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Paying for Prevention – Why, How, and When The Case of Preventing Diabetes Ronald T. Ackermann, MD, MPH Indiana University School of Medicine Regenstrief.

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Presentation on theme: "Paying for Prevention – Why, How, and When The Case of Preventing Diabetes Ronald T. Ackermann, MD, MPH Indiana University School of Medicine Regenstrief."— Presentation transcript:

1 Paying for Prevention – Why, How, and When The Case of Preventing Diabetes Ronald T. Ackermann, MD, MPH Indiana University School of Medicine Regenstrief Institute for Healthcare

2 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

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 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?

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 costs 3-arm randomized trial Intensive Lifestyle Intervention Metformin (Diabetes medication) Placebo (Basic advice) Outcomes Prevention or delay of Diabetes Costs and cost-effectiveness

7 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 AEs Cost-effective - Health Payer: $1,100/QALY

8 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!

9 Diabetes Costs – With Primary Prevention Projected Total Direct Medical Costs for Patients with Diabetes, Year 2007 $US (Billions); ADA 2008 Costs for Diabetes $130 B lower over 13 years

10 Population-based Diabetes Prevention Coverage of fasting glucose tests for persons at risk Pre-diabetes managementEarlier 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

11 Elements of Cost-Effective Diabetes Prevention Evidence / goal HealthcareCommunity 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

12 Partnered Approach for Prevention Healthcare Glucose testing Risk/benefit assessment (safe?) Prescriptive advice (role for meds?) Gateway to reimbursement Formal Programs Community Population Resources Environment Education by Schools & Media Lower intensity programs Risk assessment opportunities Reciprocal Interactions Personnel Experience Facilities Contact

13 DPP Coverage Benefit Structure Patient Primary Provider Recognized Diabetes Prevention Program Certified Instructor Health Plan Coverage? Diabetes CVDRF Outcomes Costs Sponsoring Organization ADA Community Partner

14 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)

15 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)

16 Minimizing Program Costs Cost CategoryOriginal DPPNo Incentives Group Format Group Format – YMCA Instructor Personnel$794 $156$131 Supplies $11 Incentives $123$10 Overhead $548 $108$91 Total $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… 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

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


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