On March 23, 2016, Secretary of the US Department of Health and Human Services (HHS), Sylvia Mathews Burwell, made an announcement that could prove to be nothing short of life-changing for millions of Americans.
In the year and nine months that she’d held her position, Burwell had stood in front of reporters fielding questions on a number of controversial topics.
This day, though, would be different. This was a day everyone could celebrate. This was the day that the US government made costly chronic disease prevention a national priority. Because Secretary Burwell announced that the Centers for Medicare and Medicaid Services (CMS) will begin a rulemaking process intended to extend coverage of diabetes prevention programs for at-risk Medicare beneficiaries. Did we say life-changing earlier? Let’s add game-changing to that.
Lives in the Balance
Rebecca Blocker, a mother, grandmother, and retired retail manager, sits in her Florida home surrounded by family photographs. She’s no stranger to the ravages of chronic disease. “My brother had diabetes and my oldest sister. And I have a lot of aunts and cousins that have diabetes…A lot of them have passed because of it.”
Unfortunately, Rebecca’s relatives aren’t unusual. According to the American Diabetes Association, 9.3% of our entire population has diabetes. And for seniors like her, the rate is even higher: 25.9%. That’s more than a quarter of all adults over 65.
The vast majority of diabetes cases are type 2 — this is the kind that’s related to diet and exercise, and so, is almost always preventable. And successful prevention programs exist for individuals who are at risk. But there’s a catch: the symptoms of prediabetes (the precursor to type 2 diabetes) are subtle, at best. So 90% of the time, people don’t know they’re at risk until their undetected prediabetes tips the scales and becomes full blown type 2 diabetes.
Rebecca knew her lifestyle was not so different from her relatives’. So she made it a point to ask her doctor to check her blood sugar levels at every visit. But even if her doctor did detect dangerous elevations, Rebecca would run into another catch: while screening for and treatment of type 2 diabetes are covered by Medicare, prevention of the condition currently is not.
Secretary Burwell’s announcement is eliminating the second catch. And in doing so, it could incentivize physicians and their patients to be more proactive about detecting prediabetes. And that, potentially, could eliminate the first catch.
The Path to Prevention
So, how did this all go down? It’s actually been in the works for a while. It started with the Affordable Care Act (ACA) of 2010. An important aspect of the ACA is the goal of moving from a health system that treats illness to one that prevents it (historically, the government has focused 97% of its efforts on treatment versus just 3% on prevention). Requiring health insurance providers to include recommended preventive benefits at no cost to beneficiaries is among the ACA’s prevention provisions.
Given that, in 2013 the Centers for Medicare and Medicaid Innovation (CMMI), which was also created by the ACA, partnered with the YMCA to test the value and efficacy of the Diabetes Prevention Program (DPP) for Medicare beneficiaries. The results? On average, beneficiaries in the program lost about 5% of their body weight, which is enough to reduce the risk of type 2 diabetes by 58%. And Medicare saved $2,650 per patient enrolled in the DPP over 15 months, compared to similar beneficiaries not in the program. Based on the success of the pilot, Secretary Burwell is using authority provided to her by the ACA to expand Medicare’s DPP coverage nationwide.
“The program has shown to reduce healthcare costs and help prevent diabetes,” said Burwell, making it possible to reduce Medicare spending without reducing the quality of life. Indeed, quality of life will probably improve for the seniors who will be eligible for this coverage.
DPP. Fully Covered by Medicare. Wow.
What does that mean, exactly? A whole lot. Let’s break it down.
Secretary Burwell’s announcement marks the first time HHS will use expansion authority under the ACA to require Medicare to reimburse for a preventive service. Before this, it would have taken an act of Congress to enact such a sweeping change. So that’s a pretty big deal in and of itself. But it gets bigger when you look at why HHS chose to focus on diabetes.
The CDC estimates that 86 million people, including at least 23 million people over the age of 65, have prediabetes. And as baby boomers continue to age, those numbers will grow. In addition to increasing their risk of type 2 diabetes, prediabetes also increases their risk of heart disease and stroke. These conditions are often debilitating to patients. They’re also among the most costly to manage. Simply put, diabetes prevention saves money. Lots of money.
Today, one out of three Medicare dollars is spent on people with diabetes. And without intervention, nearly a third of adults with prediabetes will progress to type 2 diabetes over the next five years. In the Medicare age group alone, that’s more than 7 million new cases. A study by Avalere Health determined that effective prevention strategies could decrease federal spending on diabetes treatment by $1.3 billion in the first decade, alone. $1.3 billion! What does that kind of coin look like? How about the total winnings from every Powerball jackpot in 2007, pre-tax?
So yeah, the savings could be huge. And not just for the Medicare and Medicare Advantage (MA) programs. Employers and commercial insurers who are looking to lower spending and improve lives among their populations also can benefit from offering diabetes prevention coverage. Some already are, and saving millions in health care costs in the process.
The DPP is a “lifestyle change program.” In this kind of program, trained coaches guide participants toward healthier eating habits and increased physical activity. It can be delivered in person, as it is at the YMCA. Or, it can be delivered digitally, as it is with Omada. Both the YMCA and Omada are DPP providers that have pending CDC-recognition.
The Omada program combines the latest advances in behavior science, easy-to-use technology, intuitive design, and trained health coaches to deliver behavior change that sticks. Our published, peer-reviewed outcomes are consistent with in-person DPPs. But when we partnered with Humana’s MA plan in 2014 to offer Omada to some of their at-risk beneficiaries, those outcomes looked a little different. But not in the way you might expect.
We met Rebecca Blocker through Humana MA. When she received the email from Humana offering the Omada program to members at risk for type 2 diabetes, she jumped on board immediately. Sixteen weeks into the program, she had lost 25 pounds, exceeding her 5% weight-loss goal. And she continues to maintain her healthier habits and weight.
Rebecca isn’t an anomaly. As a group, Humana MA seniors did even better in the program than their younger counterparts. Today, more than 2,000 participants over 65 have enrolled in Omada. And 84% of them remained active in the program after 6 months. Better still: they’ve lost an average of 7.8% of their body weight, reducing their projected 3-year risk of developing type 2 diabetes by more than 58%.
The Next Steps
This is the first time HHS will undertake the nationwide expansion of a demonstration project conducted by CMMI. So they’re still working out the details of how the coverage will be administered. We’re hopeful that CMS will be able to put the benefit into effect for all Medicare beneficiaries by January 1, 2018 at the latest.
In the meantime, some MA plans are already offering Omada to their members. And we’re working with other health plans’ MA leadership to help them understand the implications of the DPP as a new covered benefit. Those implications will likely extend beyond MA plans. Because once insurers have set up the infrastructure for MA beneficiaries, it makes sense to offer the same money-saving and life-changing benefit to all at-risk beneficiaries.
One thing’s for certain, right now HHS and CMS have a whole lot of rules to iron out pertaining to the new DPP benefit. In Chronic Boom Part 4: Building a Benefit, we’ll focus on a half dozen rules that we think are crucial to helping as many at-risk seniors as possible spend the balance of their golden years free of chronic disease.