By Sameed Ahmed M. Khatana, MD; Ann L. Albright, PhD, RD; and Darshak M. Sanghavi, MD
Current efforts to enhance rewarding value rather than volume of health care focus principally on transitioning fee-for-service Medicare payments into alternative payment models, such as accountable care organizations or bundled payment arrangements. But to promote rewarding value, we also need to focus on long-term prevention that can improve outcomes over the long run.
The Center for Medicare & Medicaid Innovation, under the Centers for Medicare & Medicaid (CMS), recently announced a model test for population-based reductions in projected 10-year cardiovascular risk. But many other opportunities for prevention-focused innovative payment models remain. One important opportunity is addressing chronic conditions such as type 2 diabetes.
The Burden of Type 2 Diabetes
Health care spending, particularly for the population served by Medicare, is dominated by chronic conditions, with 86% of all health care spending in the United States going towards people with one or more chronic conditions. Type 2 diabetes is a major contributor to this expenditure, accounting by some estimates for at least $1 in $3 spent by Medicare.
According to the US Centers for Disease Control and Prevention (CDC), one-quarter of Medicare beneficiaries have diabetes, and a further 1 in 2 have prediabetes, which places them at a 5- to 20-fold increased risk of developing type 2 diabetes within a few years. This high-risk population is in the pipeline of future Medicare beneficiaries with type 2 diabetes and presents a major opportunity for enhanced preventive care.
For more than a decade, primary prevention of type 2 diabetes has been well-studied and shown to be effective. The National Institutes of Health’s landmark Diabetes Prevention Program (DPP) clinical trial demonstrated that a structured lifestyle intervention focused on weight loss and enhanced physical activity in participants with prediabetes reduced the development of diabetes by 58% compared with placebo over a 3-year period. These results were even more pronounced in elderly persons and were durable for more than a decade of follow-up.
Many translational studies have successfully replicated the DPP clinical trial and projected lower health care costs, making a case for cost effectiveness or even cost-savings. The Affordable Care Act established the National Diabetes Prevention Program, which established infrastructure and CDC national standards for nationwide delivery of type 2 diabetes prevention interventions based on the DPP and subsequent studies. Meeting the standards of the CDC Diabetes Prevention Recognition Program (DPRP) require curriculum, duration, and intensity commitments as well as achievement of weight loss, attendance, and physical activity goals by participants. Almost 800 programs, both in-person and distance-based, have achieved recognition from the CDC, with levels of weight loss generally replicating the primary DPP trial. Additionally, several payers are using value-based payment structures for delivery of the intervention, tying payments to weight-loss goals.
Challenges for Prevention Program Coverage
Despite the evidence of efficacy, lifestyle-based programs aimed at preventing type 2 diabetes are not widely covered by insurers, possibly because the benefits of prevention may take several years to materialize. Broadly, this fits into a long-established pattern in which improved lifestyle and counseling programs are less quickly adopted than pharmaceutical or procedural treatments.
For example, liraglutide, an injectable glucagonlike peptide-1 analogue initially approved in 2010 by the US Food and Drug Administration for the management of type 2 diabetes, received additional labeling for use as a weight-loss treatment after the publication of a trial demonstrating weight loss in nondiabetic patients. It costs more than $1000 per month, and some health plans have begun providing some degree of coverage for it and other expensive weight-loss drugs. However, programs that offer the DPP lifestyle approach are still not widely covered, although the DPP is less expensive and better studied for outcomes of long-term weight loss and reduction in risk of type 2 diabetes.
To date, traditional fee-for-service Medicare has not paid for the DPP. Based on provisions of the Affordable Care Act (ACA), Medicare currently provides coverage for obesity counseling, with payments tied to weight loss to a certain degree. However, despite more than 15 million Medicare beneficiaries who are obese, only around 120 000 had participated in obesity counseling as of 2014. Patients may prefer to receive weight loss interventions outside of the physician’s office.
The CMS’s Innovation Center was established by section 3021 of the ACA for the purpose of testing “innovative payment and service delivery models to reduce program expenditures … while preserving or enhancing the quality of care.” Chronic disease prevention provides obvious areas in which both quality and cost gains can be made. But such approaches also present several challenges, particularly as the improved quality and reduced costs may not be observed for several years.
In 2012 the CMS Innovation Center funded, through an $11.8 million Round 1 Health Care Innovation Award, a large study of DPP delivered by the National Young Men’s Christian Association (YMCA) of the USA, one of the nation’s largest providers of CDC-recognized DPP interventions, to test the program’s effect on health quality and the cost of care among Medicare beneficiaries. Independent evaluation of the program funded by CMS has shown evidence of success in achieving weight loss goals and a favorable effect on total Medicare costs.
A Prevention Coverage Milestone
Based on these results from an independent evaluator, and using modeling informed by strong prior evidence and data from the CDC DPRP, the CMS Chief Actuary recently certified that an expansion of the DPP will reduce spending in the Medicare program. Additionally, after delegation of this responsibility by the Secretary of Health and Human Services, the CMS Chief Medical Officer also concluded that the program enhanced health care quality without limiting coverage or benefits. As a result, for the first time, a specific preventive model has met the eligibility criteria for expansion under the ACA criteria, allowing the Secretary of Health and Human Services to “expand (including implementation on a nationwide basis) the duration and the scope of a model that is being tested.” This is the second time that a CMS Innovation Center model has been certified for expansion, and the first time that a specific preventive benefit has met the stringent expansion criteria under the Affordable Care Act.
In other words, this creates an opportunity for wider availability of the DPP to Medicare fee-for-service beneficiaries. Although the exact details of how the DPP could be incorporated into the Medicare program will be determined in the future, the DPP has the potential to address the large burden of chronic disease among the Medicare population.
The authors acknowledge the key contributions of Juliana Tiongson, John Shatto, and Patrick Conway, MD, MSc to this work.
About the authors:
Sameed Khatana, MD, is a general internist at Brigham and Women’s Hospital in Boston, Massachusetts, and is an Initiative to Support Promising Research (INSPIRE) fellow at the Centers for Medicare & Medicaid Innovation. He is also an instructor of medicine at Harvard Medical School. His research interests include health delivery innovations in chronic disease care and measuring quality and value in clinical care.
Ann Albright, PhD, RD, is the Director, Division of Diabetes Translation at Centers for Disease Control and Prevention (CDC). Previously, she served as chief, California Diabetes Program, for the California Department of Health Services and held an academic appointment in the Institute for Health and Aging at the University of California, San Francisco. She has also served as the Senior Health Policy Advisor in the office of the US Surgeon General. She has published in areas of exercise, nutrition, body composition, diabetic nephropathy, care among Medicaid recipients with type 2 diabetes, and public health practice in diabetes prevention and control.
Darshak Sanghavi, MD, (Darshak.email@example.com) is director of Prevention and Population Health Care Models at the CMS Innovation Center at the Centers for Medicare & Medicaid Services, where he directs efforts to create innovative federal payment models for population health. Previously, he was a fellow and managing director working on health care at the Brookings Institute. He is also associate professor of pediatrics and recent chief of pediatric cardiology at UMass Medical School. His research interests range from tuberculosis in Latin America to the molecular biology of cell death. He writes regularly on health topics for Slate and The New York Times, and has appeared often on NBC’s Today.
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