Starting patients on insulin is not easy. Patients have to be counseled, educated, introduced to self-monitoring, and need to be seen more frequently till they are comfortable and have achieved their treatment goals.
For this, in many countries, there are dedicated billing codes – some of which can be rather attractive. As a case in point, in Germany, billing codes for starting patients with type 2 diabetes on insulin, have resulted in Germany perhaps being the world leader in the use of insulin in patients with T2D.
As we now enter the era of increasingly effective anti-obesity medications, resulting in two-digit weight loss, there will be a growing number of T2D patients, who will eventually need to be taken off their insulin.
This again, is not as simple as it sounds. Many T2D patients are on rather high doses of various types of insulin and will need to be gradually tapered off. During the time of active weight loss, insulin doses will need to be adjusted, both to avoid hypoglycemic episodes but also to ensure that the HbA1c targets are maintained.
This is extra work for doctors (and their staff) and will need to be accounted for.
Thus, it may be reasonable to ask whether it is time to introduce billing codes for stopping insulin, given the large number of patients who are currently on it but will need to come off as they experience significant weight loss.
We have already seen such situations in patients undergoing bariatric surgery, but there, due to the rather rapid improvement in glycemic control, we can often simply hold the insulin following surgery.
With the more gradual weight loss seen with anti-obesity medications, this process will take longer and needs to be closely monitored.
In jurisdiction where there are no special billing codes for starting insulin, this may not be an issue.
However, in jurisdictions, where such billings provide an incentive to doctors to start patients on insulin, we may need to create new billing codes to incentivise docs to take their patients off insulin as effective anti-obesity medications become more widely available.