Paying for Prevention –Why, How, and WhenThe Case of Preventing Diabetes Ronald T. Ackermann, MD, MPH Indiana University School of Medicine Regenstrief Institute for Healthcare
Diabetes – The Tip of the Iceberg… • Diabetes – • 21 million Americans • Pre-Diabetes – • 65 million Americans (30% of all adults) • Progression to diabetes 5 – 15% per year
Lifetime Risk of Diabetes by BMI Predicted lifetime prevalence of diabetes for 18 year old today; Narayan et al., 2007
Escalating Costs of Diabetes Projected Total Direct Medical Costs for Patients with Diabetes, Year 2007 $US (Billions); ADA 2008 (based on methods from Hogan, 2003)
Policy Goal Population-Level Diabetes Prevention! • How much can / should the healthcare system invest toward this goal? • In which persons will these resources have the biggest impact? • How should resources be distributed across different “at-risk” groups?
Obesity Programs that Work – Targeting the Highest Risk • Diabetes Prevention Program (DPP) • >3,000 overweight / obese adults with Pre-diabetes (IGT) • High short-term risk for diabetes, CVD, and costs • 3-arm randomized trial • Intensive Lifestyle Intervention • Metformin (Diabetes medication) • Placebo (Basic advice) • Outcomes • Prevention or delay of Diabetes • Costs and cost-effectiveness
DPP Lifestyle Intervention • 16 “core” one-on-one meetings ~1hr/week • Monthly lifestyle maintenance visits • Safe and Effective • 11 pounds (~5%) weight loss = 58% in diabetes • Improved control of other CVD risk factors • No major AE’s • Cost-effective - Health Payer: $1,100/QALY
Diabetes Can be Prevented! • People have pre-diabetes for 8-10 years before getting diabetes • Routine blood tests can identify pre-diabetes • Intensive interventions reduce diabetes development & reduce future costs • Cannot assume that lower intensity interventions with same goals will have the same results
Diabetes Costs – With Primary Prevention Costs for Diabetes $130 B lower over 13 years Projected Total Direct Medical Costs for Patients with Diabetes, Year 2007 $US (Billions); ADA 2008
Population-based Diabetes Prevention Identify adults with diabetes risk factors (EHR; Claims) Coverage of fasting glucose tests for persons at risk Pre-diabetes management Earlier detection and management of T2DM DPP Coverage Benefit Tight CVDRF Control & Follow-up Lower PMPM cost; Improved outcomes Lower Diabetes & CVDRF Burden
Partnered Approach for Prevention Community Healthcare Population Resources Environment Education by Schools & Media Lower intensity programs Risk assessment opportunities Reciprocal Interactions Personnel Experience Facilities Contact Formal Programs Glucose testing Risk/benefit assessment (safe?) Prescriptive advice (role for meds?) Gateway to reimbursement
DPP Coverage Benefit Structure ADA Diabetes CVDRF Outcomes Costs ↓ Recognized Diabetes Prevention Program Patient Certified Instructor Sponsoring Organization Primary Provider Community Partner Health Plan Coverage?
Community Linkage Partner – The YMCA? • 2,600 YMCAs in the U.S. • 42M U.S. families within 3 miles of a Y • Strong history of disseminating structured programs nationally (arthritis) • Operate to achieve cost recovery only • Policy to turn no person away for inability to pay for a program (financial assistance)
Group Delivery of DPP • Offers program to a group of 10 – 12 • Enhances social support and accountability • Lowers direct intervention costs by 50-85% • Allows cost-savings within 2 years of coverage for health plan that pays intervention fees (greater ROI if cost-sharing)
But can a Certified Community Vendor (The YMCA) Achieve 5% weight loss in Adults with Pre-Diabetes?
DEPLOY Study (NIH) • Community-based randomized trial • Test the feasibility and effectiveness of training YMCA employees to deliver a group-based version of the DPP lifestyle intervention in YMCA branch facilities
DEPLOY Outcomes - % Weight Reduction *p-values comparing Group DPP to Brief Advice
Bottom Line • DPP lifestyle programs… • Cut diabetes development in half • Are cost-saving when delivered efficiently in community settings • PMPM for Group DPP • Yr 1 - $21 • Yrs 2 to 13 - $11 • Time to ROI for payer <2 years • By 2020, U.S. healthcare system would manage 113M fewer member-months of adult diabetes
Questions? Ronald T. Ackermann, MD, MPH Indiana University School of Medicine Regenstrief Institute for Healthcare RTACKERM@IUPUI.EDU Thanks to CDC-RTI Economic Evaluation Workgroup and the DEPLOY Study Team