1. Advancing Legislation for Community-based Diabetes Prevention in Congress Katie Clarke Adamson YMCA of the USA Director of Health Partnerships and Policy * Many slides c/o Ronald Ackermann, IU

2. Goals  What’s the issue?  How we messaged it to get Champions  How we advanced DPP  Where we are today?

3. What’s the issue?  We can prevent a disease from occurring in the first place with lifestyle interventions at a very reasonable cost  There’s a “tsunami effect” of not intervening in pre-diabetes  Leaders care about costs and are skeptical about prevention working  We can show it works and provide a return on investment

4. Message: Economic Burden of Diabetes in U.S. Exploding *Projections from Hogan et al. Diabetes Care. 2003 Mar;26(3):917-32. AND American Diabetes Association. Diabetes Care. 2008 Mar;31(3):596-615

5. Message: We Can Reduce the Burden of Diabetes  Type 2 diabetes accounts for >95% new cases  T2 diabetes can be prevented or delayed* Lifestyle interventions prevent more than HALF of new cases each year Lifestyle works for all age, gender, SES and race/ethnicity groups Lifestyle interventions are more cost-effective than medications Medications may simply mask conversion to diabetes by lowering glucose levels *Gillies, C. L et al. BMJ 2007;334:299; DPP Research Group. N Engl J Med. 2002 Feb 7;346(6):393-403.

6. Message: To Address Pre-diabetes is to Address Obesity-related Cardiovascular Disease Genetics Age Inactivity Poor Diet Abdominal Obesity Insulin Resistance Hyper- insulinemia Metabolic Syndrome Impaired Glucose Tolerance T2DM Endothelial Dysfunction Inflammation Thrombosis Oxidation Athero- sclerosis CVD Event *Adapted from Hsueh WA, Law R. Am J. Cardiol. 2003;92(Suppl):3J-9J. ↑ TG ↓ HDL ↑ BP ↑ small LDL 2x4x Prediabetes as Metabolic Risk Marker

7. Message: We Needed a Different Translation Model for Population-based Diabetes Prevention 1. Early studies used very intensive / costly programs 2. Few payers today finance these up-front costs 3. Health benefits immediate but cost recovery takes time 4. Cost recovery occurs sooner for persons who are at the highest risk for developing T2 diabetes 5. Best practices to identify those at highest risk (e.g. prediabetes) require clinical information or tests 6. Most clinical settings lack the capacity to delivery large scale lifestyle interventions programs

8. Traditional DPP Lifestyle Intervention  16-session course over 24 weeks  One-on-one coaching format  Goal to lose/maintain ≥7% of body weight Caloric & fat restriction ≥150 min/week moderate physical activity  Education & training in behavior modification (Self- monitoring; problem solving)  Strong support structure (building self esteem, empowerment, social support; accountability)

9. Known Outcomes of DPP Delivery Treating 100 high risk persons (at age 50) for 3 years… Prevents 15 new cases of Type 2 Diabetes 1 Avoids $91,400 in healthcare costs 2 Prevents 162 missed work days 3 Avoids the need for BP/Chol pills in 11 people 4 Adds the equivalent of 20 perfect years of health 5 1 DPP Research Group. N Engl J Med. 2002 Feb 7;346(6):393-403 2 Ackermann, et al. 2008 Am J Prev Med 35 (4), pp. 357-363; estimates scaled to 2008 $US 3 DPP Research Group. Diabetes Care. 2003 Sep;26(9):2693-4 4 Ratner, et al. 2005 Diabetes Care 28 (4), pp. 888-894 5 Herman, et al. 2005 Ann Intern Med 142 (5), pp. 323-32

10. WE CAN PROVIDE THE DPP TO ALL AMERICANS WHO ARE AT THE HIGHEST RISK FOR DEVELOPING DIABETES TODAY? Message: We have a new model of community-based DPP Translation

11. Indiana University’s Community-Based Approach for DPP Translation  Maintain fidelity to “core” evidence from DPP Goal-oriented; weight loss through diet & exercise Paying for intensive lifestyle interventions is a value for the dollar in adults with PREDIABETES We don’t know if other strategies are cost-effective  Less intensive interventions (e.g. fewer contacts; web/telephonic)  Targeting lower risk groups (e.g. all with obesity)  Adopt “practical” solutions for key barriers Minimize intervention costs Preserve effectiveness (weight maintenance)

12. DEPLOY Study To test the feasibility and effectiveness of training YMCA employees to deliver a group- based version of the DPP lifestyle intervention in YMCA branch facilities

13. Message: “If we cannot do this at the YMCA we cannot do it…”  Lower Cost Programs Lower cost “lay” group leaders Operate to achieve cost recovery only Policy to turn no person away for inability to pay for a program (financial assistance)  Promise for National Scalability 2,686 YMCAs in U.S. 59 M U.S. households within 3 miles of a Y History of national program rollouts (arthritis)

14. DEPLOY Study Design  Matched pair, group randomized pilot trial  Adults living within 5 km of 2 community YMCAs  Participants Overweight/obese High random capillary glucose + risk factors* Allocated based on YMCA site for screening  Intervention – Offered group-based DPP  Control – Given basic advice & other Y programs *From Rolka et al. Diabetes Care. 2001 Nov;24(11):1899-903.

15. DEPLOY Weight Loss Outcomes *p-values comparing Group DPP to Brief Advice Ackermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63; Long term results under review 6 monthly visits NO VISITS! 12 visits in 8 mos Same Intervention both groups

16. Message: It’s Cost-effective/Savings PRE Diabetes TreatmentCost per year$US /QALY Intensive Lifestyle$1,500 / $700$11,000* Metformin$600$36,000* Group Lifestyle$300 – 450Cost Saving† Group Lifestyle at YMCA$240Cost Saving‡ * https://research.tufts-nemc.org/cear/ratio0.aspx † Herman, et al. 2005 Diabetes Care ‡ Ackermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63 YUSA now estimates costs are between $300-400 with maintenance fees

17. Message: Bottom Line  Community-based DPP lifestyle programs… Cut diabetes development in half Lower overall cardiovascular risk without the need for pills Improve quality of life measurably Can achieve similar weight loss when offered by the YMCA for a fraction of the cost Have a very strong potential to achieve cost- savings for a health payer when delivered efficiently in community settings

18. Tools to Advance Message  Several peer review journals saying this thing really works and can save money  Health affairs piece describing it in English  Urban Institute says we can save $190 Billion over 10 years if we scale this  WALL STREET JOURNAL ARTICLES!!!!!!!!

19. Okay, Now What? How Do We Scale? We have the best community-based lifestyle intervention ready to go! We are going to save lives and money! We don’t have the people trained or the infrastructure to deliver it today!

20. What We Have and What We Need….

21. The Critical Challenge of Scaling Nationally  Scaling requires payment  Need “fidelity assurance” for healthcare to pay Recognition / certification by national body  Training Outcomes On-going training and evaluations / On-site audits  Physicians to refer people to the program

22. “Linkage Process” for Diabetes Prevention CMS Already CoversPayment Policies are Still Needed

23. Message to Payers: Ingredients for Healthcare Cost-Savings as a Potential Lever for Sustainability Program Delivery Avoids Future Health Care Costs Program Delivery Costs are Less than Costs Avoided Ability to Identify Persons at High risk for Avoidable Costs Program Accessible to High Risk Persons

24. Some avoidable Short-term Costs of Untreated Obesity  Development of type 2 diabetes Self-management education & MNT DME/supplies New medications – glycemic and CVD Increased utilization – tests, vaccines, visits, eye screening Management of complications (hypoglycemia, Rx AE’s)  Treatment $ for cardiovascular events  Other obesity-related treatments/complications Bariatric surgery Pain, depression

25. Net Cost Predictions for a Group-based DPP Program in the Community Predicted Cumulative HC Cost Savings with YMCA Group DPP Model * Estimates derived from CDC/RTI Diabetes Model after Scaling to 2008 $US see: Ackermann, et al. Diabetes Care. 2006 Jun;29(6):1237-41; assumes equal effectiveness as DPP

26. Senators Franken/Lugar Bill Addresses the recognition/training issue and helps build knowledge base for referral and payment issues Passed the Senate as part of the Senate’s version of health care reform Massachusetts happened…Congressional action on health care unclear Senator Franken has bill as top priority on HELP committee, briefing scheduled March 11

27. Dissemination: Experience to date  Indianapolis: 22 trained coaches  Minnesota: 75 trained  Louisville: 16 trained  Washington State: 14 trained  New York: 20 to be trained  Others?

28. CDC Funding to YMCA of the USA  Funded Indiana and Louisville translation pilots  Will fund 10 additional sites, including one state (DE) for further translation effort  Enabling matching funds for NYC for a NY State investment in 10 sites

29. Other YMCA strategies  Working with large 3 rd party payer  Can and will use our vast training network  Testing innovation in referral mechanisms  Discussions with other government payers like IHS and Veterans

30. Questions?  Contact information Katie.adamson@ymca.net 202-835-9043