Paying for Prevention –

Why, How, and When

The Case of Preventing Diabetes

Ronald T. Ackermann, MD, MPHIndiana University School of MedicineRegenstrief Institute for Healthcare

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

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

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)

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

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!

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

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

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

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

DPP Coverage Benefit Structure

Patient

Primary Provider

Recognized Diabetes Prevention Program

Certified Instructor

Health Plan Coverage?

Diabetes

CVDRF Outcomes

CostsSponsoring Organization

ADA

↓

Community Partner

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)

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

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, MPHIndiana University School of MedicineRegenstrief Institute for HealthcareRTACKERM@IUPUI.EDU

Thanks to CDC-RTI Economic Evaluation Workgroup and the DEPLOY Study Team