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Paying for Prevention –
Why, How, and When
The Case of Preventing Diabetes
Ronald T. Ackermann, MD, MPHIndiana University School of MedicineRegenstrief Institute for Healthcare
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Pre-Diabetes – • 65 million Americans
(30% of all adults)• Progression to diabetes
5 – 15% per year
Diabetes – The Tip of the Iceberg…Diabetes – • 21 million Americans
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Lifetime Risk of Diabetes by BMI
0%10%20%30%40%50%60%70%80%90%
White Female
White Male
Black Female
Black Male
Hispanic Female
Hispanic Male
<18.518.5 - 24.925 - 29.930 - 34.935+
Predicted lifetime prevalence of diabetes for 18 year old today; Narayan et al., 2007
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Escalating Costs of Diabetes
$205$241
$338
$0
$100
$200
$300
$400
Bil
lio
ns
$U
S
2007 2010 2020
Year
Projected Total Direct Medical Costs for Patients with Diabetes, Year 2007 $US (Billions); ADA 2008 (based on methods from Hogan, 2003)
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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?
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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
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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
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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 Can be Prevented!
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Diabetes Costs – With Primary Prevention
$205$241
$209
$338
$260
$0
$100
$200
$300
$400
Bil
lio
ns
$US
2007 2010 2020
Year
Projected
With DPP
Projected Total Direct Medical Costs for Patients with Diabetes, Year 2007 $US (Billions); ADA 2008
Costs for Diabetes $130 B lower over 13 years
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Population-based Diabetes Prevention
Coverage of fasting glucose tests for persons at risk
Pre-diabetes management
Earlier detection and management of T2DM
Tight CVDRF Control & Follow-up
Identify adults with diabetes risk factors (EHR; Claims)
Lower Diabetes & CVDRF Burden Lower PMPM cost; Improved outcomes
DPP Coverage Benefit
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Elements of Cost-Effective Diabetes Prevention
Evidence / goal Healthcare Community
Target adults with pre-diabetes X
Provide structured lifestyle program to achieve 5-7% weight loss X
Link to health plan / employer payment (physician initiated) X
Provide ongoing behavior support at least monthly X
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Partnered Approach for Prevention
Healthcare
Glucose testingRisk/benefit assessment (safe?)Prescriptive advice (role for meds?)Gateway to reimbursement
Formal Programs
CommunityPopulation Resources
EnvironmentEducation by Schools & Media Lower intensity programsRisk assessment opportunitiesReciprocal
InteractionsPersonnelExperienceFacilitiesContact
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DPP Coverage Benefit Structure
Patient
Primary Provider
Recognized Diabetes Prevention Program
Certified Instructor
Health Plan Coverage?
Diabetes
CVDRF Outcomes
CostsSponsoring Organization
ADA
↓
Community Partner
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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)
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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)
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Minimizing Program Costs
Cost Category Original DPP No IncentivesGroup Format
Group Format –
YMCA Instructor
Personnel $794 $794 $156 $131
Supplies $11 $11 $11 $11
Incentives $123 $10 $10 $10
Overhead $548 $548 $108 $91
Total $1,476 $1,363 $284 $243
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BUT CAN A CERTIFIED COMMUNITY VENDOR (THE YMCA) ACHIEVE 5% WEIGHT LOSS IN ADULTS WITH PRE-DIABETES?
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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
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DEPLOY Outcomes - % Weight Reduction
*p-values comparing Group DPP to Brief Advice
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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
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Questions?
Ronald T. Ackermann, MD, MPHIndiana University School of MedicineRegenstrief Institute for [email protected]
Thanks to CDC-RTI Economic Evaluation Workgroup and the DEPLOY Study Team