Health disparities limit access to diabetes technology

In this issue, Susan Weiner, MS, RDN, CDE, CDN, FAADE, talks with Diana L. Malkin-Washeim, PhD, MPH, RDN, CDE, who is director of the nutrition and diabetes program in the population health department at BronxCare Health System. The patients Malkin-Washeim works with have the highest poverty and diabetes rates in New York City.

What are the health statistics relevant to diabetes care in the South and Central Bronx, where you practice?

Malkin-Washeim: Bronx County has a population of 1.4 million people. According to the New York City Department of Health and Mental Hygiene’s 2015 Community Health Profiles report, 31% of adults in the Bronx have obesity, and 14% have diabetes. In the Highbridge and Concourse areas of the Bronx, 29% of adults have obesity, and 15% have diabetes. These two South and Central Bronx County communities serviced by BronxCare Health System have a higher combined prevalence of diabetes (15%) than the 7% reported for Manhattan, 10.6% reported for New York state and 12.3% reported for the United States. The South Bronx is the epicenter of severe poverty in New York City, where there is a lack of affordable housing as the primary reason for homelessness among households with children. It is conceivable to link severe poverty as a platform for chronic illnesses, hence putting individuals at risk for developing type 2 diabetes as well as microvascular and macrovascular complications. In addition, the 2015 Community Health Profiles reported that 31.5% of Bronx residents are impoverished, 13.9% of those younger than 65 years are without health insurance and 57.6% speak a language other than English at home.

What are some of the barriers to care that Bronx residents with diabetes face?

Malkin-Washeim: A multitude of barriers inhibit the delivery of diabetes self-management education in the South and Central Bronx, including psychosocial issues, such as depression, anxiety, isolation and schizophrenia; substance abuse; poor health literacy; lack of transportation; unemployment; inadequate housing; limited or nonexistent health insurance; insulin insecurity; food insecurity; insufficient coping skills; and health perceived as fair to poor. These factors are interrelated and lead to the persistent challenges of diabetes self-management education. For example, limited education or illiteracy leads to increased unemployment and decreased annual income that inhibits the purchase of nutrient-dense foods, basic household resources and necessary health care services.

Does lack of health insurance make it difficult to obtain diabetes technology for this population?

Malkin-Washeim: In New York, having managed Medicaid medical insurance or being health illiterate both complicate access to the newer technology on the diabetes market. For example, if a woman with type 1 diabetes has a high-risk pregnancy and does not have commercial or private insurance, she may be able to get an insulin pump; however, she can receive only a continuous glucose monitoring system, the Dexcom G5, not the G6 that requires no calibration of blood glucose with finger sticks. It is the same for our pediatric patients with type 1 diabetes — even if they are living in a shelter, are food insecure and have hypoglycemic unawareness, they can receive only the CGM.

Some patients with type 2 diabetes who use an insulin pump or multiple daily injections and check blood glucose four times per day may be eligible for Medicaid coverage for the Abbott Libre or the Dexcom G5 or G6. The rules change frequently, and health care providers need to stay on top of these by checking in with their representative from the company.

The newer insulin pumps, such as the Tandem t:slim with the new Basal-IQ, require the Dexcom G6 to benefit from the predictive low feature. However, depending on the insurance, the person will be able to access only half the technology, which is the insulin pump. Health illiteracy puts many patients at risk for reduced health outcomes when it is challenging to navigate the language of health insurance, technology companies and our health system.

How can diabetes educators help patients use the latest technology?

Malkin-Washeim: If the system is frustrating for health care providers, imagine how patients feel, especially those with English as a second language and with a fourth-grade education level who depend on suboptimal medical insurance to make life decisions.

It is our responsibility to help our patients reduce the barriers they face by understanding which health insurance plans cover what products with or without a prior authorization. We must keep close ties with our clinical and sales representatives from the many medical device and pharmaceutical companies — they can be an asset to how we manage our diabetes programs and our patients. We need to urge our pharmaceutical and medical device companies to have their materials in multiple languages — and not just on their website, because not everyone is technologically savvy enough to navigate websites for information. We also need to press upon insurance companies by either calling or writing letters of medical necessity for all of our patients who can benefit and who deserve all of the technology that private insurers have.

Technology access should be a right for all people with type 1 diabetes and not just for our clients with private insurance. Health care on all levels should be accessible for every person regardless of their insurance type. Technology should be a choice, whether someone wants to use that particular technology for diabetes self-management. However, when that choice is limited by type of health insurance, it becomes a health disparity.

• References:
• CDC. Adolescent and School Health: Health disparities. Available at: www.cdc.gov/healthyyouth/disparities/index.htm. Accessed May 21, 2019.
• Malkin-Washeim D. Electronic benefit transfer: Food choices, food insecurity, and type 2 diabetes (Doctoral dissertation). Retrieved from ProQuest Dissertations and Thesis. 2015;Publication No. 3714993.
• Malkin-Washeim D, et al. Multidisciplinary team visits offer unique approach in the Bronx. American Association of Diabetes Educators-In Practice. 2017;doi:10.1177/2325160316685608.
• Malkin-Washeim D, et al. Risk for type 2 diabetes among SNAP participants with prediabetes. J Soc Behav Health Sci. 2016;doi:10.5590/ JSBHS.2016.10.1.06.

• For more information:
• Diana L. Malkin-Washeim, PhD, MPH, RDN, CDE, is director of the nutrition and diabetes program in the population health department at BronxCare Health System in New York. She can be reached at dwasheim@bronxleb.org.
• Susan Weiner, MS, RDN, CDE, CDN, FAADE, is the 2015 AADE Diabetes Educator of the Year and author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com.

Disclosures: Malkin-Washeim reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.