Medicare Expands the Diabetes Prevention Program

The best way to cut costs is to prevent disease

Older couple cooking together
Medicare wants to help you prevent diabetes. franckreporter/Getty Images

More than 29 million Americans have diabetes and one in every three adults has prediabetes, a condition that occurs when blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. No matter how you look at it, diabetes is an epidemic in our country leading to health complications and rising costs.

The Cost of Diabetes

Altogether, diabetes costs the nation $245 billion each year.

A whopping 62.4 percent of these costs are covered by Medicare, Medicaid, and the military. This includes hospitalizations, nursing home stays, office visits, and prescription drugs. Those costs add up.

Nearly 6 million Americans rely on insulin, not only to keep their blood sugar in control but to stay alive. This hasn't stopped the rising costs of insulin by the pharmaceutical industry. Truven Health Analytics reports that the price of Novo Nordisk's insulin Novolog is up 381 percent, Eli Lilly's Humalog is up 380 percent and Sanofi's Lantus is up 400 percent since 2004. The bad news? These are the three companies that make insulin in the United States.

For years, there has been no "generic" insulin to keep costs down. This is because of how complex it is to produce insulin. Rather than being a synthetic chemical, insulin is a biosimilar drug made from live cells. A generic insulin will be introduced in December 2016 but it is only projected to decrease costs by 11 to 15 percent.

Is that enough to rein in costs for millions of Americans?

Medicare is taking notice and is changing tactics. The program hopes to save on health care by decreasing the prevalence of diabetes in our country.

Medicare's Plan for Diabetes Prevention

Think how much Medicare could save if it helped prevent people from getting diabetes in the first place.

A pilot program with the  National Council of Young Men’s Christian Associations of the United States of America (YMCA) was initiated in 2013 with this goal in mind. The Affordable Care Act funded the initiative with $11.8 million to explore a model that promoted healthy lifestyle choices.

The results were a boon!

  • More than 80 percent of people who started the program completed at least four weekly sessions. This shows that the program is both accessible and agreeable to those who use it. 
  • Those who participated in the pilot program averaged a five percent weight loss. The longer someone participated in the program, the greater the weight loss.
  • Medicare averaged savings of $2,650 over a 15-month period for each beneficiary who participated in the program. In this way, the Diabetes Prevention Program pays for itself in the short-term. By preventing diabetes and complications of the disease, overall savings will extend far into the future.

Given the success of the program to date, the Centers for Medicare and Medicare Services has announced plans to expand the Diabetes Prevention Program nationwide for 2018.

Interestingly, pharmaceutical companies are in opposition to the program's expansion.

They claim more time is needed before funds should be committed on such a large scale. It looks more like they see that preventing diabetes will drop their profit margin.

Who Is Eligible for the Diabetes Prevention Program?

Unfortunately, not everyone is eligible for the Diabetes Prevention Program, at least not yet. As it stands, you have to meet all four of these criteria to participate.

  1. You are overweight with a Body Mass Index (BMI) of 25 or greater.
  2. You have prediabetes.
  3. You have no prior diagnosis of diabetes.
  4. You have no physical limitations that would prohibit your ability to participate in the program.

    Prediabetes must be confirmed by one of three tests.

    • The least expensive screening test is a fasting glucose level. It can be performed by drawing blood from a vein or by a simple finger prick. Levels between 110 and 125 mg/dL are diagnostic for impaired fasting glucose and are consistent with prediabetes.
    • Alternatively, a Hemoglobin A1C test may be performed. This test estimates your blood sugar levels over a three-month period. Values between 5.7 and 6.4 percent are indicative of prediabetes.
    • More often used to screen for gestational diabetes, an Oral Glucose Tolerance Test (OGTT) shows how well your body processes a glucose load. Your blood sugar is measured before and after ingesting a certain amount of glucose. For the purposes of the Diabetes Prevention Program, the OGTT should challenge you with a 75-gram glucose load and your blood sugars should be checked after two hours. Levels that fall between 140 mg/dL and 199 mg/dL at that time are consistent with prediabetes.

    How the Diabetes Prevention Program Works

    A lifestyle coach will lead you through group meetings in a classroom-style format. All coaches will be trained to deliver the same content, and the intention is to be hands-on, to give you practical advice on making real changes that will prevent the development of diabetes. Some of the covered topics will include:

    The first phase of the Diabetes Prevention Program starts out with 16 "core" sessions that occur on a weekly basis. This then transitions into monthly "maintenance" meetings that keep you on track toward your goals. The goal of the program, according to CMS, is not only to prevent progression to diabetes (and maybe even to cure your prediabetes), ​but for you to lose at least 5 percent of your body weight. To this end, you will be weighed at each session.

    In the first year, you are covered for 6 maintenance sessions over a 6 month period after you complete the core sessions. In subsequent years of participation, there is no limit to the number of maintenance sessions you can attend. However, it is required that you participate in at least 3 sessions per quarter for Medicare to cover the visits you attended.

    The idea is to seek guidance from a knowledgeable coach while getting support from others who face similar challenges. The format may seem simple but results don't lie. Hopefully, the Diabetes Prevention Program will be well utilized and make America healthy again.

    Sources:

    Blank C. Insulin makers accused of price collusion. Formulary Journal | Modern Medicine Network. http://formularyjournal.modernmedicine.com/formulary-journal/news/insulin-makers-accused-price-collusion.

    Certification of Medicare Diabetes Prevention Program. Centers for Medicare and Medicaid Services website.  https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/Diabetes-Prevention-Certification-2016-03-14.pdf.

    The Cost of Diabetes. American Diabetes Association website. http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html?referrer=https://www.google.com/.

    Diabetes Supplies & Services. Centers for Medicare and Medicaid Services website. https://www.medicare.gov/coverage/diabetes-supplies-and-services.html.

    Independent experts confirm that diabetes prevention model supported by the Affordable Care Act saves money and improves health. U.S. Department of Health and Human Services website. http://www.hhs.gov/about/news/2016/03/23/independent-experts-confirm-diabetes-prevention-model-supported-affordable-care-act-saves-money.html.

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