Ontario. The economic & social costs of diabetes All Ontarians ultimately pay the cost of diabetes and its costly complications when people do not have the programs or support needed to manage their diabetes appropriately. The annual personal cost for medications and supplies to manage diabetes is five times greater for those Ontarians living with diabetes than for those without the disease. Research by the Ontario Ministry of Health and Long-Term Care estimates the direct cost of providing healthcare services to care for people with complications related to their diabetes at approximately $1 billion each year. Direct costs only include physician services, hospitalization, and medications covered under the Ontario Drug Benefit Plan. Indirect costs of rehabilitation after amputation or blindness, post-hospitalization care, or diabetes education, for example, would increase dramatically the cost of diabetes and complications in Ontario. 1 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Canadian Diabetes Association 2003 2 Projection of Prevalence & Cost of Diabetes in Canada: 2000-2016, Canadian Journal of Diabetes, June 2004 2
    • In 2003, people with diabetes comprised 6% of Ontario’s population, yet they accounted for: • 32% of heart attacks • 43% of heart failure cases • 30% of strokes • 51% of new kidney dialysis patients • 70% of amputations 3 These are costly complications not only for government, but also for the individual and their family. The personal toll is so great that the Honourable George Smitherman, Ontario’s Minister of Health and Long-Term Care was moved to state, “Diabetes is a personal health tragedy for those afflicted, creating enormous disability and depriving too many Ontarians of a full and productive life.” 4 Research in Ontario An important component to diabetes prevention, management, education and a potential cure, is research. Strong research initiatives in Ontario in particular have brought forward advances in diabetes care and saved lives, improved the quality of life, and as well, saved money for our healthcare system. In 2004 the Canadian Diabetes Association invested over $5.7 million dollars in research funding on projects aimed at preventing type 2 diabetes, managing type 1 or type 2 diabetes and at preventing or delaying the costly complications associated with diabetes. Last year alone over 20 research programs in Ontario were funded directly by the Association. Some examples of this excellent research activity includes work in the following areas: DNA vaccination against autoimmune diabetes; genetic determinants of diabetes complications in Aboriginal Canadians; specialty care for diabetes: determinants of meal tolerance in type 2 diabetes; fetal macrosomia and adolescent obesity; and many more investigator driven research projects. Unfortunately, too many viable diabetes research proposals remain at the proposal stage, unable to proceed due to lack of funding. The Canadian Diabetes Association encourages the government of Ontario to become a leading partner in funding this essential research in Ontario’s universities, institutes and hospitals. Our mutual objective is to help Ontarians avoid type 2 diabetes as well as to better manage their type 1 or type 2 diabetes and thereby avoid costly complications. Ultimately our objective remains find cures for all diabetes. Previous government action to tackle diabetes The Ontario government announced an Ontario Diabetes Strategy in 1992. It included key initiatives such as: - The Northern Diabetes Health Network - Improving access to programs and services for seniors and Aboriginal people with diabetes - A Diabetes Complication Prevention Strategy - Evaluation to assess the impact of diabetes, the effectiveness of diabetes programs and the cost in relation to health benefits 3 ICES Practice Atlas: Diabetes in Ontario, June 2003 4 Health Minister George Smitherman in a speech to the Empire Club, Toronto, 8 April 2004 3
    • These programs increased access to diabetes education and care for Ontarians living with diabetes, and the Canadian Diabetes Association continues to support their expansion. In 1995, the government’s Diabetes Strategy (Taking Charge: A New Approach to Preventing Diabetes Complications) introduced a five-year approach to reducing the complications of diabetes with specific targets for reducing nephropathy, neuropathy and retinopathy. As part of this strategy 33 new or expanded basic diabetes education programs, were put in place in southern Ontario in 1998. This built on the earlier establishment of 37 diabetes education programs in Northern Ontario. In the ensuing years, these programs benefited from increased funding, most recently in this fiscal year. In 1999, two additional initiatives were added to Ontario's Diabetes Strategy: - The paediatric diabetes initiative - Development of a primary prevention framework for Type 2 diabetes In 2003, the Deputy Minister of Health and Long-Term Care “appointed a Task Group for the secondary prevention of Diabetes Mellitus to provide advice regarding ways in which the Province can maximize outcomes of patients diagnosed with diabetes".5 As part of its mandate, this Task Group undertook a review, analysis and evaluation of diabetes care, education, management and treatment including medications, equipment and supplies currently being provided for the management of diabetes, identifying gaps and positioning an integrated approach to the issue. The Task Group submitted its final report with recommendations to the Deputy Minister in the autumn of 2004. The Ontario government showed leadership in appointing this Task Group. Funding and policy support to implement the Task Group's recommendations will be crucial if the trends of exponential growth in the healthcare costs associated with diabetes and its complications are to be slowed, and in the long-term reversed in Ontario. The Canadian Diabetes Association strongly urges the government to ensure the needs of Ontarians living with diabetes are met by enhancing the Ontario Diabetes Strategy. The recommendations of the Task Group may provide a map showing the steps that should be taken in the short, medium and long-term to ensure optimal results for both the government and for those living with diabetes in Ontario. Until the recommendations of the Task Group are released, the Canadian Diabetes Association strongly urges the government to expand the existing Ontario Monitoring for Health program as a first step towards meeting the very real needs of Ontarians living with diabetes. Monitoring for Health The Ontario Monitoring for Health program is designed to help Ontarians of any age, who use insulin (type 1, type 2 or gestational diabetes), pay for their test strips, lancets and blood glucose monitors. The Canadian Diabetes Association administers this program on behalf of the Ontario Ministry of Health and Long-Term Care. Currently this program helps approximately 3,000 low income Ontarians. Every year over 1,000 new claimants begin on this program to receive assistance for these supplies. In addition, thousands of people apply but do not qualify because their diabetes is controlled by oral medication. To qualify, applicants must be an Ontario resident with a valid healthcare card, injecting insulin and receiving no other financial coverage for the items being claimed. The Monitoring for Health program reimburses up to 65% for the cost of blood testing strips and lancets up to $500 each year. Once every five years the program may reimburse an individual up to 65% for a blood glucose meter (maximum $75) and if 5 Letter to the Canadian Diabetes Association from George Smitherman, Minister of Health and Long-Term Care, August 2004. 4
    • visually impaired the participant may be eligible for up to 65% for the cost of a talking blood glucose meter to a maximum reimbursement of $300. Self-monitoring of blood glucose (SMBG) is an essential part of daily diabetes management for all people using insulin or oral antihyperglycemic agents. Evidence-based clinical practice guidelines used by Ontario physicians recommend that people with type 1 diabetes should test their blood glucose a minimum of 3 times per day.6 Each blood glucose test strip costs approximately $1 – an average cost of $1,095 in just one year. People living with type 2 diabetes should test their blood at least once a day, however most will also follow an individualized testing schedule that depends on the glycemic control and type of therapy (insulin or oral anti-hyperglycemic agents) prescribed by their doctor. In many situations, more frequent testing may be required to provide both the diabetes patient and the physician with the information needed to make behavioural or treatment adjustments required to achieve desired blood glucose levels.7 Monitoring for Health: limitations of current criteria The current Monitoring for Health program does not serve Ontarians living with diabetes as well as it could or should. The program's criteria, including eligibility, maximum reimbursement levels, and the selection of items covered, limits the number of Ontarians who can be helped. Only Ontarians living with type 1diabetes using insulin are eligible under the current criteria. Insulin is a life-sustaining therapy for Ontarians living with type 1diabetes. There is no question that this program assists them with the management of this disease 24 hours a day, 7 days a week. However, type 1diabetes comprises 10% of diagnosed diabetes in Ontario. Ninety percent of Ontarians living with diabetes have type 2 diabetes and take oral medication so are ineligible for any support from Monitoring for Health. Their physicians may prescribe people with type 2 diabetes oral medications, however in some cases, some may also be prescribed insulin. The costs associated with managing type 2 diabetes may be slightly lower than those to manage type 1 diabetes, but the individual is still personally paying a minimum of $365 a year just for test strips. A person with type 2 diabetes must also pay for lancets, blood glucose meters, and ketone strips for example. These items will cost an individual approximately $1,000 each year. The Monitoring for Health program reimburses up to a maximum of $500 each year, an amount that covers less than 50% of the estimated annual cost paid by an individual with either type 1 or type 2 diabetes to monitor their blood glucose levels. Over 26% of program participants are young people who would be just entering the workforce. An additional 23% of participants are early retirees between 55 and 65 who may no longer be working with employers who provide benefit plans due to layoffs or other work disruptions. Just over 12% of participants are youths and 35% of participants are in mid life. While any financial assistance is welcome by people living with diabetes, this program was designed to assist those Ontarians working at minimum wage or people living below the low income cut off as defined by Statistics Canada. Research clearly shows that Ontarians living with diabetes in lower income groups or in the north, had greater numbers of hospitalizations and emergency department visits for their diabetes than those with diabetes in higher income groups.8 For these Ontarians, the gap between the amount of the reimbursement and the real cost for their diabetes supplies is very high. These Ontarians often confront the stark choice between paying for food and rent or being able to manage their blood glucose as recommended 6 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Canadian Diabetes Association 2003 7 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Canadian Diabetes Association 2003 8 ICES, Diabetes in Ontario, June 2003, p. 2.23. 5
    • by physicians to avoid the serious complications that result in a visit to the emergency department or a stay in hospital. An individual with diabetes is more susceptible to complications from infections than the overall population. Added to that is the fact that having a simple cold for example can dramatically affect an individuals blood glucose control during a cold or other illness. These health challenges coupled with the financial limitations individuals face when purchasing supplies can dramatically impact rates of hospitalization for individuals with diabetes, and may be impacting the wait-lists for hospitalization faced by all Ontarians. Research also confirms that Ontarians living with diabetes are 11 times more likely to be admitted to hospital for congestive heart failure, and will stay in hospital beds longer than others living without this chronic disease. The evidence also shows that lower income Ontarians with diabetes use emergency departments and require hospitalization more often than other Ontarians with or without diabetes.9 Lastly, research indicates that tight control of blood glucose levels may help individuals lower their risk of complications from diabetes. Eighty percent of people with diabetes will die from heart disease or stroke. Ontarians living with diabetes are three to four times more likely to have a cardiac admission into hospital than those without diabetes. Forty percent will develop debilitating complications. Yet, there is solid evidence showing the growth of end stage renal disease is reduced by effective preventive interventions including blood pressure reduction and tight blood glucose control.10 A further limitation to the Monitoring for Health program is the selection of items the program will cover. Self-monitoring blood glucose supplies (test strips, lancets and monitors) are only a part of the comprehensive care package needed by people living with diabetes. Insulin dependant people with diabetes also need needles and syringes. Others are prescribed an insulin pump by their doctor, and need not only the insulin pump but also its associated supplies to manage their diabetes. Today an insulin pump costs just over $6,000 in Canada and pump supplies (infusion sets) range from $250- $300 per month. Currently no Ontario government program covers the purchase of an insulin pump. Private insurance coverage of the pump and supplies does exist but is not widespread. Access to sufficient, safe and nutritious foods is also a critical component of recommended diabetes care and management. However, for the majority of those eligible for the Monitoring for Health program, healthy food choices such as fruit and vegetables are often limited by low-income, geography or both. Evidence from other jurisdictions indicates that the provision of a small healthy food allowance improves health outcomes for people with diabetes by helping them make healthier food choices. Monitoring for Health: proposed expansion The Monitoring for Health program is delivered today by the Canadian Diabetes Association on behalf of the government for $878,000 a year. Expansion to meet the needs of all Ontarians living with diabetes who do not have access to insurance or financial coverage would require an investment from the province of: $7.5 million Expansion to enhance reimbursement limits to cover the actual costs and to expand coverage to include needles, syringes, and healthy food allowances. $7 million Expansion to provide insulin pumps and supplies to Ontarians with diabetes where medically appropriate. $85.5 million Expansion to include people with type 2 diabetes, including those using oral medications as well as insulin. Our ask: 9 ICES, Diabetes in Ontario, June 2003, p. 2.23. 10 ICES, Diabetes in Ontario, June 2003, p. 8.166. 6
    • The Canadian Diabetes Association asks that the members of the Ontario Standing Committee on Finance and Economic Affairs recommend in their final pre-budget report that the government of Ontario: 1. Demonstrate leadership not only in the prevention of type 2 diabetes, but also in the prevention of the serious complications of both type 1 and type 2 diabetes by enhancing the Ontario Diabetes Strategy and providing the resources necessary to ensure success implementation of the strategy. 2. As a first step, invest $100 million dollars to expand the Monitoring for Health criteria to include Ontarians living with both type 1 and type 2 diabetes. This will not only help them to manage their diabetes and prevent costly complications such as heart attack, stroke, kidney failure, amputations and blindness, but will also help contain the escalating healthcare costs associated with diabetes and its complications. Conclusion: The Canadian Diabetes Association believes that the enhancement of the existing Ontario Monitoring for Health program would be a positive first step. We recognize that tackling diabetes in Ontario will require a comprehensive, integrated, dedicated, multi-sectoral diabetes strategy that is fully resourced and supported during implementation. We also understand that the government will need to stage the full implementation over a period of time. However, we urge the government to move forward as soon as possible because the direct costs associated with diabetes in Ontario are projected to be more than $2 billion in 2005.11 By 2016, predicted direct healthcare costs to treat patients with diabetes in Ontario will increase by 78% to an estimated cost of $3.56 billion.12 It is highly likely that the indirect costs of diabetes to Ontario’s GDP will increase at a similar rate. Ontarians are faced with a straightforward challenge. With diabetes, we can pay now….or pay much more later! Attending to diabetes prevention, management and research today will pay significant dividends over time when fewer Ontarians are diagnosed with type 2 diabetes, and those diagnosed with type 1 and type 2 are living healthier, more productive lives. 11 Projection of Prevalence & Cost of Diabetes in Canada: 2000 - 2016. Canadian Journal of Diabetes, June 2004 12 Projection of Prevalence & Cost of Diabetes in Canada: 2000 - 2016. Canadian Journal of Diabetes, June 2004 7