Posts Tagged ‘diabetes’

A Few Items To Ponder, Two Of Them Important

Wednesday, November 30th, 2022

Type 1 Diabetics get good news

As I have written before, Type 1 diabetes (T1D) is a horrific disease. It is a leading cause of stroke, heart disease, blindness, kidney disease and non-traumatic amputations. It also costs a lot to manage. The media has been full of stories of unfortunate people who have had to choose between taking insulin or food. The Inflation Reduction Act, passed in August, caps the cost of a vial of insulin at $35 for Medicare beneficiaries, but does nothing for diabetics not on Medicare. About 70% of the nation’s 1.9 million Type 1 diabetics are on Medicare.

Research has proven Type 1 diabetics contract the disease in three stages over time. According to a 2015 study on the presymptomatic stages of Type 1 diabetes:

Insights from prospective, longitudinal studies of individuals at risk for developing type 1 diabetes have demonstrated that the disease is a continuum that progresses sequentially at variable but predictable rates through distinct identifiable stages prior to the onset of symptoms. Stage 1 is defined as the presence of β-cell autoimmunity as evidenced by the presence of two or more islet autoantibodies with normoglycemia and is presymptomatic, stage 2 as the presence of β-cell autoimmunity with dysglycemia and is presymptomatic, and stage 3 as onset of symptomatic disease.

Type 1 diabetics go through two stages of disease development before full-blown diabetes appears in Stage 3. Imagine a platform diver. Stage 1 is climbing to the platform and standing at the edge. Stage 2 is lifting off and moving through the air. Stage 3 is hitting the water and getting very wet. Diabetics don’t know they have the disease until they hit the water. But what if they did, and what if the time in the air between the platform to the water could be extended, say by 25 months?

On 17 November, the FDA approved a biologic therapy that delays the onset of Stage 3 by about that much.

The monoclonal antibody teplizumab, which will be marketed under the brand name Tzield, from ProventionBio and Sanofi is given daily through intravenous infusion over two weeks. And it works. Patients who take it extend Stage 2 by a little more than two years.

But there’s a catch, two, in fact. First, PreventionBio announced last week it is pricing Tzield at $193,900, which is considerably higher than insurers anticipated. Second, how does a person know they’re in Stage 2 and, therefore, should be taking the drug? The answer is screening for autoantibodes that are markers for diabetes. This will also incur a cost. More about that below.

The question to be answered is will insurers cover the considerable cost for screening and drug infusion?

In 2014, the FDA approved Harvoni as treatment for Hepatitis C, which is the leading cause of liver failure. Hep C is a life-threatening disease. Harvoni cured it. Completely. Its maker, Gilead, priced the pill at $95,000 for a twelve-week course of treatment. At the time, I was a Director at a Boston HMO. We wrestled with the cost issue. In the end, because Harvoni cured what was a horrific and terrifically costly disease, we gladly decided to provide it for our members.

Tzieild is different. It does not cure diabetes. Rather, it delays its onset. The American Diabetes Association and the Juvenile Diabetes Research Foundation (JDRF) are ecstatic about the arrival of Tzield. They point out this is the first time a successful treatment for diabetes has appeared on the scene, although it’s not really a treatment. However, they’re concerned about the screening issue.

Aaron Kowalski, CEO of JDRF, says the main challenge in prescribing Tzield will be finding people who need it. The drug is approved for people who don’t have any symptoms of the disease and may not know they’re on the road to getting it.

“Screening becomes a really big issue, because what we know is, about 85% of type 1 diagnoses today are in families that don’t have a known family history,” Kowalski said. “Our goal is to do general population screening” with blood tests to look for markers of the disease.

It will be interesting to learn how insurers and health plans react to Tzield. According to the JDRF, 64,000 people a year are diagnosed with Type 1 diabetes. If every one of them received the drug the total cost would be about $12.5 billion. But if you were one of the 64,000, my guess is you’d happily stand in line for it. So would I.

Donald Trump and the Mar-A-Lago fiasco

By now, every sentient person in America knows ex-president Donald Trump dined last week with Nick Fuentes, the poster child for anti-Semitic white nationalism, and Kanye West, who now calls himself Ye and has also spouted anti-Semitic whinge. Afterwards, when social media lit up like the Rockefeller Center Christmas tree, Trump claimed he didn’t know Fuentes was going to be there; West just brought him along.

Putting aside the fact that Trump’s Secret Service detail would never in a month of Sundays allow just anyone to drop in to break bread with the big cheese without getting clearance from the big cheese himself, I’m more concerned with the response of the Republican Party’s leadership to this. Republicans who are likely to run for President, notably Mike Pence and Chris Christie, criticized their former leader, although it took them two or three days to do it. It took more than a week for anyone in Republican leadership to put their wet finger in the air and decide to say he shouldn’t have done it.

The stench wafting from the halls of Congress is remarkable, indeed.

A personal note

Starting tomorrow I shall be away from this, and any other, keyboard for a little bit.

Since I was eight years old, I have been an avid, competitive, pretty good, tennis player. I’ve calculated that in the intervening years I have hit somewhere around just under a million overhead smashes. That’s a lot of serves and put-aways. And they have taken their toll. So, at 7:00 AM tomorrow morning, a very good doctor (I hope) will be concentrating deeply (I hope) on the job of giving me a new shoulder. I’m told it will be a little painful for a while, but on the other side lies bliss, and more overheads.

I look forward to being back at the keyboard.

On Health, History And The Fine Art Of Fudging Data

Wednesday, August 10th, 2022

The cost of insulin, or, half a loaf is better than none

The Inflation Reduction Act (IRA), passed this past Sunday in the Senate and now sitting for certain passage in the House this week, will cap the cost of an insulin vial at $35 for Medicare beneficiaries with diabetes. However, for those not on Medicare, insulin costs will remain unchanged.

Of the 30 million Americans who have diabetes, more than 7 million of them require daily insulin. A Kaiser Family Foundation study released in July, 2022, found 3.3 million of the 7 million are Medicare beneficiaries  and documented the rise in insulin’s cost since 2007.

Aggregate out-of-pocket spending by people with Medicare Part D for insulin products quadrupled between 2007 to 2020, increasing from $236 million to $1.03 billion. The number of Medicare Part D enrollees using insulin doubled over these years, from 1.6 million to 3.3 million beneficiaries, which indicates that the increase in aggregate out-of-pocket spending was not solely a function of more Medicare beneficiaries using insulin.

The IRA is great news for the Medicare beneficiaries who make up nearly half of the population needing daily injections of insulin to live, but a provision in the original bill that would have capped the cost at $35 for all diabetics, not just those on Medicare, never made it to the final bill. Left out in the cold are the 3.7 million diabetics requiring insulin to keep living who are privately insured or not insured at all. That was an expense bridge too far for Republicans.

Will you permit a bit of cynicism here? Needing 60 votes to pass, 57 senators voted in favor of capping insulin at $35 per vial for all diabetics, 50 Democrats, seven Republicans.  Americans overwhelmingly support this as is shown in this Kaiser Family Foundation poll taken recently:

Eighty-nine percent consider this a priority, 53% a top priority. I suggest Republican leadership, never intending to allow this to pass, permitted those seven, standing for reelection this fall, to vote for the bill to give them cover in the upcoming election. Is that too cynical?

If that’s not bad enough, a study by Yale University researchers, published in Health Affairs, also in July, concluded that “Among Americans who use insulin, 14.1 percent reached catastrophic spending over the course of one year, representing almost 1.2 million people.” The researchers defined “catastrophic spending” as spending more than 40 percent of postsubsistence family income on insulin alone. Postsubsistence income is what’s left over after the cost of housing and food.

Nearly two-thirds of patients who experience catastrophic spending on insulin, about 792 thousand people, are Medicare beneficiaries. The IRA will help these people immensely. However, as it stands now it will do nothing to assist the non-Medicare diabetics who annually face catastrophic spending due to the cost of insulin. This group numbers about 408 thousand who need insulin just to go on living, and, yes, these are poor people with few resources.

Not to put too fine a point on it, but we should not forget that insulin isn’t the only medical resource diabetics use and need. There are also the syringes used to inject the stuff, not to mention the testing strips and glucose monitors that analyze the levels of blood glucose, which diabetics have to track religiously. Diabetes is an expensive disease, and insulin is only one part of the expense.

Every time I and others write about the cost and quality of health care in the US, it almost seems as if we’re all standing on the shore throwing strawberries at a battleship expecting some sort of damage. The Inflation Reduction Act contains the first significant health care move forward since the Affordable Care Act of 12 years ago. It’s progress at last, but so much more is needed.

A great historian and better American is now history himself

David McCullough has died. We have lost a giant.

McCullough had that special gift of telling stories of our past in ways that made us think we were there when they happened. He put us solidly in the shoes of the people he was writing about. For him, history is not about a was; it is about the is of the time. Like us, his subjects lived in a present, not a past. He never judged the choices made in the past; he just told the truth through stories meticulously researched and empathically written. That’s how he could win two Pulitzer Prizes, two National Book Awards and a Presidential Medal of Freedom.

I first met McCullough in the 1980s through his first book, The Johnstown Flood, published in 1968. I could not put it down. Read it through in one sitting. It was the start of his brilliant career, and its success gave him  hope he could actually devote himself to history and do well at it. But he never wrote for the money. What drove him was his love for and curiosity about understanding from whence we came.

In a 2018 interview for Boston Magazine with Thomas Stackpole, he was discussing his latest, and last, historical work, The Pioneers, about a group of New Englanders in the 19th century who picked themselves up, headed west,  settled Ohio, and courageously kept it an anti-slavery state. During the interview, he said:

There are an infinite number of benefits to history. It isn’t just that we learn about what happened and it isn’t just about politics and war. History is human. It’s about people. They have their problems and the shadow sides of their lives, just as we do, and they made mistakes, as we do. But they also have a different outlook that we need to understand. One of the most important qualities that history generates is empathy—to have the capacity to put yourself in the other person’s place, to put yourself, for example, in the place of these people who accomplished what they did despite sudden setbacks, deaths, blizzards, floods, earthquakes, epidemic disease. The second important thing is gratitude. Every day, we’re all enjoying freedoms and aspects of life that we never would have had if it weren’t for those who figure importantly in history.

Today’s Americans seem to think history begins about ten years ago. It is a modern day tragedy, and we own it.  Consequently, humanity keeps making the same mistakes over and over again, never learning from those who showed us where the land mines were lying, hidden underfoot. McCullough did that for 50 years. He leaves a large hole in our American universe.

Fudging data with style

Heading back to diabetes for a moment. You may recall the old adage, “Figures lie, and liars figure.” Well, this is not about that. The fudging I’m going to show has not a lie in it. What it does have is deception on a grand scale, and it comes from our CDC, which, usually, I greatly admire. But not this time.

As we’ve all learned throughout the COVID pandemic, the CDC tracks and reports data — a lot of it.

One of the things the CDC  reports about is Diabetes Mortality By State. It’s been doing it since 2005, and it’s in the last six years that we see, if we look, deception.

Here is how the CDC reported this data in 2015:

The redder things are, the worse they are, so this looks bad, and it is.  The scale above shows the distribution of the colors for the states, starting at 13.4 in Colorado and Nevada and ending at 32.4 in West Virginia. Those are deaths per 100,000 people.

Now, here is how the CDC reported diabetic mortality six years later in 2020:

In 2015 there were three dark red states, eight almost dark red states, and 20 almost almost dark red. But now we have only two dark red, three almost dark red, and those 20 semi dark states have turned to light tan. Wow! What an improvement.

One could be forgiven for going away happy….if one did not look at the actual numbers.

In 2015, Mississippi and West Virginia were the highest mortality states, 32.4 and 31.7 deaths per 100,000 people, respectively. Their numbers in 2020 soared about 30% to 41.0 and 43.1. The states with the lowest mortality in 2015, Nevada and Colorado (13.4 and 15.9), in 2020 are 18.0 and 24.2 deaths per 100,000. Wyoming now comes in with the second lowest mortality at 20.7.

But things look so much better. The distribution scale is different, but who looks at that?

The CDC has done something shameful; it has moved the goalposts and didn’t tell anyone. In reality, diabetic mortality has gotten much worse over the last six years, but unless you dug deep, not only would you not know that, you’d think there was an actual big improvement.

This is another reason why the insulin provision in the Inflation Reduction Act is a big deal.

 

 

Gavin Newsome And Insulin: An Example Of What Leadership Looks Like

Monday, July 11th, 2022

Having just returned from a wonderful and pretty much off the grid trip to America’s southwest, I discover some pennies have dropped.

Roe is now in Wooly Mammoth land; New Yorkers, and soon many others, will now find it easier to pack a bit of heat; the EPA (and, presumably a lot of other governmental agencies) is no longer going to be able to regulate what its been regulating for the last 50 years; the January 6 Select Committee continues to unearth the sewer-living sludge of the Trump Big Lie; another mass shooting happened, the 309th of 2022, at a July 4th parade no less (only in America); the charlatan Boris Johnson is officially on the way out; and, this past Friday morning, a 41-year-old Shinzo Abe hater, assassinated the former prime minister of Japan at a campaign stop.  Abe’s killer made the gun himself, because it’s nearly impossible to procure a gun in Japan—Japan, the country with the lowest rate of handgun violence in the developed world.

With all of that, I’m thinking Chicken Little was right, and the sky is about to fall any minute now and land on my bucolic, Berkshire back deck.

Nonetheless, today’s Letter is not about any of that sky is falling stuff. We’ll get to all of it later. No, today’s Letter is about a momentous, and non-COVID, medical development that happened while I was gone, when California’s Governor Gavin Newsome announced the state would commit $100 million to making its own insulin for California’s diabetics.

Diabetes kills one American every three minutes. It affects children and adults, both genders, every race and ethnic group and leaves a vicious imprint on those who suffer from it and on those who love them. It is a leading cause of blindness, heart disease, stroke, kidney failure and non-traumatic amputations.

According to a nationwide survey by the Juvenile Diabetes Foundation International, 75 percent of Americans do not know how deadly the disease is, and 38 percent believe that either insulin cures diabetes, makes it harmless, or they don’t know what effect it has.

In 2017, the nation’s total direct medical cost due to diabetes was $237 billion. Average medical expenses for diabetics were 2.3 times higher than for non-diabetics.

Based on information found on death certificates, diabetes was the 7th leading cause of death in the United States in 2015, with 79,535 death certificates listing it as the underlying cause of death, and 252,806 listing diabetes as an underlying or contributing cause of death. However, diabetes is underreported as a cause of death; studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on their death certificates and only 10% to 15% had it listed as the underlying cause of death. An example of best practice would be, “Death caused by infection contracted from hemodialysis due to kidney failure, a complication of the patient’s diabetes.”

At 10.2%, California ranks 31st among US states in the percent of adults with diabetes*. There are more than 3.2 million of them in California, the great preponderance being Type 2 diabetics.

There are close to 35 million Type 2 diabetics in the nation. T2Ds still make some insulin, just not enough. For most, lifestyle changes will improve their health, sometimes to the point where they will no longer have to inject insulin. Some will become insulin dependent, and without it, those people will face life-changing complications.

There is a rarer, but much worse, kind of diabetes. That would be Type 1, also known as Juvenile Diabetes. There are 1.6 million T1Ds in the country. According to the CDC, of all the states, California has the lowest rate of juvenile, Type 1 diabetes. T1Ds make no insulin and will die quickly if they don’t get it. Type 1 diabetes can happen at any time in life, but is vastly more prevalent in young people. My daughter came down with Type 1 diabetes at 21 years of age; my late wife Marilyn, at 12. You wouldn’t be wrong to think I’m invested in this topic.

I have argued strenuously in the past (here and here) that the country should guarantee insulin to T1Ds, regardless of their ability to pay for it. It is quite literally a matter of life and death. I can think of no other disease in which, if a patient is deprived of their medicine, death will result within a couple of weeks. But that’s the world T1Ds inhabit.

Government has been kicking the diabetes can down the road for generations. It’s been playing patty-cake with it since then Speaker of the House Newt Gingrich made it a core cause of his 25 years ago, in 1997. This has resulted in two things: government investing more money in looking for a cure—unsuccessfully, and skyrocketing insulin costs for patients. As President Biden noted correctly in his State of the Union address, insulin costs its manufacturers less than $10 per vial to make. Yet, depending on their circumstances, patients are paying anywhere from $300 to $800 for that same vial.  Reprehensible doesn’t begin to describe this situation.

While it is true that most of the ~50% of Americans who have employer sponsored insurance (ESI) only pay co-pays of $30 to $50 for a month’s supply of insulin, nearly all of them pay the full, painful cost until they meet their pharmacy deductible requirements. And one thing more to keep in mind: before Congress Passed the Affordable Care Act in 2010, the 1.9 million diabetics without ESI found their diabetes treated as a pre-existing condition. They paid full freight every time. Fast forwarding to now, some T1Ds are dying, because they either ration, or even go without, their insulin. Why? Because they can’t afford the price.

In my 2018 series on this topic, What Price Life?, I concluded:

So, here’s a question: Should anyone in the United States who requires a daily drug just to stay alive be forced to come up with the money to pay for it? Or, should that be a government-sponsored, health care right, as in the Declaration Of Independence’s “self-evident…unalienable right…to life.”

Gavin Newsome has answered that question. He has had enough. In taking matters into his own hands, he is extending a lifeline to California’s diabetics who struggle with the cost of staying alive. His move will both help those diabetics and provide good paying jobs to the people hired to build the manufacturing process and supply chain. He promises to provide California’s insulin to its diabetic citizens at “a little above cost.”

I don’t know what you think of Gavin Newsome. He certainly has his critics. But on this critical, life and death issue, he is showing a brand of leadership seldom, if ever, seen in that bought-and-paid-for vacuum of mediocrity we call the United States Senate.

_______________________

*It may not surprise you to learn the states with the highest incidence of diabetes, primarily Type 2, are the states whose citizens have the worst health care problems in the country. They are Red states, and are led by Senator Joe Manchin’s West Virginia at 15.7%, followed by Louisiana, Mississippi and Alabama. Mississippi. Always Mississippi. Pounded so low it has to look up to tie its shoes.

What Price Life?

Thursday, November 29th, 2018

Part One

“Insulin is my gift to mankind” – Frederick Banting

A Quick Quiz

Question 1: Name a chronic disease requiring medication, which, if not taken every day, guarantees death within two weeks.
Answer: Type 1 Diabetes.

Question 2: Name the medication.
Answer: Insulin.

Question 3: What is the monthly cost of insulin for a Type 1 diabetic?
Answer: As we shall see, that depends.

Question 4: If Type 1 diabetics cannot afford the cost of insulin, without which they will surely die, what should they do?
Answer: This is happening at this moment, and people are dying.  In these two blog posts we’ll examine why and what can be done about it. But we need to first posit some truths about diabetes, and then describe how, in 1922, Canadian doctor Frederick Banting made the ground-breaking discovery that allowed Type 1 diabetics, for the first time in history, to live.

Ten Fast Facts

  1. Insulin is a hormone made by the pancreas that allows the body to use sugar (glucose) from carbohydrates in the food we eat for energy or to store glucose for future use. Insulin helps keeps blood sugar levels from getting too high (hyperglycemia) or too low (hypoglycemia). Type 1 diabetics, T1Ds, can no longer produce insulin. They have none of it. Although older adults can also contract Type 1 diabetes, it usually strikes children and young adults. Without insulin, whether old or young, they die.
  2. There are about 1.3 million T1Ds in the U.S. They comprise one half of one percent of the population. Currently, there is no cure for any of them. Without insulin, they will die.
  3. There are about 29 million Type 2 diabetics. T2Ds still make some insulin. In most, lifestyle changes will improve their health, sometimes to the point where they will no longer require insulin or any other medical prescriptions. Some will become insulin-dependent, and without it, they face life-changing complications.
  4. Diabetic Retinopathy is the leading cause of blindness.
  5. Diabetes is the leading cause of non-traumatic amputation.
  6. Diabetes is a leading cause of heart attack and stroke.
  7. Diabetes is the leading cause of kidney failure.
  8. Complications from diabetes sometimes cause workplace injuries and often exacerbate the severity and length of recovery.
  9. In 2017, the nation’s total direct medical costs due to diabetes were $237 billion. Average medical expenses for diabetics were 2.3 times higher than for non-diabetics. The extent to which diabetes added to workers’ compensation medical costs is unknown.
  10. Based on information found on death certificates, diabetes was the 7th leading cause of death in the United States in 2015, with 79,535 death certificates listing it as the underlying cause of death, and 252,806 listing diabetes as an underlying or contributing cause of death. However, diabetes is underreported as a cause of death; studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on the death certificate and only 10% to 15% had it listed as the underlying cause of death. An example of best practice would be, “Death caused by infection contracted from hemodialysis due to kidney failure, a complication of the patient’s diabetes.”

Banting and Insulin

Image result for photo of frederick banting

Frederick Banting is perhaps Canada’s greatest hero. Born in 1891, he graduated medical school with a surgical degree in 1915 and found himself in a French trench by the end of 1917. In December of that year, he was wounded during the Battle of Cambrai, the first great tank battle in history. He remained on the battlefield for 16 hours tending to other wounded soldiers until he had to be ordered to the rear to have his own wounds treated. For this action he won the British Military Cross, akin to America’s Silver Star. After returning to Canada, he continued his studies and, in 1920, secured a part time teaching post at Western Ontario University. While there, he began studying insulin Why? Serendipity. Someone had asked him to give a talk on the workings of the pancreas.

Banting became interested – and then obsessed – with trying to come up with a way to get insulin to people who couldn’t make any of their own. In November 1921, he hit on the idea of extracting insulin from fetal pancreases of cows and pigs. He discussed the approach with J. R. R. MacLeod, Professor of Physiology at the University of Toronto. MacLeod thought Banting’s idea was doomed to failure, but he allowed him to use his lab facilities while he was on a golfing holiday in Scotland. He also loaned him two assistants, Dr. Charles Best and biochemist James Collip. Collip devised a method to purify the insulin Banting and Best obtained from the fetal pancreases.

To MacLeod’s surprise, Banting’s procedure worked, and in 1922 Banting and Best successfully treated the daughter of US Secretary of State Charles Evans Hughes.

In 1923, one year later, Banting, at the age of 32, won the Nobel Prize, which, to his disgust, he had to share with MacLeod. To this day, Frederick Banting is the youngest person ever to win the Prize in Physiology or Medicine.

His discovery could have made Banting mind-numbingly rich, but he would have none of that. Along with Best and Collip, Banting patented his method and then the three of them sold the patent to the University of Toronto for the princely sum of $3.00. When asked why he didn’t cash in on his discovery, Banting said, “Insulin is my gift to mankind.” With Banting’s blessing, the University licensed insulin’s manufacturing to drug companies, royalty free. If drug companies didn’t have to pay royalties, Banting thought they would keep the price of insulin low.

And they did. For decades.

But patents expire, and capitalism being what it is, people get greedy, and greed is why we have no generic, low-cost insulin today and why, over the past 20 years, insulin prices have risen anywhere from 800% to 1,157%, depending on the variety and brand. It’s why, lacking health insurance, some Type 1 diabetics have recently been driven to ration their precious insulin. Some of them have died.

More about all that in Part Two.

 

 

 

Annals of Compensability: These Boots Ain’t Made for Walking…

Friday, November 16th, 2012

John Pearson was diagnosed in his mid-20s with diabetes and was insulin dependent. About fifteen years after the diagnosis, he was working for an Arkansas temporary placement agency, Worksource, which sent him to a steel fabricator. His temporary employer gave him a pair of steel toe boots and assigned him the task of covering warm steel bundles with blankets. The job required a lot of rapid walking across a large field, as the bundles emerged from the plant at odd intervals. In the course of the day he experienced discomfort in his left foot and at the end of the day he found a blister on his left great toe. The next day he requested a wider pair of boots, but none were available. The employer suggested he buy them, but he could not afford to do so before being paid – and payday was still a couple weeks away.
Two weeks later Pearson was diagnosed with “diabetic neuropathy and cellulitis.” Worksource sent him to another doctor, who diagnosed a diabetic ulcer and cellulitis and placed him on light duty, restricting his standing and walking. (The court is silent on how long Pearson continued to work at the steel fabricator.) Ultimately, surgery was performed on the toe, which fortunately did not require amputation, and Pearson was able to begin working again, albeit with (temporary) restrictions. Pearson took a job in a Waffle House, where he was able to resume full time work. In the meantime, he was faced with lost wages and formidable medical bills.
Proving Compensability
Pearson filed a workers comp claim, which at first was accepted and then denied on appeal to the Arkansas Workers Compensation Commission. The denial was based upon an interpretation of state law:

(4)(A) “Compensable injury” means:
(i) An accidental injury causing internal or external physical harm to the body
or accidental injury to prosthetic appliances, including eyeglasses, contact lenses, or
hearing aids, arising out of and in the course of employment and which requires
medical services or results in disability or death. An injury is “accidental” only if it
is caused by a specific incident and is identifiable by time and place of occurrence;
(ii) An injury causing internal or external physical harm to the body and arising
out of and in the course of employment if it is not caused by a specific incident or is
not identifiable by time and place of occurrence, if the injury is:
(a) Caused by rapid repetitive motion.
[Arkansas Code Annotated section 11-9-102(4)(A) (Supp. 2011)]

The Arkansas Court of Appeals agreed with the commission that the injury did not meet first criteria: there was no specific incident identifiable by time and place. However, the Court found that the injury was caused by “rapid repetitive motion,” applying a two-pronged test that is stunning in its obviousness: did injury involve “repetition” and did it involve “rapidity”?
The “repetitive” part involved walking itself: Pearson walked up and down the field in tight boots, watching for the steel bundles as they emerged from the plant. The rapid part involved his walking briskly to protect the bundles as they appeared. He walked from bundle to bundle, as fast as he could, performing the job as instructed. In doing so, the boots rubbed his toe continuously over the course of the day, resulting in a blister. For most people, a blister is no big deal. For a diabetic, it could lead directly to amputation.
Lessons for management?
It is difficult to draw conclusions from this unusual case. Because Pearson was a temporary employee, the steel company had no awareness of his diabetes and no reason to be aware of it: he was able to perform the work as assigned. Theoretically, they could have done better on Pearson’s request for wider boots, but they had no reason to anticipate a serious problem beyond a bit of discomfort. Pearson himself was probably unaware of the risks involved in wearing the tight boots. He obviously was feeling pressure to earn money and probably thought the discomfort, while painful, was not a serious matter.
Perhaps the most important aspect of this case is Pearson himself: despite a life-altering health problem, he is strongly motivated to work. In the few months described in the court narrative, he tries hard to do what he’s supposed to do and he keeps working as best he can. Given comfortable footwear, Pearson will do just fine.

In Harm’s Way: A Non-Compensable Fall

Monday, November 28th, 2011

Geoffrey Hampton worked as a laborer for Intech Contracting LLC. Hampton, an insulin dependent diabetic, was working with a crew on September 9, 2009, repairing a bridge in Muhlenberg KY. Hampton suddenly uttered a profanity and walked to the edge of the bridge. He climbed over a 4 foot barrier and fell 60 feet, suffering permanent injuries.
Hampton has no memory of the incident. His co-workers testified that he had been complaining about not feeling well; that he had taken a snack of sweets to adjust his blood sugar; and that the fall did not appear to be an act of suicide.
Hampton was certainly “in the course and scope” of employment, but the question for the courts was whether his injuries arose “out of” employment. The Appeals Court found that his idiopathic condition – diabetes – was the likely cause of his actions and that his extensive injuries did not arise “out of” employment. As a result, Hampton was unable to collect workers comp.
It’s important to note that Hampton’s employer took specific steps on that fateful evening to remove Hampton from harm’s way:
– When he requested time for a break to adjust his blood sugar, they immediately consented.
[NOTE: Hampton had inadvertently left his insulin at the hotel room.]
– When Hampton complained about not feeling well toward the end of the shift, he was told to sit in the truck. He left the truck and walked toward the bridge rail on his own.
Not All Risk is Work-Related
The court noted that Hampton’s diabetes was not under control, which certainly raises the issue as to whether it was safe for him to perform this kind of work; if the employer had awareness of the medical condition, they should have required a note from Hampton’s doctor that it was safe for him to perform the essential job duties.
The court implies that there were circumstances where an injury might have been compensable: for example, if Hampton had been working near the edge of the bridge and had experienced a black out due to hypoglycemia, he would likely have been eligible for comp benefits. However, if it could be proven that the black out was the result of his own negligence in attending to his illness, perhaps the claim would still have been denied.
But Hampton was sitting in a truck, safe and secure, with no unusual risks or exposures. He was clearly out of harm’s way. There is no way of knowing why he did what he did, but it is clear that work had nothing to do with it. When he went over the rail of the Muhlenberg bridge, he gave no thought to the workers comp safety net that usually covers his every working moment. The findings of the court are both harsh and fair. For Geoffrey Hampton, the fateful date of 9/09/09 will resonate every moment of his diminished life.

Fresh Health Wonk Review & assorted news briefs

Thursday, April 15th, 2010

New Health Wonk Review – David Harlow of Health Blawg has posted an entertaining and informative Tax Day edition: Health Wonk Review: Block That Metaphor. Grab your coffee and dig in.
Diabetes prevention – At GoozNews, Merrill Goozner writes about the cost-effectiveness of diabetes prevention programs. Employers take note. We’ve frequently talked about the effect of co-morbidities such as diabetes and obesity on comp claims. Any progress on the prevention front would be good news for employers – both for the workers comp costs, and also for overall employee health and productivity.
Handy new toolCompPharmaPedia, a glossary of terms commonly used in the comp pharmacy business, published by CompPharma LLC, a consortium of workers comp PBMs. Not sure what a PBM is? Look it up!
Fleet safety – At the MEMIC Safety Blog, Randy Klatt posts about how GPS as a safety tool for fleet safety. “You can instantly see where all your trucks, vans, or cars are located and their current speeds… More efficient responses will also mean less temptation for drivers to exceed speed limits, especially since they know their movements can be seen. For those who have hours-of-service restrictions, GPS can be used to ensure accurate reporting and log keeping.”
Trainer killed by elephant – It’s been a tough time for animal trainers. A few weeks ago, a trainer was killed by a whale at a Florida”s SeaWorld, and last week, elephant handler Andrew Anderton was killed by Dumbo, the elephant that he trained and lived with for 15 years. The death is under investigation by OSHA, but was thought to be an accident after the elephant had a run in with sparks from an electrical wire. Animal-related occupational fatalities are more common than many might realize. Over a 6-year study period in the 1990s, the Department of Labor logged 350 animal-related fatalities.
Bullying – teen bullying has been much in the news of late, but unfortunately, this is not a phenomena that people outgrow. At Strategic HR Lawyer, Diane Pfadenhauer talks about workplace bullying.
Time lapse – At Comp Time, Roberto Ceniceros offers his nomination for strange claim of the month. OK, and while we’re on the theme of “strange,” we nominate the case of Copenhagen workers who went on strike in protest after an unusual work benefit was rescinded. You have to wonder what the safety record had been like.
10 ways to trigger a lawsuit – At HR Daily Advisor, Attorney Barbara Meister Cummins offers her picks for the 10 most lawsuit-attracting lines she hears from managers, part 1 and part 2. We’d add one that my colleague wrote about recently: “Don’t report that, you’ll screw up the safety bonus.”
Scary medical story of the week – If you think getting a computer virus in email program is bad, just wait until the hackers turn their sights to implantable medial devices. According to the MassDevice blog, hackers have already hijacked a patient support website for epileptics, MRI machines and electronic medical records. The post talks about these incidents and discusses the need for heightened security for devices with life-sustaining functions.
Scam alert – The National Association of Insurance Commissioners (NAIC) to consumers: Beware of health insurance scams.