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Ronald T. Ackermann, MD, MPH Indiana University School of Medicine

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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, MPH Indiana University School of Medicine Regenstrief Institute for Healthcare

2 Diabetes – The Tip of the Iceberg…
21 million Americans Pre-Diabetes – 65 million Americans (30% of all adults) Progression to diabetes 5 – 15% per year This 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 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 AE’s Cost-effective - Health Payer: $1,100/QALY

8 Diabetes Can be Prevented!
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

9 Diabetes Costs – With Primary Prevention
Costs for Diabetes $130 B lower over 13 years Projected 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 risk Pre-diabetes management Earlier detection and management of T2DM DPP Coverage Benefit Tight CVDRF Control & Follow-up Lower PMPM cost; Improved outcomes Lower Diabetes & CVDRF Burden

11 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 Link to health plan / employer payment (physician initiated) Provide ongoing behavior support at least monthly

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

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

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 Category Original DPP No 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… PMPM for Group DPP
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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