I've received an email reply from Richard Kahn, Chief Scientific Officer of the American Diabetes Association, whose seemingly anti-diabetes-technology comments at a recent conference have created quite a storm.

He encouraged me to post his email, and thus I do so here, unabridged:

"I've looked at your web-site, and certainly part of the answer to your question is that your own biased and inflammatory reporting contributes greatly to the mis-perceptions surrounding my talk. For the record, the talk I gave was exactly as it was written. There were not "many asides" -- not even one, and I don't understand how ones "demeanor" influences matters when I read the talk verbatim. Also, what do you mean by a "cryptic" speech and "plain vanilla"? Don't those words seem contrary to the many quotes you provide and language you use that suggest otherwise?

Of note, you seem to have many quotes from individuals as well as your own reporting, but not one word on the actual content of the paper itself. What sentences do you find to be wrong (and why) ? Rather than serve to incite your viewers in a fashion unfair to me and the ADA, perhaps you should have a discussion on the actual ideas and concepts in the talk? It that asking too much?

Moreover, I don't think " everyone was stunned," since innumerable people who actually heard the talk, or read it, applauded my comments in subsequent written and verbal interaction. As for why some in the audience came away with a negative feeling, there are many possible reasons. Perhaps it would be best for you to ask them directly. Of course, in addition to getting their feelings and perceptions, it would be valuable to learn what exactly they disagreed with. After all, its the actual talk they had problems with, or so they say. Yes, you're welcome to post my comments. "

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Yesterday's post was directly reporting on conversations with audience members -- highly informed, industry-connected people who were quite upset over Kahn's speech. I had also printed out the full 15-page script of Dr. Kahn's talk, and pored over it myself.

As I was reading, I found myself questioning, whom is he speaking for? Here are some excerpts (highlights and asides added by me):

After a long introduction to the evolution of diabetes treatments, he says, on page 5:

"Although patients were now, in the '80s, routinely asking questions, and physicians could no longer get by easily without any discussion of treatment options and effects—our health care system was still structured to pay any cost incurred, regardless of whether the service was necessary, appropriate, or even if there were no robust studies showing clinical benefit."

Aren't patients still struggling to get the basics covered?


"In the late '80s, in diabetes care, self-monitoring of blood glucose was simply a given. That is, it was of virtually unquestioned benefit, although still not commonly done by most patients. And a similar benefit was bestowed to nearly every other office-based practice related to diabetes care. Tests, procedures, drugs—whatever got approved—was marketed as if there were no shortcomings, no patient who couldn't benefit, no limits or constraints to their use, and most important—everything was well worth the price—any price."

No limits on coverage? Has this been anyone's experience, ever?

On page 6:

"In a totally unconscious and unwitting confluence of circumstances that would feed on each other, patients wanted health care at any cost, clinicians were ready and eager to deliver therapy with virtually no constraints, industry couldn't deliver novel tools fast enough, and payers (particularly employers) had no choice but to pony up."

Then, in what appears to be an about-face, on page 7:

"Recent reports suggest that only about half of US adults or children receive care consistent with current recommendations. In other words, the technology, medications and information are all there—but they are not getting to the patient. We seem to have what we need, but putting it into routine practice seems to allude us."

So the technology IS necessary? And didn't he just imply that the problem is, patients are being showered with unnecessary and costly technology?

And on page 8:

"The '90s also gave birth to many other advances in technology without which we would have made little progress in controlling the ravages of the disease.... They have certainly saved lives, improved many more lives, and made diabetes manageable for millions of people. Yet in some instances, for example self-monitoring in type 2 patients on oral drugs, the technology was not preceded by any long-term, randomized controlled study showing benefit. Of note, for that technology, even now, we do not have robust proof that the technology works in such patients, yet Medicare is spending over 1 billion dollars to provide it."

Two questions: 1) What about the landmark DCCT study showing that tight glucose control, achieved in large part by using self-monitoring, does improve outcomes? Does this knowledge not apply at all to people with Type 2?, and 2) How many limbs and lives are lost every year to uncontrolled Type 2 diabetes because the patients were not aware of their high glucose levels?

Then, on page 10:

"Insulin delivery devices and more sophisticated glucose monitoring devices were introduced, but medicine, as I've just reviewed, could no longer embrace the simple construct of, 'if you make it, they will buy it.' Technology introduced in recent years and in the foreseeable future, undergoes much more scrutiny. The value proposition, cost-effectiveness, and most important, the need to prove real benefit are concepts that have become no less of concern than showing the technology actually works*."

"... For example, I believe the sale of insulin pumps or continuous glucose monitors would soar if there were a long-term, randomized—controlled trial showing that either of these technologies really do benefit people with diabetes, and are worth the added cost."

What do you think that means?

Further, on page 12:

"A technology that gets the 70% or so of people with diabetes who are not taking their medications as directed, to start taking their drugs like they should, would much more likely have greater benefit than another monitoring or insulin delivery device... And my bet is that another gadget that adds complexity will receive far more scrutiny, and have many more hoops to jump through, before any health plan or clinic approves its use."

Wow. Is he trying to scare us?

In conclusion, on page 15:

"All that I've said is certainly not meant to scare or criticize. We must not disparage technology, nor slight its contribution. We should, however, more fully appreciate that the nature of American medicine is changing. The years of unlimited spending and the ready acceptance of any technology that simply works* are drawing to a close."

*If the medical technology works, why wouldn't it be a priority for patient care??

Hence, my takeaway from Dr. Kahn's speech is that his words do not read like the words of a chief advocate for diabetic patients, but rather like a chief advocate for health insurance payers -- trying to drive down their own costs by denying support for new technology, in particular at the expense of Type 1 diabetics.

Are Kahn's sweeping comments, calling into question the value of all glucose monitors and insulin pumps, really in patients' best interest? I think not. This is my personal opinion after analyzing the text. I realize that others may agree or disagree. What's your take?

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