How does the largest payer in a state with a large senior population respond to the rising need for diabetes care and prevention?
At Florida Blue, we saw a trend.
As Florida’s largest health insurer, with more than 4 million members, we saw that the risk for diabetes was one of the top 4 risks found in the majority of our members who completed a personal health assessment. Furthermore, at Florida Blue, the average per member per month (PMPM) medical cost trend of someone with diabetes is approximately 3 times higher than for someone without diabetes.
According to the American Diabetes Association (ADA), more than half of Americans, age 65 or older, have prediabetes and are at risk of developing type 2 diabetes (T2D).1 Prediabetes is a “yellow light,” warning individuals that blood sugars are higher than normal, but not yet high enough for a diabetes diagnosis. Nearly 12 million, or 26%, of Americans age 65 and older already have a diagnosis of diabetes, and that figure is climbing.2 An analysis by the CDC, in 2010, estimated that 1 in 3 adults could have diabetes by 2050 if nothing is done to stop existing trends.3 The current national spending to treat diabetes, prediabetes, and related complications is staggering. In 2012, the United States spent $322 billion on diabetes care, according to the ADA, with 1 out of 3 Medicare dollars spent treating diabetes or its complications.4
With Florida’s large senior population, these numbers are particularly worrisome. However, they present an opportunity to improve the health of people in our communities.
The good news is that we know how to prevent or delay T2D. The National Diabetes Prevention Program (NDPP) was started by the CDC after gathering information from a successful clinical trial carried out by the National Institutes of Health.5 Outcomes from the trial demonstrated that individuals can reduce their risk of developing T2D by 58% through changes in lifestyle such as better nutrition, increased physical activity, and weight loss of as little as 5% to 7%.6
Another key finding from the study was that weight loss is the most important factor in reducing the overall risk. While exercise is an important component, its effect on reducing risk for T2D is only moderate without weight loss.6 More recent studies have shown that even limited periods of these lifestyle changes have long-lasting effects on diabetes occurrence.7,8
An even more exciting fact is that participants in the clinical trial who were over the age of 60 reduced their risk for T2D by 71%.9 As adults experience age-related health changes, they gain a strong desire to change their health behaviors. Results from a study focusing on older adults and which factors encourage them to participate in group exercise classes, demonstrated that 84% like the socialization factor.10 Respondents also stated they gained encouragement from peers and the instructors, and enjoyed being able to ask instructors health and fitness-related questions. The classes during the initial diabetes prevention clinical trials and those provided as part of the NDPP are offered in small group settings, providing socialization as well as peer support, and information that allows senior participants to improve their health and avoid further decline that may result from aging.
Data released in 2015 show that, for the first time in a generation, fewer Americans are being diagnosed with diabetes. New cases in the United States fell from 1.7 million in 2008 to 1.4 million in 2014.11 Much of this progress may be a result of NDPP programs, which have been launched across the country. The NDPP has partnered with multiple organizations to offer classes in community settings across the United States, including government agencies such as health departments, private insurers, churches, and community organizations such as the YMCA.12
Florida Blue reviewed the program knowing our members’ high risk for diabetes and the subsequent increased costs of their medical care. We also evaluated the clinical efficacy, cost effectiveness, and sustainability of the NDPP and determined it was the right type of program to offer to our members, as it works to prevent disease and can improve their quality of life.
Florida Blue applied for, and was awarded, a grant to provide a diabetes preventative program through America’s Health Insurance Plans and the CDC, in 2012. Our program, called My Healthy Turnaround, consists of 16 weekly sessions with a lifestyle coach in a group setting. Participants learn lifestyle changes that can positively affect the onset or delay the effects of diabetes, including:
• How to lose weight through healthy meal planning
• Understanding food and nutrition labels
• Nutrition, exercise, and healthy lifestyle changes
• Group support and encouragement
To help individuals stay on track after the program ends, 8 monthly maintenance sessions are also held. Florida Blue began providing classes under the grant in late 2012. To date, more than 1500 individuals have enrolled in our classes, with more than 76% completing the program. In 2013, more than 13% of participants achieved weight loss goals—34% in 2014 and more than 45% in 2015. In addition, members completing the entire program had a $166 PMPM lower medical cost compared with individuals who enrolled but did not complete the program. Those participants who had any weight loss greater than 5% also saw a reversed medical cost trend of approximately 20%. We have seen great results in the diabetes prevention program over the past 4 years.
Preventing this devastating disease has a profound impact on quality of life for our members and our community. We are excited about the prospect of offering this program more widely through a health insurance plan benefit.
On March 23, 2016, the Obama administration announced plans that proposed Medicare coverage of programs to prevent diabetes for those at risk of developing T2D. Sylvia Burwell, HHS secretary, announced the proposal at a YMCA in Washington, DC. The YMCA of the USA has provided the NDPP under a federal grant since 2012. After evaluation of the results, Burwell said, “This program has been shown to reduce healthcare costs and help prevent diabetes.”13
Federal officials have reported a savings to Medicare of $2650 after 15 months for each participant enrolled in the prevention program, compared with similar beneficiaries not in the program. This is more than sufficient to cover costs, as the average cost per participant is approximately $425. In addition, officials said Medicare beneficiaries in the program lost about 5% of their body weight, which was enough to reduce their risk of developing T2D.
Under the Affordable Care Act, the health secretary can, by regulation, expand projects such as the NDPP nationwide if they are found to reduce Medicare spending without reducing the quality of care, and if the Medicare actuary agrees. This proposal will go through a public comment period, but it is expected that regulators will have the program in place before President Obama leaves office in January 2017. This summer, Florida Blue will start a pilot program for members of our Medicare Preferred HMO plan in collaboration with our partner, Alignment Health.
About the Authors
Carmella Sebastian, MD, MS, is vice presdient of medical affairs for Florida Blue.
Karla Logston, RN, BS, CDE, is senior manager for the Florida Blue health promotion department, Better You.
1. National Diabetes Prevention Program named the first preventive health initiative eligible for Medicare coverage via CMMI [press release]. Alexandria, VA: American Diabetes Association; March 23, 2016. http://www.diabetes.org/newsroom/press-releases/2016/nationaldpp-named-first-preventive-health-initiative-eligible-for-medicare.html.
2. Statistics about diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/. Updated April 1, 2016. Accessed April 11, 2016.
3. Number of Americans with diabetes projected to double or triple by 2050 [press release]. Atlanta, GA: CDC Newsroom; October 22, 2010. http://www.cdc.gov/media/pressrel/ 2010/r101022.html. Accessed April 11, 2016.
4. The staggering cost of diabetes in America. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/infographics/adv-staggering-cost-ofdiabetes. html. Accessed April 12, 2016.
5. What is the National DPP? CDC website. http://www.cdc.gov/diabetes/prevention/about/index.html. Updated January 14, 2016. Accessed April 12, 2016.
6. Tuomilehto J, Lindstrom J, Eriksson JG, et al; Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344:1343-1350. doi: 10.1056/NEJM200105033441801
7. Tabak RG, Sinclair KA, Baumann AA, et al. A review of diabetes prevention program translations: use of cultural adaptation and implementation research. Transl Behav Med. 2015;5(4):401-414. doi:10.1007/s13142-015-0341-0.
8. Tuomilehto J, Schwarz P, Lindstrom J. Long-term benefits from lifestyle interventions for type 2 diabetes prevention: time to expand the efforts. Diabetes Care. 2011;34(suppl 2): S210-S214. doi:10.2337/dc11-s222.
9. Preventing diabetes in seniors. American Diabetes Association website. http://www.diabetes.org/advocacy/advocacy-priorities/prevention/preventing-diabetes-in.html. Updated May 29, 2015. Accessed April 12, 2016.
10. Danilowski J. What factors influence persistence rates in active older adult group exercise programs? Presented at the 14th Annual South Florida Education Research Conference, Miami, Florida. June 6, 2015. http://digitalcommons.fiu.edu/.
11. Diabetes Public Health Resource. Annual number (in thousands) of new cases of diagnosed diabetes among adults aged 18-79 years, United States, 1980-2014. CDC website. http://www.cdc.gov/diabetes/statistics/incidence/fig1.htm. Updated December 1, 2015. Accessed April 12, 2016.
12. Caramenico A. Drop in new diabetes cases shows value of prevention programs. AHIP coverage website. www.ahipcoverage.com/2015/12/03/drop-in-new-diabetes-cases-showvalue-
of-prevention-programs/. Published December 3, 2015. Accessed April 12, 2016.
13. Independent experts confirm that diabetes prevention model supported by the Affordable Care Act saves money and improves health [press release]. Washington, DC: HHS Newsroom; March 23, 2016. http://www.hhs.gov/about/news/2016/03/23/independent-experts-confirm-diabetes-prevention-model-supported-affordable-care-act-saves-money.html. Accessed April 12, 2016.