The Challenges of Diabetes Prevention Programs

Dennis P. Scanlon, PhD: We talked earlier about payers and the need for evidence. This was a big decision for CMS (the Centers for Medicare & Medicaid Services) to decide that they were going to go ahead and pay for this. It is not a decision that has not been uncontroversial. Any thoughts? Will other payers follow?

Kenneth Snow, MD, MBA: It obviously is a huge decision. Any decision by CMS, whatever cost there is, has to be multiplied by millions, and so this becomes a very expensive type of project very quickly. But, clearly, the data was highly suggestive that this would be a wise thing to do—that in the overall scheme, not only would it obviously lead to better care and better health outcomes (the best way to treat diabetes is to prevent it from developing in the first place), but also, in the long term, this would be a financial success.

One of the advantages that CMS has is that folks, once they’re on Medicare, stick with Medicare until the day they pass away. For payers in the commercial space, clearly this was a decision that was looked at quite extensively. Some payers have already made decisions regarding continuing coverage or providing coverage similar to CMS (my company is among those that have). Not everybody, yet, has. And some will be looking at the type of data that comes out in a real-world, real-life experience, to see if the results that are hoped for are actually achieved.

Neal Kaufman, MD: I think another way to recognize this transformation over the last 10 years is to look at what the Office of Personnel Management (OPM) has done for federal employees. OPM sets the standards for health plans (Aetna, and all the large plans, as well as a number of smaller plans) in terms of what the benefit package is. And over the last few years, they’ve been very much more specific on what you need to do for prevention.

This year, for the first time, in the letter that goes out to all plans and describes to them what they need to do, they specifically call out the Diabetes Prevention Program (DPP), as well as other things for people with diabetes, as a very high priority for them as a federal employer with 9 or 10 million beneficiaries, or members, or employees. That often sets the standard because the plans will want to meet federal requirements so they can maintain federal programs. That also means they offer them for other patients. That’s another watershed event that’s occurred over the last couple of years.

Robert Gabbay, MD, PhD, FACP: The other thing, I think, highlights back to the YMCA study. That study provided not only the evidence that this could work in a community setting (which I think was important to take, as we said, from a very structured environment to a less resource-intensive approach, although certainly structured program), but also, what convinced CMS, was the cost savings that was demonstrated in that study. And so, now it’s no longer a theoretical, “Will it save money?” They were able to demonstrate that it did. And that, in essence, was exactly what CMS (the Centers for Medicare & Medicaid Services, The Innovation Center) was set up to do—to be able to do pilot studies that show cost savings or high value, and then spread that more broadly. I think this is, in a sense, one of the better examples of how CMMI (The Innovation Center) has been successful in driving that.

Dennis P. Scanlon, PhD: Estimating a return on investment. Let’s talk a little bit more about prevention. Mary Ann, as a diabetes educator, certainly you work with patients that are already diagnosed. But tell us a little bit about prevention and the role for educators and others in working with patients when talking about prediabetes and risk factors.

Mary Ann Hodorowicz, RDN, MBA, CDE: I’m glad you asked that, Dr. Scanlon, because it’s been frustrating for diabetes educators all across the country to get referrals from physicians, like on this panel, for diabetes self-management education. And yet, the patients being sent to us have prediabetes and they don’t qualify, maybe, for the coverage of prediabetes because the payer is now paying. Yet, we’re getting those people with prediabetes. Now that CMS is going to pay, and Aetna, and different companies, diabetes educators feel it’s been mandated from heaven. We’re in a perfect role to include that in our clinical expertise.

The American Association of Diabetes Educators is now training the DPP lifestyle coaches. They have a recognized training program to train the coaches for the DPP, and they’re focusing on the diabetes educator and locations that already have a self-management program. It’s an easy fit to include prevention with an existing self-management program run by diabetes educators. It’s a perfect marriage.

Neal Kaufman, MD: I’d like to comment on something that might be slightly controversial. To me, when a person’s blood sugar is fasting, whether it’s 98 and they don’t have prediabetes, 110 and they do, 130 and they have diabetes, isn’t that important? If they’re overweight and sedentary, they have risk factors for diabetes and other chronic conditions. They have high cholesterol, high blood pressure, arthritis, a range of different conditions, and we need to help them to improve their life’s trajectory. We need to help them so that they don’t add a new chronic condition every 3 to 5 years (as many people do), and help them manage their multiple chronic conditions if they have them. So, yes, it makes sense for the DPP to focus on people with prediabetes, but lifestyle intervention is the first prescription for persons with type 2 diabetes if they are overweight and sedentary.

A glucocentric requirement of eligibility for a program that we know helps people lose weight, become more active, and improve these other outcomes is a little too restrictive. I really think we should be thinking about individuals at risk for multiple chronic conditions and how to help them have a trajectory so they can have the health they need for the life they want (not necessarily change from prediabetes to diabetes, which they probably don’t even know they have). Nine out of 10 people with prediabetes don’t know that they have it, so it’s both practical and theoretical.

Kenneth Snow, MD, MBA: Because these programs will be out there and there will be data available, it also allows payers or anybody who has access to the data to be able to look beyond just glucose benefit or the diabetes-related benefit. But there are other benefits, as well, that are associated with obesity or with excess weight—joint issues or back issues, things that are clearly not glucocentric but are still related to the same population and have a significant deleterious effect.

Neal Kaufman, MD: We, and others, have demonstrated that. For example, lowering the rate of sleep apnea. We went from 5.7% in a comparison group to 1.6% in those in our intervention, called the DPP. That improvement, alone, paid for two-thirds of the entire cost and wouldn’t have been calculated if you only looked at diabetes prevention (which also happened). Cardiovascular disease, high cholesterol, high blood pressure, arthritis, sleep apnea—those are expensive conditions. If you can demonstrate, and I think if we have Aetna’s help and others, we can look at those kinds of secondary outcomes to be able to show an even better return on investment and a better improvement on health.