My son moved to California and is seeing a family doctor for his diabetes. Because of his insurance HMO, he is required to get a referral from his family doctor to see an endocrinologist. His doctor refuses to refer him to an endocrinologist saying he is perfectly qualified to treat his diabetes. My son always saw an endocrinologist when he lived with us in Alaska. His doctor put him on a drug called Lotensin, saying it would be good for his kidneys. I have never heard of giving a type 1 diabetic this drug and it worries me. What do you think about this?

In healthcare markets where HMO models predominate at the delivery system, it is important to have access to specialty care. It is true that many primary care physicians have the skills and expertise to provide good care for patients with diabetes. However, in most markets, patients with type 1 diabetes still see an endocrinologist. There are several key issues related to your son’s right to specialty care. First, is he having good results? If his blood sugars are not in good control, it makes it difficult to ethically withhold specialty care. If he is doing well, and he still wants to see an endocrinologist, he may have to chose another primary care physician who has a different philosophy regarding endocrine referral.

With regard to Lotensin, this medication is from a group of medications known as ACE inhibitors. ACE inhibitors are appropriate therapy for patients with type I diabetes who also have elevated albumin excretion in their urine or if their blood pressure exceeds 130/80. In the absence of these indications, it is controversial as to whether ACE inhibitors should be used. It is important to note that if patients do have diabetes involvement of their kidneys, ACE inhibitors have been shown to protect their kidneys from further disease progression.

JTL