Presentation on theme: "Ronald T. Ackermann, MD, MPH Indiana University School of Medicine"— Presentation transcript:
1 Paying for Prevention – Why, How, and When The Case of Preventing Diabetes Ronald T. Ackermann, MD, MPHIndiana University School of MedicineRegenstrief Institute for Healthcare
2 Diabetes – The Tip of the Iceberg… 21 million AmericansPre-Diabetes –65 million Americans (30% of all adults)Progression to diabetes 5 – 15% per yearThis ok?
3 Lifetime Risk of Diabetes by BMI Predicted lifetime prevalence of diabetes for 18 year old today; Narayan et al., 2007
4 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)
5 Population-Level Diabetes Prevention! Policy GoalPopulation-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?
6 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 costs3-arm randomized trialIntensive Lifestyle InterventionMetformin (Diabetes medication)Placebo (Basic advice)OutcomesPrevention or delay of DiabetesCosts and cost-effectiveness
7 DPP Lifestyle Intervention 16 “core” one-on-one meetings ~1hr/weekMonthly lifestyle maintenance visitsSafe and Effective11 pounds (~5%) weight loss = 58% in diabetesImproved control of other CVD risk factorsNo major AE’sCost-effective - Health Payer: $1,100/QALY
8 Diabetes Can be Prevented! People have pre-diabetes for 8-10 years before getting diabetesRoutine blood tests can identify pre-diabetesIntensive interventions reduce diabetes development & reduce future costsCannot assume that lower intensity interventions with same goals will have the same results
9 Diabetes Costs – With Primary Prevention Costs for Diabetes $130 B lower over 13 yearsProjected Total Direct Medical Costs for Patients with Diabetes, Year 2007 $US (Billions); ADA 2008
10 Population-based Diabetes Prevention Identify adults with diabetes risk factors (EHR; Claims)Coverage of fasting glucose tests for persons at riskPre-diabetes managementEarlier detection and management of T2DMDPP Coverage BenefitTight CVDRF Control & Follow-upLower PMPM cost; Improved outcomesLower Diabetes & CVDRF Burden
11 Elements of Cost-Effective Diabetes Prevention Evidence / goalHealthcareCommunityTarget adults with pre-diabetesXProvide structured lifestyle program to achieve 5-7% weight lossLink to health plan / employer payment (physician initiated)Provide ongoing behavior support at least monthly
12 Partnered Approach for Prevention CommunityHealthcarePopulation ResourcesEnvironmentEducation by Schools & MediaLower intensity programsRisk assessment opportunitiesReciprocal InteractionsPersonnelExperienceFacilitiesContactFormal ProgramsGlucose testingRisk/benefit assessment (safe?)Prescriptive advice (role for meds?)Gateway to reimbursement
14 Community Linkage Partner – The YMCA? 2,600 YMCAs in the U.S.42M U.S. families within 3 miles of a YStrong history of disseminating structured programs nationally (arthritis)Operate to achieve cost recovery onlyPolicy to turn no person away for inability to pay for a program (financial assistance)
15 Group Delivery of DPP Offers program to a group of 10 – 12 Enhances social support and accountabilityLowers 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)
16 Minimizing Program Costs Cost CategoryOriginal DPPNo IncentivesGroup FormatGroup Format – YMCA InstructorPersonnel$794$156$131Supplies$11Incentives$123$10Overhead$548$108$91Total$1,476$1,363$284$243
17 But can a Certified Community Vendor (The YMCA) Achieve 5% weight loss in Adults with Pre-Diabetes?
18 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
19 DEPLOY Outcomes - % Weight Reduction *p-values comparing Group DPP to Brief Advice
20 Bottom Line DPP lifestyle programs… PMPM for Group DPP Cut diabetes development in halfAre cost-saving when delivered efficiently in community settingsPMPM for Group DPPYr 1 - $21Yrs 2 to 13 - $11Time to ROI for payer <2 yearsBy 2020, U.S. healthcare system would manage 113M fewer member-months of adult diabetes
21 Questions?Ronald T. Ackermann, MD, MPH Indiana University School of Medicine Regenstrief Institute for Healthcare Thanks to CDC-RTI Economic Evaluation Workgroup and the DEPLOY Study Team