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