For a while now, diabetes has been at epidemic proportions in this country, with nearly 24 million Americans currently suffering from the disease. The great majority have Type-2 diabetes, the kind that is linked to obesity and physical inactivity and is responsible for 90-95% of all cases in people over 40. The costs associated with this epidemic are also enormous: $218 billion each year in medical expenses and lost productivity. In fact, about 10 percent of all U.S. health care spending and a whopping one-third of Medicare dollars is spent on people with diabetes.
The epidemic shows no signs of abating. In the next 25 years, the number of cases is expected to double. According to a report on obesity released last month by the Trust for America’s Health, “Since 1995, diabetes rates have doubled in eight states. Then, only four states had diabetes rates above 6 percent. Now, 43 states have diabetes rates over 7 percent and 32 have rates above 8 percent.
Finally, according to the Robert Wood Johnson Foundation, as a result of the U.S. having the highest rate of obesity among all developed countries, we now have the highest rate in the world of hospitalization of diabetes patients.
The only glimmer of hope in this epidemic is that for a while now there has been incontrovertible evidence that relatively inexpensive community-level prevention efforts can really pay off. This evidence includes results of a national comparative effectiveness trial that included 27 centers with over 3,000 participants, all at high risk of contracting diabetes. The trial, funded by the National Institutes of Health back in 1999, compared how effective three interventions were in preventing the onset of diabetes in these high-risk individuals: 1) basic advice that you might get at the doctor’s office once a year or twice a year, 2) diabetes medication to lower blood sugar levels and 3) an intensive lifestyle intervention. It was the intensive lifestyle intervention that worked the best.
Ron Ackermann, associate professor at Indiana University School of Medicine and a principal investigator of what is now known as the Diabetes Prevention Program (DPP) described the lifestyle arm of the investigation at a conference last July sponsored by the non-partisan Alliance for Health Reform.
“It was a one-on-one coaching intervention. That’s important to recognize. The goal was not 40 pounds of weight loss or 50 pounds of weight loss…It was seven-percent of body weight, which amounted to about 13-14 pounds on average.”
“It’s important to recognize that in the DPP, one did not need to lose 50 pounds to be successful in preventing diabetes. Many people think boy, weight loss, yes it’s not going to happen in the real world. It’s too hard. People won’t do it.”
Ackermann says that only half of the people in the trial achieved the goal of just seven-percent weight loss but on the whole, some 58-percent of diabetes cases were prevented by the intervention. “Just one kilogram or two pounds of weight loss reduces the risk of diabetes by 16-percent or about a sixth,” says Ackermann, adding that it’s important to note that smaller changes still bring results and that “complete success is not essential.” In seniors, the intervention was even more successful; 71-percent of those older than 65 managed to prevent or significantly delay the onset of diabetes.
He adds that if DPP were offered to 100 pre-diabetics at an average age of 50 for three years, 15 new cases of Type II diabetes would be prevented along with 162 missed work days. Add in the savings from not needing blood pressure or cholesterol pills in 11 people, and Ackermann says the DPP would save $91,400 in health care costs.
The problem was that the original Diabetes Prevention Program was not cheap to run. In 2008 dollars it would cost about $1800-$1900 per person for just the first year alone. The 3-year government-funded trial took place at multiple academic campuses and was staffed by master-level dieticians and physiatrists with a lot of specialized training.
As exciting as these results were, the intervention was unrealistic in its original form. It was important to design a program that could be accessible—and affordable—to the nearly 75 million American adults with “pre-diabetes” who have risk factors such as higher than normal levels of blood sugar, obesity, hypertension and/or a family history of disease. Diabetes is sometimes referred to as a “gateway” disease—meaning that it often leads to still more chronic—and costly—health problems like cardiovascular and kidney disease and arthritis, among others.
With this in mind, Ackermann and colleagues at Indiana University began a four-year demonstration effort (funded by the Centers for Disease Control) that would determine if the DPP could be scaled back cost-wise but still retain the promising prevention results. This time, instead of one-on-one counseling, groups of 10 or so pre-diabetic adults were offered 16 “core sessions” that included counseling on nutrition and exercise and multiple follow-up visits. Instead of health care professionals at academic medical centers, the demonstration program would depend on “wellness instructors” at the local YMCA. According to Ackermann, the cost of this intervention was about one-eighth that of the original trial—and it proved equally successful.
The YMCA, says Ackermann, could potentially reach at-risk people at 2,700 sites in 10,000 communities across the United States. Many of these people at highest risk of diabetes are drawn from low-income minority populations. So the question still remained: Who would pay for the program?
Prevention is one of the key tenets of the Patient Protection and Affordable Care Act. One arm of the legislation includes increased funding for mammograms, colonoscopies and other screening programs that qualify as “preventive” strategies. But these clinical interventions—aimed at early detection and then early (but sometimes inappropriate) treatment of disease—are a very different kettle of fish from community-based prevention programs like the DPP. Clinical interventions are performed by hospitals and doctors and are readily covered by third-party payers—private insurers, Medicare, Medicaid, and the Veteran’s Administration. Community-based prevention efforts occur outside of traditional medical settings, employ community health workers and don’t make any money for providers. For financing, they usually depend on shorter-term government or private foundation funding that is always at risk of running out.
According to Jeffrey Levi, executive director of the Trust for America’s Health, a key distinction between clinical preventive interventions and community-based efforts that focus on behavioral changes like physical activity, nutrition and smoking cessation, is that payers still aren’t convinced they will save money by covering them. And if they do, it’s not clear how long it will take for them to see the financial rewards.
Steven Woolf , who practices family medicine and is director of the Virginia Commonwealth University’s Center for Human Needs says this prejudice against community prevention efforts doesn’t make sense:
“So if I were to talk to you about a new imaging device, a new antibiotic, a new cancer therapy, you would not ask me does it save money. We don’t talk about saving money when we go to the grocery store to buy our groceries. We don’t expect to get up to the cash register and get money handed back to us.
“We do talk about saving money at the grocery store by getting better value on our dollar. So what we really ought to be thinking about in health policy, whether its prevention or treatment, is are we getting the most health benefit per dollar spent?”
Levi says that based on studies by health economists at the Urban Institute and the New York Academy of Medicine, evidence-backed, community based interventions like DPP do provide significant health benefit per dollar spent; “Indeed, the bottom line…is that if we invested $10 per person per year, within five years, we’d be saving $16 billion annually in these chronic disease costs that we are talking about. That’s a $5.60 return on investment for every dollar invested in these types of programs.”
So far, the federal government has invested about $200 million in the Diabetes Prevention Program. Lynne Vaughan, Senior Vice President and Chief Innovation Officer at the YMCA would like to see more of this funding to help scale the program up further and for the CDC to get involved in making sure future sites have standardized programs and well-trained staff. “The Urban Institute has said that making this program available nationwide with organizations like the Y, we can save $190 billion over 10 years,” says Vaughan. “In order to be able to do this, we need to be able to scale the DPP, which means that we’re going to need $80 million a year and we need this from the mandatory prevention funds that are already there.”
Vaughan was referring to the ACA’s Prevention Fund which—barring cuts during the next budget negotiations—is set to provide communities around the country with nearly $18 billion over the next 10 years to invest in proven prevention efforts for problems like childhood obesity, smoking and diabetes. (Not surprisingly, in yet another attempt to gut the health reform law, the House voted in April to kill the Prevention and Public Health Fund. Republican leaders called the initiative a “slush fund” that they claim will spend money on initiatives like new signs identifying bike lanes and funding for family planning centers that perform abortions. The House vote came just moments after the White House said President Obama would veto the bill if it were presented for his signature.)
Meanwhile, representatives from Novo Nordisk, one of world’s largest diabetes drug makers, and advocates for diabetes patients went to Capitol Hill just days before the debt ceiling agreement was signed to try and convince Congress to preserve the Prevention Fund and provide additional funding for the Diabetes Prevention Program.
The Prevention fund remains intact for FY2012, but the issue is still not settled. Levi, for one, believes that depending on government funding for the program is ultimately a losing strategy. The NIH and CDC have been key players for over a decade in the quest to provide evidence that the Diabetes Prevention Program is feasible on a larger scale. But Levi says now “it’s time for the insurance system to be supporting it and not scarce discretionary dollars.”
UnitedHealth has been the first insurer to commit. The company is providing coverage for its members at several of the 500 DPP program sites that have been set up in partnership with the YMCA in 23 states.
Why is United agreeing to pay for this prevention initiative that, realistically, may not realize health care cost savings for a decade or so? “I think at United Health Group and payers across the country, what we are beginning to see [is] an adoption of the philosophy that we pay for evidence-based care,” Deneen Vojta, Senior Vice President of the UnitedHealth Center for Health Reform and Modernization, told the Alliance for Health Reform conference last July.
Levi adds that “I think there are beginning to be discussions with CMS along these same lines,” although, he adds, there are still hold-outs in the agency.
Whatever the case, the Diabetes Prevention Program is a good model for the federal government’s future role in developing prevention efforts that demonstrate effectiveness and cost-savings while taking place outside the typical clinical setting. This model begins with initial NIH funding of a randomized, controlled study of a promising intervention to demonstrate effectiveness. Once the evidence is there, the agency, along with the CDC can get involved with funding a larger-scale pilot project to prove that the intervention can work in the “real world.” To fund preventive efforts just like this the ACA created the Innovation Center at CMS and appropriated $10 billion for the agency to spend on testing a wide range of new programs.
This level of government funding is important because in our current medico-economic model, drug companies and hospitals have little incentive to invest in community-based prevention. For example, hospitals that in the past tried to run diabetes prevention programs have proven ill-suited for the task. In 2006, the New York Times revealed that three out of four “boot camps” for diabetics that were set up at non-profit hospitals in the city (centers where patients were taught to test their own blood sugar, given nutrition and exercise counseling and careful monitoring) had recently been shut down. “They did not shut down because they had failed their patients,” according to the Times. “They closed because they had failed to make money. They were victims of the byzantine world of American health care, in which the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications.”
Achieving greater third-party insurance coverage for the DPP would be an important step—and precedent—for other community-level initiatives that will eventually offer evidence-based benefits in curbing disease and cutting spending on similar high-cost public health problems. These include pediatric asthma and HIV/AIDS; conditions that become far more expensive and devastating problems once patients get sick enough to end up in emergency rooms and hospitals.