Prevention: The key to healthcare’s fiscal sustainability

A simple premise: individuals cost the American healthcare system more once they are sick. And today in the United States, the most common illnesses — and the ones that are the primary drivers of rising health costs – are chronic conditions like type 2 diabetes, hypertension, and heart disease. The Centers for Disease Control and Prevention has called chronic disease “the public health challenge of the 21st century.”

So as Congress continues to debate the balance between access to affordable healthcare, controlling healthcare costs, and encouraging personal responsibility, members should consider the pivotal role played by prevention. No matter what coverage mechanisms Congress chooses to implement, healthcare costs will continue to rise unless we invest in prevention.

{mosads}Diabetes provides a perfect example. From 1988 to 2014, the prevalence of diagnosed diabetes in the U.S rose by 274 percent. According to the American Diabetes Association, more than 30 million Americans have diabetes, with at least another 86 million perched on the tipping point of the disease with pre-diabetes.

More worrisome, a full 90 percent of those with pre-diabetes are unaware they have the condition. People with diagnosed diabetes incur average medical expenditures of about $13,700 per year. In fact, people with diagnosed diabetes spend an average of 2.3 times on their healthcare than they would have in the absence of diabetes and one out of every three dollars spent in Medicare is spent on a beneficiary with diabetes.

Congress and the Administration have committed to ensuring that people with pre-existing conditions have access to coverage, so all of these people will be insured. But stemming the costs of coverage means we need to find ways to promote a healthier population.

The National Diabetes Prevention Program is an approach that is working.  By targeting people at risk for developing type 2 diabetes, it spurs lifestyle changes that help individuals to manage their diet and fitness, lowering diabetes prevalence, and saving significant healthcare spending.  Today, commercial and Medicare Advantage health plans have deployed the program as a preventive benefit to their populations, with tremendous results. A 2016 analysis certified by the Actuary of the Centers for Medicare and Medicaid Services (CMS) demonstrated that among Medicare fee-for-service beneficiary, the program saved an average of $2,650 per beneficiary in just 15 months.

Recently, a study in the Journal of Aging and Health showed that implementation of Omada Health’s virtual Diabetes Prevention Program in a Medicare Advantage population can be an effective strategy for reducing incidence of diabetes.  Six months after beginning the Omada Program, participants lost an average of 8.0 percent of their body weight. Twelve months after enrolling, participants had kept the weight off with an average loss of 7.5 percent of their body weight. Participants with available clinical data also showed improvements in glucose control and reported improvements in well-being, depression symptoms and self-care.

Participant engagement was also impressive, with 92 percent of participants meeting the CDC definition of program completer by completing at least nine of 16 core lessons online. These lessons focus on topics like nutrition, activity level, and breaking unhealthy habits. On average, participants engaged with the program nearly 20 times every week.

In its 2016 analysis, the CMS Actuary reviewed three Diabetes Prevention Programs (DPP) – one hosted by the YMCA, one certified by the Centers for Disease Control and Prevention, and one by a major national insurer.  The Actuary found the results from Y-USA, CDC, and a large national provider DPP indicate that “beneficiaries participating in diabetes prevention programs have achieved success with losing weight and reducing the incidence of diabetes. While each of the programs we evaluated has some limitations, we believe that the results indicate that the intervention has resulted in reductions in medical spending in the near term.”

CMS is now in the process of expanding the Diabetes Prevention Program to Medicare beneficiaries nationwide, buttressed by the evidence that an ounce of prevention now can save pounds of treatment down the road – resulting in better individual health for Americans, and better fiscal health for the U.S. healthcare system. As Congress continues to look for ways to improve the American healthcare system while driving fiscal sustainability, prevention will be critical.