The U.S. Department of Health and Human Services (HHS) announced it soon will begin covering diabetes prevention programs for Medicare beneficiaries as the result of a successful demonstration project. It is the first time a preventive service model from the Center for Medicare and Medicaid Innovation (CMMI) has been expanded into the Medicare program, and the agency said the model holds promise for employers, private insurers and patients.
Success in preventing type 2 diabetes
The announcement highlights the success of a three-year demonstration project, funded by CMMI, that allowed the YMCA of the USA to deliver its Diabetes Prevention Program through local YMCAs to nearly 8,000 Medicare beneficiaries at a high risk of developing type 2 diabetes at no cost.
As part of its Improving Health Outcomes initiative, the AMA teamed up with the Y-USA and 26 physician practice pilot sites (log in) in eight states to develop tools and resources to increase physician screening, testing and referral for prediabetes.
The practices referred their patients with prediabetes to diabetes prevention programs offered by local YMCAs. Medicare beneficiaries were able to participate in this program at no cost as a result of the award from the Center for Medicare and Medicaid Innovation.
The Y-USA’s Diabetes Prevention Program is modeled after the Centers for Disease Control and Prevention (CDC) National Diabetes Prevention Program (DPP), which is a proven, evidence-based lifestyle change program. This 12-month lifestyle behavior intervention program helps patients adopt and maintain healthy lifestyles by eating healthier, increasing physical activity and losing a modest amount of weight in order to reduce their chances of developing the disease.
At a time when more than 11 million seniors have diabetes and another 26 million seniors (about one-half of all Americans over the age of 65) have prediabetes, the results of the demonstration project speak for themselves:
- The estimated savings for Medicare per enrollee in the diabetes prevention program was $2,650 over a 15-month period, according to the HHS Office of the Actuary. The savings more than recoups the cost of participating in the program.
- Patients who enrolled in the diabetes prevention program lost about 5 percent of their body weight, which is enough to substantially reduce the risk of developing type 2 diabetes.
- More than 80 percent of participants attended at least four weekly sessions.
Research by the National Institutes of Health has shown that diabetes prevention programs can reduce the incidence of new cases of type 2 diabetes by 58 percent. The reduction in incidence increases to 71 percent for adults over the age of 60.
“This program has been shown to reduce health care costs and help prevent diabetes, and is one that Medicare, employers and private insurers can use to help 86 million Americans live healthier,” HHS Secretary Sylvia M. Burwell said in a news release. “The Affordable Care Act gave Medicare the tools to support this groundbreaking effort and to expand this program more broadly. Today’s announcement is a milestone for prevention and America’s health.”
A time for action
A study released in 2014 that used methods similar to those of the Congressional Budget Office estimated that Medicare coverage of diabetes prevention programs would reduce federal spending by $1.3 billion over a 10-year budget window. The research was conducted by Avalere Health and released by the American Diabetes Association, the Y-USA and the AMA.
The study estimated that the cumulative rate of diabetes in the Medicare population would be reduced by an estimated 37 percent after a decade, resulting in nearly 1 million fewer cases of diabetes among seniors.
Risk of developing type 2 diabetes extends to a major portion of the U.S. population beyond Medicare beneficiaries. More than 86 million adults currently are living with prediabetes, but only 10 percent of them know that they have prediabetes and are at risk of developing type 2 diabetes.
“Today’s announcement signifies an important step toward ensuring all Americans at risk for type 2 diabetes have access to the resources they need to prevent this debilitating disease,” AMA President-Elect Andrew Gurman, MD, said in a statement. “Research shows that up to one-third of these individuals will develop type 2 diabetes within five years unless they lose weight through healthy eating and increased physical activity.”
The AMA sent a letter to the Centers for Medicare & Medicaid Services last month, calling for coverage of prediabetes screening, referrals to diabetes prevention programs and participation in diabetes prevention programs. These services recently received a Grade B from the U.S. Preventive Services Task Force.
Under the Affordable Care Act, private health plans participating in the health insurance marketplaces and the Medicaid program are required to cover preventive services that are recommended with a grade of A or B by the task force.
For patients who have insurance through private plans, the AMA is encouraging employers and health insurance companies to cover participation in diabetes prevention programs as well. The entities can use the AMA’s diabetes prevention cost-savings calculator to better understand why they should offer this coverage, including the potential benefits for improving health outcomes while reducing health care costs.
What you can do
Now is the perfect time to start talking to your patients about prediabetes and referring them to diabetes prevention programs that are part of the National DPP. National efforts are underway to prevent the onset of type 2 diabetes. Earlier this year, the AMA, the CDC, the American Diabetes Association and the Ad Council launched a highly visible public service ad campaign that clearly delivers an important message: Everyone needs to know whether they have prediabetes or not.
The ads use humor to grab people’s attention and ensure they know that there’s no excuse not to find out their prediabetes risk, which they can do through a simple risk assessment at DoIHavePrediabetes.org.
For physicians, the AMA and the CDC offer practical resources through the joint Prevent Diabetes STAT: Screen, Test, Act–Today™ initiative. The resources center on three important steps to take with your patients:
- Screen patients for prediabetes risk using the CDC Prediabetes Screening Test or the American Diabetes Association Diabetes Risk Test
- Test patients to confirm prediabetes using one of three blood tests
- Act by referring patients with prediabetes to a nearby diabetes prevention program
Depending on what makes the most sense for your practice, there are two different options for how your practice team can identify patients with prediabetes and refer them to the prevention program they need. Members of your practice team can either screen and test patients at the point of care, or they can do so by generating a registry of at-risk patients via your electronic health record system and referring them.
The Prevent Diabetes STAT toolkit offers everything you need for either approach, including patient handouts, risk assessments, prediabetes identification algorithm and patient flow process for engaging patients at the point of care, retrospective diabetes identification algorithm, sample patient letters and phone scripts.
Table of Contents
Essential Tools & Resources
Managing Type 2 Diabetes: A Team-Based Approach
AMA Doc Talk podcast series
Visit AMA’s Diabetes Prevention Guide