October 2010

Out on a Limb: Cold cuts

By, Jordana Bieze Foster, Editor

For centuries, the Greeks set the bar for the rest of the world to follow—in architecture, in literature, in medicine. Now they appear to be setting a new kind of example in health care. But we can only hope the rest of the world knows better than to follow their lead this time around.

On October 9, the Greek newspaper To Vima reported that the National Social Security Foundation (IKA) pension fund had announced it would no longer be covering therapeutic shoes for patients with diabetes. As if that wasn’t bad enough, the reason given for discontinuing coverage was downright shocking.

In a letter to a diabetes association, the IKA claimed that the use of therapeutic shoes does not prevent amputation but rather only delays it by one or two years. Therefore, they reasoned, it would be more cost-effective to skip the shoes and go straight to the amputation.

That’s right. Patients with diabetes should get amputations instead of shoes. Because it’s cheaper.

In the interest of full disclosure, I don’t speak Greek. I’ve seen the To Vima newspaper article as translated by a search engine, but I haven’t seen a translation of the original letter. It’s possible that we’re missing some important details about the IKA policy decision. Maybe they actually meant that they would cease covering therapeutic shoes in patients with ulcers that had not healed after, say, a year. One might be able to make an argument for the cost-effectiveness of amputation under those circumstances.

But if we take the To Vima reporting at face value, the IKA announcement is not only unbelievably harsh, it’s also based on logic that is just plain wrong.

A 2001 cost-utility analysis from Sweden calculated that prevention strategies – including appropriate footwear – would be cost-effective if they reduced the risk of foot ulcers and amputation by 25%. Dedicated foot care initiatives in multiple countries have been associated with published amputation rate reductions of up to 82%. Therapeutic shoes alone have been reported to decrease foot ulcer recurrence rates by 53%.

It’s possible that the Greeks were taking into account the elevated mortality rates that are typically seen in patients with diabetes following amputation. Once a patient dies, the costs associated with his or her health care go down in a hurry. But that doesn’t make it a desirable outcome.

Now that would make Hippocrates turn over in his grave. Do no harm, indeed.

I prefer to think that the IKA did actually have good intentions, and is less guilty of malice than of sheer ignorance. The country is bankrupt, after all. Clearly it isn’t run by people who are good with numbers.

The good news is that after three days of backlash, the general manager of IKA announced that the shoes would be covered after all. But as government entities in the U.S. work to reign in our own national health care expenditures, hopefully the Greeks’ misadventure will be seen as a cautionary example of how not to go about it.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.