Medicare Diabetes Prevention Program Saves $2,650 per Patient

November 03, 2016 - In March 2016, the Department of Health & Human Services (HHS) proposed the expansion of Medicare coverage for the Diabetes Prevention Program. The funding for this program comes from the Affordable Care Act and research shows that Medicare costs are lowered when the Diabetes Prevention Program is implemented.

It is hoped that expanding Medicare coverage for this program will improve health outcomes and work to reduce the rates of Americans diagnosed with diabetes. This past June, the Health Care Cost Institute released research showing that healthcare spending among diabetes patients who have employer-sponsored plans rose close to 6 percent in 2014.

A group of patients without diabetes showed their costs increase 3.2 percent in the same year. This shows that individual patient spending may be nearly twice as much for diabetes patients.

Working to decrease the rates of diabetes could go a long way to reducing healthcare spending. When physicians uncovered the medical condition prediabetes, more research went into finding ways to prevent the condition from transitioning to diabetes including weight loss, nutrition advice, and fitness programs, said Matt Longjohn, MD, MPH, and National Health Officer for YMCA of the USA.

The YMCA administers the coaching and training of the Diabetes Prevention Program for prediabetic patients to lose weight and make adjustments to their diets and exercise plans.

“The Medicare Diabetes Prevention Program benefits that are being debated by policymakers right now and moving into a final rule is the latest in a long string of organizations to pick up and incorporate the Diabetes Prevention Program,” Longjohn told HealthPayerIntelligence.com. “Before Medicare went so far as establishing these rules, there were already commercial insurers and  community-based organizations such as the YMCA working together to cover employees and insured individuals with this program.”

“The reason why that was happening was due to the CDC back in 2012 setting up standards by which the Diabetes Prevention Program could be judged as being high quality,” Longjohn said. “The reason that could happen is because, by that point, there was 15 to 20 years of research behind this program.”

Longjohn explained that in the 1990s, doctors and pathologists were finding organ damage because of diabetes among patients who were never diagnosed until it was too late. This showed that these patients had some symptoms of diabetes before they could be fully diagnosed with the disease.

By the late 1990s, the term and condition prediabetes was born. Since then stakeholders have worked to prevent the condition from progressing to diabetes and its many severe symptoms.

“It turns out that YMCA’s Diabetes Prevention Program was shown to prevents new cases of diabetes 58 to 71 percent of the time in people with prediabetes,” added Longjohn. “The reason why Medicare is covering this is because the science is clear. It helps people with prediabetes prevent new cases of becoming diabetic. In the most recent studies we did with Medicare, we were able to show with about 8,000 Medicare beneficiaries, for a roughly $500 investment, Medicare could save $2,650 in total cost of care for those individuals within a 15-month period. That’s really the big additional driver that CMS needed to see to start writing rules and cover this program.”

The Diabetes Prevention Program is conducted as a group meeting at YMCAs, churches, employee break rooms, or any community center, Longjohn explained. Often those who are overweight and prediabetic attend the meetings to be coached on diet and fitness in order to lose weight and prevent or delay the onset of diabetes.

“The program is a copyrighted curriculum that comes straight out of the universities and academic centers that were testing this intervention in the NIH study. This is the exact same curriculum and intervention that was shown to prevent new cases of diabetes 58 to 71 percent of the time when clinicians were using it,” continued Longjohn. “The biggest difference between how we use it and how folks used it in the clinical setting is that our YMCA employees are not clinicians. Instead of delivering inside clinics, we deliver the program in YMCAs, church basements, employee break rooms or wherever it is that people need us to show up. That’s an important change for accessibility.”

When asked about some of the biggest challenges with meeting the goals of the Diabetes Prevention Program, the YMCA National Health Officer explained that many people with prediabetes have not been diagnosed and have no symptoms showing their health risks. This makes it much harder for the program to proliferate and make a difference among the many people who could end up with diabetes.

“One of the biggest challenges that anyone delivering this program faces is that there’s very low awareness or intrinsic motivation for the millions of people with prediabetes to go through a program like this,” he noted. “86 million Americans have prediabetes but only about 10 percent have ever been told by their doctor they have it. They’re generally asymptomatic so signing up for a year-long behavior change program is probably not the first thing they’re thinking of. That enrollment challenge is a behavioral challenge that we’re always confront with.”

Longjohn also mentioned that the YMCA faced obstacles when it comes to operating electronic medical records and keeping their clients’ data secure.

“The second challenge is that we have as an organization had to figure out how to use an electronic medical record system,” he continued. “We hired athenahealth this year to be our electronic medical record and claims processing vendor. Our program is fueled by a great partner who can live up to the highest data security standards and integrate our program data with clinicians so that people are coming to the YMCA and going to their doctors in a way that helps facilitate sustainable behavior change.”

“We also had to create a CPT code to allow non-licensed providers of standardized diabetes prevention to be able to bill insurance companies,” said Longjohn. “We’ve had to figure out how to help the YMCA become a provider of preventive services in a healthcare world.”

Some of the outcomes of the Diabetes Prevention Program include an average of a 5 percent weight loss among participants as well as a reduction or delay of new cases of diabetes. The Medicare program has also seen a reduction of healthcare spending totalling more than $2,000 per patient.

Dr. Longjohn advised other commercial health insurance companies to take up these type of cost savings by partnering and contracting with the YMCA as well as other community resources available in the realm of diabetes prevention.

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