Unless we develop better programs for detecting people with elevated blood sugar and helping them to improve their diet and physical activity and control their weight, diabetes will inevitably continue to impose a major burden on health systems around the world,“ Goodarz Danaei said from the Harvard School of Public Health in the United States. The most common type of diabetes, Type 2, is strongly associated with obesity and a sedentary lifestyle, which means Americans are not doing what the have to stay healthy and fit.
“Unless we develop better programs for detecting people with elevated blood sugar and helping them to improve their diet and physical activity and control their weight, diabetes will inevitably continue to impose a major burden on health systems around the world,” Danaei added in a joint statement.
The United States of America is on track to become the United States of Diabetes . The epidemic of type 2 diabetes and its warning sign, prediabetes, is sweeping across the country . By 2020, an estimated 52 percent of the adult population will have diabetes or prediabetes . Yet shockingly, the vast majority— more than 90 percent—of people with prediabetes, and about a quarter of people with diabetes, are unaware of their condition
This will have major implications for people’s health and life expectancy . It will also make a major contribution to out-of-control U .S . health care costs, placing growing strain on the budgets of families, employers, states and the federal government . This new study estimates that health spending associated with diabetes and prediabetes is about $194 billion this year (approximately seven percent of total U .S . health spending) . That cost is projected to rise to $500 billion by 2020.
It is estimated that as a nation we could in theory save up to $250 billion in health care costs net of projected intervention costs (which is about 7 .5 percent of estimated spending on diabetes and prediabetes) over the next 10 years if an intensive strategy was implemented at scale across the diabetes continuum engaging all at-risk individuals . In practice this would be hard to achieve, so the figure is illustrative of the size of the opportunity—and the costs of inaction .
• Of those savings, it is estimated that $144 billion, or about 58 percent, might accrue to the federal government through savings in Medicare, Medicaid, and exchange subsidies .
• In addition, employers could see improvements in workforce productivity, and employees could see increased wages, together worth an estimated $239 billion over 10 years.
Many health promoting and potentially cost-saving intervention strategies depend on voluntary participation of individuals most likely to benefit . In this context, it is likely that a wide variety of environmental and social factors will influence the degree to which support for those interventions will result in optimal results . To support broader action to tackle prediabetes and diabetes, a number of policy changes could potentially make a positive contribution and simultaneously enhance the overall benefit of health system-based strategies . These could include:
1 . Strengthen resources for public awareness .
The established link between obesity, prediabetes, and diabetes is generally not well understood by the public, nor is the ability to effectively manage these conditions . A broad campaign at the national or state level akin to anti-smoking campaigns could focus on describing the clinical chain of obesity, prediabetes and type 2 diabetes . It could additionally offer data on prevalence, outcomes and information on how individuals can avoid or control these conditions . A comprehensive campaign could help spur positive behavior change at multiple levels, ranging from screening, improved health actions, and enrollment in appropriate intervention programs .
2 . The United States Preventive Services Taskforce should examine evidence for prediabetes screening .
The USPSTF currently recommends targeted testing for diabetes only among adults with hypertension or at high risk for cardiovascular disease . With cost-effective and evidence-based diabetes prevention programs rapidly becoming more available in community settings, there may be greater benefit now than ever before from clinical efforts to identify high risk persons with prediabetes who could benefit most from these new preventive services .
3 . Use predictive analytics in the meantime to help identify the population with prediabetes, in combination with patient outreach .
New risk identification models and support for the wider team of health professionals and staff can help expand targeted screening . Identifying at-risk individuals with advanced analytics helps employers and health plans improve the wellness of their populations . Medicare and Medicaid should also make use of this emerging science .
4 . Expand the evidence base for diabetes care and treatments through comparative effectiveness research .
While there are a number of effective treatments for diabetes, there are many unanswered questions that physicians and patients face daily . These include:
• What are the optimal combinations of medications for patients with different combinations of risk factors?
• What are the best ways to monitor the progression of diabetes and intensify care in a timely way?
• What are the best strategies to manage diabetes among patients with multiple chronic conditions?
• What are the best strategies to promote patient education and healthier lifestyles among patients with low literacy levels?
• How should community-based and clinical interventions work together to optimize population health? • What are the best ways to broadly disseminate new research findings into practice more quickly?
5 . Ensure reimbursement for evidence-based diabetes interventions in federal health programs .
Both the DPP and the DCP have credible clinical trials supporting the interventions and private sector applications that further support the effectiveness of these solutions . Coverage of these interventions as a FFS- reimbursed benefit for individuals with prediabetes and diabetes in Medicare and Medicaid could make substantial progress to reduce the diabetes risk and health costs for the populations in those programs .
6 . Update CMS-approved diabetes screening options to include a HbA1c test as recommended by the American Diabetes Association .
The A1c test is the only test option that does not require an overnight fast, and it is currently used routinely by healthcare providers to monitor the status of patients who already have diabetes . For these reasons, this is becoming a preferred test for diagnosis by many health care providers .
7 . Raise reimbursement levels for primary care providers for evidence-based diabetes prevention and care .
Physicians and other providers who actively engage in diabetes prevention and control activities should receive additional funding for those activities with funding released as a share of savings from improved “upstream” care, perhaps through patient-centered medical homes or other similar payment reform models . These typically pay physicians higher amounts for the provision of high-quality care, and for their leadership in ensuring their patients receive appropriate and efficient care more broadly .
8 . Create new reimbursement models for community-based providers .
Public and private payers should encourage new models of care for populations with prediabetes and diabetes . In Medicare and Medicaid, solutions could be pursued that reimburse trained “extenders” such as the Y lifestyle coaches and retail pharmacists in community settings for the delivery of DPP and DCP benefits, using funding from shared savings from improved “upstream” care .
9 . Employ incentives to strengthen employer wellness programs .
PPACA includes new provisions that allow financial incentives tied to health status to go up to 30 percent of the cost of employee coverage . The Secretaries of Labor and Health and Human Services have the ability to increase wellness rewards to 50 percent of the cost of coverage . Where needed, this should be available to promote diabetes prevention and diabetes management .
10 . Provide incentives for consumers to participate .
Getting consumer participation in health interventions is a significant and ongoing challenge . Just as private sector payers have created value-based insurance designs that encourage participation, policymakers should consider doing the same for fee-for-service Medicare and Medicaid . Enrollees in the new state exchanges should also see meaningful financial incentives to stay healthy or to maintain compliance with chronic care treatment programs . Mandated or incentive-based consumer models will drive appropriate adoption rates and meaningful health and cost reduction outcomes .
11 . Maintain continuity of care for people with diabetes .
It is important for people with diabetes to maintain a consistent source of care that is coordinated to ensure they can most effectively manage their conditions . This is particularly an issue for low-income enrollees in Medicaid programs where enrollees lose eligibility due to fluctuations in their income . State Medicaid programs could adopt continuous eligibility for six months or longer to improve continuity of care for this population . New health insurance exchanges should adopt strong incentives for eligible individuals to enroll in coverage at the start of the year and then stay continuously enrolled .
12 . Deploy network models in Medicare for complex case management .
The cost of network-based interventions such as Centers of Excellence for complex case management is low relative to the savings opportunity, and provides a strong incentive for payers and employers to pursue similar initiatives . For people with diabetes with complications this model promotes high-achieving hospitals and the opportunity to manage intensively the course of this disease and reduce net spending
Source: United Healthcare “Diabetes of America