Diabetes Prevention & the Medicare Diabetes Prevention ActErin Kibbey, BS, RN, CCRNFerris State University

Hello and welcome to my presentation. My name is Erin Kibbey and today I will be presenting information about diabetes prevention and the Medicare Diabetes Prevention Act. 1ObjectivesDiabetes prevalence & costsDiabetes Prevention Program (DPP) landmark studyMedicare Diabetes Prevention Act of 2013 (MDPA)Implications of proposed legislationKey stakeholdersPolitical strategies

In this presentation you will learn that diabetes is a costly and prevalent disease. However, diabetes can be prevented. This presentation will provide key statistics and evidence related to the prevention of diabetes. The landmark study of the Diabetes Prevention Program, here on referred to as the DPP, will be introduced as well as current legislation seeking to provide funding from Medicare in order for seniors to participate in such programs. Implications and consequences of this proposed legislation, entitled the Medicare Diabetes Prevention Act of 2013, or MDPA, are addressed as well as the identification of key stakeholders and their support for this important legislation. Finally, a summary of political strategies are provided in order to help facilitate the passage of the MDPA.

2Diabetes prevalence, Costs, & Prevention25.8 million people in the United States$174 billion dollars per year1 in 3 adults in the United States will have diabetes by the year 20506 in 10 diabetics have at least one related complicationNorthern Michigan prevalence of 15.2% compared to state and national rates of 7.5% to 9.0%

(ADA, 2011; Centers for Disease Control and Prevention, 2011; Michigan Department of Community Health, 2011; National Diabetes Education Program, 2011a; Northwester Michigan College-Research Services, 2012; Orleans & Cassidy, 2011)

Prevention is possible!

It is estimated by the Centers for Disease Control and Prevention (CDC, 2011) that 25.8 million people in the United States have diabetes and the total costs associated with diabetes in 2007 was $174 billion. Perhaps more importantly, if the current trend in new cases of diabetes continues at its current rate, 1 in 3 adults in the United States will have diabetes by the year 2050 (CDC, 2011). Furthermore, the economic burden of both pre-diabetes and diabetes in Michigan is estimated at $9 billion according to the Michigan Department of Community Health (MDOCH, 2011). As a resident and registered nurse in northern Michigan this disease is particularly concerning since its prevalence is estimated at rates of 15.2 percent compared to state and national rates of 7.5 to 9.0 percent (Northwestern Michigan College-Research Services, 2012). According to the American Diabetes Association (ADA, 2011), complications directly linked to diabetes include heart disease, stroke, neuropathy, hypertension, blindness, and kidney disease. 6 in 10 people with diabetes have at least one of these related complications (MDOCH, 2011).

The good news is that prevention and control of diabetes is possible and the advent of evidence-based programs can be seen as one essential prevention method used to help reverse the growing trends (CDC, 2011; MDOCH, 2011). Many studies have focused on the relationship between dietary patterns and health outcomes due to the fact that not only type 2 diabetes but also coronary artery disease, some cancers, and strokes are leading causes of death associated with unhealthy diets (Orleans & Cassidy, 2011). Additionally, it was found that 50 80% of type 2 diabetes cases are associated with both unhealthy diet and sedentary lifestyles (as cited in Orleans & Cassidy, 2011). In the landmark DPP study it was shown that modification of diet and exercise by participants in a lifestyle intervention group reduced their risk of developing diabetes by 58 percent (National Diabetes Education Program, 2011a).

The high prevalence and costs associated with diabetes combined with the fact that it is preventable and controllable, demonstrate why it should be viewed as a highly significant health care issue that needs addressing. Besides the effort to implement more evidence-based education programs to prevent and manage diabetes, proposed federal legislation in the form of the MDPA seeks to amend the Social Security Act, thus reducing the incidence of diabetes among Medicare beneficiaries, is also being advocated.

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Diabetes Prevention Program (DPP)Landmark study in 2002Community preventionLifestyle interventions58% reduction in risk for developing diabetes10 year follow up reduction in incidence of diabetes by 43%(Diabetes Prevention Program Research Group, 2002, 2009; National Diabetes Education Program, 2011a, S.B. 452)

Currently policy efforts have been focused on the landmark DPP study of more than 3,000 overweight participants with impaired glucose tolerance (Diabetes Prevention Program Research Group, 2002). Results from this important study found that those in a lifestyle intervention group receiving intensive counseling on effective diet, exercise, and behavior modification were able to significantly reduce their risk of developing diabetes. Equally important, these results were validated across all participating ethnic groups and for both men and women, deemed to work particularly well for those aged 60 and older (National Diabetes Education Program, 2011a). This studies lifestyle intervention program or DPP, as mentioned earlier, is the basis for currently proposed legislation under the MDPA. In a 10 year follow up study of DPP participants it was concluded that the positive effects of the DPP have persisted for years, with a reduction in the incidence of diabetes by 43 percent for those in the lifestyle intervention group (Diabetes Prevention Program Research Group, 2009).

4Diabetes Prevention Program (DPP) Study Results(Berenson et al., 2009; Diabetes Prevention Program Research Group, 2002; Franken, Lugar, & Rockefeller, 2012; Rockefeller, 2012b)

As a result of this study and further positive outcomes from replicated DPPs, it is believed that DPPs are a proven, community-based intervention focused on changing lifestyles of obese or pre-diabetic overweight adults through activities that improve dietary choices and increase physical activity in a group setting (Rockefeller, 2012b). Consequently the proposal of the MDPA seeks to improve access for seniors to DPPs by allowing Medicare to provide the program through various community settings, based on a referral from the seniors doctor. It has been estimated that implementation of DPPs nationally could yield $191 billion in savings in over 10 years (Berenson et al., 2009). According to the bills sponsors, the MDPA is nationally endorsed by several prominent organizations, later identified in this presentation (Franken, Lugar, & Rockefeller, 2012).

5Medicare Diabetes Prevention Act of 2013 (MDPA)Federal legislation to amend Social Security ActMarch 5, 2013 Senator Al Franken (Democrat) introduced Senate Bill 452Identical bill introduced as H. R. 962 to House of Representatives on same date by Representative Susan Davis (Democrat)Previously introduced in 2012Bipartisan support

Goal: Reduce incidence of diabetes among Medicare beneficiaries(S. 3463, 2012; H. R. 962, 2013; S. 452, 2013)

The MDPA was introduced in the Senate on March 5, 2013 under Senate Bill 452 by Senator Al Franken, a Democrat from Minnesota. The bill is co-sponsored by 13 Senators, one of which is a republican. Currently this bill is being reviewed by the Senate Finance Committee. Notably, this bill is a re-introduction of prior proposed legislation from Senate Bill 3463 (2012) also sponsored by Senator Franken and previously referred to the Senate Finance Committee. At the time this bill was introduced it was supported by 19 co-sponsors, three of which were republican. An identical bill, under the same name, was introduced to the House of Representatives by Representative Susan Davis (Democrat) on March 5, 2013 (H. R. 962). The House of Representatives bill has been referred to the House Energy and Commerce Health Committee.

The purpose of the MDPA (2013) is to amend title 18 of the Social Security Act to reduce the incidence of diabetes among Medicare beneficiaries. Accordingly, this proposed legislation seeks to invest in the health of seniors by allowing DPPs to be covered by Medicare (Rockefeller, 2012b). In addition, this bill would allow Medicare to provide DPPs in community settings including non-profit organizations, departments of public health, public and private hospitals, and federally qualified health centers that meet established criteria (MDPA, 2013). Based on the current growing statistics regarding the prevalence and costs of diabetes, I believe including DPP as a covered benefit for people on Medicare, who are at high risk for diabetes, will help shift our health system from focusing on treating the sick to one that focuses on keeping people healthy. According to numerous sources, which will be discussed next, it is surmised that this legislation will allow seniors to live a better life as well as save billions of dollars in health care costs. 6Implications of proposed legislationPrevention7 out of 10 eligible for Medicare have diabetes or pre-diabetesImproved access for seniors to national diabetes prevention programPotential reduction in 3 million pre-diabetic individuals from developing diabetesExpansion of programs in community settingsFocus on keeping people healthy

Cost savingsSpending estimates 2011-2020 for Medicare recipients with diabetes & pre-diabetes is $1.7 trillion paid by federal government$191 billion in national savings over 10 years$61 billion in federal government savings over 10 yearsSavings of $4 for every dollar spent investing in programCost-effective way to improve quality of care

(Academy of Nutrition and Dietetics, 2013; Berenson et al., 2009; Franken, A., Lugar, R., Rockefeller, J., IV., 2012; UnitedHealth Center for Health Reform & Modernization, 2010)Creates Jobs

As previously stated, the statistics regarding the prevalence and costs associated with diabetes are staggering. Possibly even more astounding are the statistics referring to the prevalence of diabetes among those eligible for Medicare. Out of those eligible for Medicare, diabetes or pre-diabetes affects 7 out of 10 individuals, however, prevention could be obtained in half of these people if DPPs were accessible (Academy of Nutrition and Dietetics, 2013). In addition, estimates show that spending for Medicare recipients with diabetes and pre-diabetes from 2011 to 2020 will be around $2 trillion, with $1.7 trillion paid for by the federal government (UnitedHealth Center for Health Reform and Modernization, 2010).

The DPP is a structured, 16-session program focused on healthy eating and physical activity; it is designed, tested, and certified by the CDC (Franken, Lugar, & Rockefeller, 2012). With the passage of this legislation, seniors would be able to be accessed for their risk of diabetes at their regular check-up and if determined to be at high risk could be offered an opportunity for enrollment in a DPP. Currently the YMCA of the USA offers the DPP in more than 30 states, although seniors are required to pay out of pocket in order to take part in the program (Franken, Lugar, & Rockefeller, 2012). If eligible Medicare beneficiaries with pre-diabetes were enrolled in a DPP, not only could $61 billion be saved over 10 years, but a potential reduction in three million pre-diabetic individuals from developing diabetes could also result (UnitedHealth Center for Health Reform and Modernization, 2010).Three large private insurers are already backing DPPs for their pre-diabetic beneficiaries at local YMCAs. According to United Healthcare (as cited in Franken, Lugar, & Rockefeller, 2012) they have already had a savings of four dollars for each dollar spent investing in the program. In addition, West Virginia has already received funding to begin DPPs allowing the state to train at least 100 community health workers to help spread the program throughout the state over the next five years (Rockefeller, 2012a). In all, this bill works to improve health, save money, and create jobs; affecting the nation, including nurses and the general public, alike. 7Key stakeholders & their positionsAmerican Public Health AssociationPhysicians or ProvidersLifestyle coaches, Nurses/Diabetic nurse educatorsResearchers/Task Force

YMCANon-profit organizationsDepartments of Public Health

SeniorsFamilies of patients (ADA, 2012; American Public Health Association, 2012; CDC, 2012; Diabetes Advocacy Alliance, 2012; HHS, 2004; McGinnis, 2002; )

The burden of diabetes on our nation is enormous and the key stakeholders are countless when it comes to prevention of this disease, as shown on this slide. In terms of the MDPA, the American Diabetes Association or ADA is a key stakeholder and major national organization believing in DPPs as an important prevention effort and as such strongly supports the passage of this legislation (ADA, 2012). The ADA is also part of the Diabetes Advocacy Alliance, considered another key stakeholder and supporter of this legislation. Their vision is to influence change in health care systems in order to improve diabetes prevention, detection, and care. Members of the Diabetes Advocacy Alliance also include the Academy of Nutrition and Dietetics, American Association of Clinical Endocrinologists, National Kidney Foundation, Novo Nordisk Inc., VSP Vision Care, and the YMCA. The American Public Health Association is another organization supportive of the MDPA. This organization could be considered another key stakeholder that represents health professionals as well as individuals that care about their own health and the health of their communities. The American Public Health Association wrote a letter of support to Senator Franken and noted that they believed the DPP has demonstrated reductions in the incidence of diabetes and has been found to be cost-effective (American Public Health Association, 2012). Another key stakeholder in the effort to pass legislation aimed at prevention of diabetes and the MDPA is the Task Force on Community Preventive Services, or Task Force. The Task Force uses a comprehensive approach to determining the scientific base for community-led interventions related to disease prevention. Recommendations by the Task Force recognize an important link between clinical and community interventions (Mcginnis, 2002). As such, it is believed that pairing aggressive clinical interventions with equally aggressive community action fundamental to broad lifestyle changes should be considered the best approach to diabetes prevention. Since the CDC is the organization funded with the grants to implement the DPPs they would also be considered an important stakeholder. Accordingly, the CDC has received $6.75 million in grants under the Prevention and Public Health Funds (CDC, 2012). In order to expand DPPs, the CDC has developed partnerships for disbursement of the grant monies for qualified programs. In addition, the CDC will work with third-party payers, including public and private health insurance companies, to facilitate performance-based reimbursement directly to organizations delivering the lifestyle change program. Grantees that will be offering qualified DPP programs include: American Association of Diabetes Educators, Americas Health Insurance Plans, Black Womens Health Initiative, National Association of Chronic Disease Directors, OptumHealth Care Solutions, and YMCA of the USA. As recipients of grants for the DPPs these organizations would also be considered key stakeholders and supporters in the implementation of the MDPA and the push towards prevention of diabetes at the community level.

8Political strategies

In an effort to voice support for the passage of the MDPA (2013) a variety of strategies could be utilized. Strategies include a combination of providing awareness of the issue, recruiting additional supporters, and voicing support to legislation. These strategies include:sending letters to Senator Franken and Representative Davis and other bill co-sponsors; calling members of Congressand ask policymakers to support the MDPA;sending letters to the members of the Senate Finance Committee as well as the House Energy and Commerce Health Committee; promoting awareness of the MDPA by writing letters to local and state diabetes organizations; actively recruiting other health care professionals and those inflicted with diabetes or pre-diabetes to educate and gain support of the MDPA; promoting the publication by the National Diabetes Education Program (2011b) called the Power to Prevent: A Family Lifestyle Approach to Diabetes Prevention; andusing social media websites such as Facebook and Twitter, as well as written letters to local news editors.

9Summary

In conclusion, given the current evidence and statistics it is easy to see why diabetes is a pressing health care issue that needs desperate attention. At the forefront of this issue should be the focus of prevention in order to decrease the alarming rates at which people are developing pre-diabetes and diabetes. As such, the DPP has achieved much success according to research studies. To this end, legislation is currently being proposed that would cover participation by Medicare beneficiaries. Economic studies have also provided insight that the DPPs could save trillions of dollars with the passage of this legislation. Several key stakeholders were described, all of which maintain support for the passage of this important legislation. Finally, a description of several political strategies was included in order to help thwart the passage of the MDPA. Thank you, I hope you will join me in supporting the passage of this important legislation.

10ReferencesAcademy of Nutrition and Dietetics. (2013). The preventing diabetes in Medicare act. Retrieved from http://www.phcnpg.org/docs/Legislation/Issue%20Brief%20Preventing%20Diabetes%20Medicare%20Act%20PPW%202013.pdf

American Diabetes Association [ADA]. (2011). Diabetes basics: Symptoms. Retrieved from http://www.diabetes.org/diabetes-basics/symptoms/?loc=DropDownDB-symptoms

American Diabetes Association [ADA]. (2012). American Diabetes Association applauds the introduction of the Medicare Diabetes Prevention Act. Retrieved from http://www.diabetes.org/for-media/2012/medicare-diabetes-prevention-act.html

American Public Health Association. (2012). Legislative update. Retrieved from http://action.apha.org/site/MessageViewer?dlv_id=33542&em_id=28621.0

Berenson, R. A., Holahan, J., Blumberg, L. J., Bovbjerg, R. R., Waidmann, T., Cook., A., & Williams, A. (2009). How we can pay for health care reform. Retrieved from Urban Institute website: http://www.urban.org/UploadedPDF/411932_howwecanpay.pdf

Centers for Disease Control and Prevention [CDC]. (2011). Chronic disease prevention and health promotion: Diabetes. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/AAG/ddt.htm

Centers for Disease Control and Prevention [CDC]. (2012). National diabetes prevention program. Retrieved from http://www.cdc.gov/diabetes/prevention/foa/index.htm

Diabetes Advocacy Alliance. (2012). Letter of support to cosponsors of S. 3463. Retrieved from https://www.aace.com/files/views/090512-medicare-diabetes-prevention-act.pdf

Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393-403. doi: 10.1056/NEJMoa01251211References continuedDiabetes Prevention Program Research Group. (2009). 10-year follow-up of diabetes incidence and weight loss in the diabetes prevention program outcomes study. The Lancet, 374(9702), 1677-1686. doi: 10.1016/S0140-6736(09)61457-4

Franken, A., Lugar, R., Rockefeller, J., IV. (2012). The Medicare Diabetes Prevention Act of 2012. Retrieved from http://www.franken.senate.gov/files/documents/120731_Medicare_Diabetes_Prevention_Act.pdf

McGinnis, J. M. (2010). Diabetes and physical activity: Translating evidence into action. American Journal of Preventive Medicine, 22(4S), 1-2. Retrieved from http://www.thecommunityguide.org/diabetes/dm-AJPM-c-diabetes-and-pa.pdf

Medicare Diabetes Prevention Act of 2012. S. 3463, 112th Cong. (2012).

Medicare Diabetes Prevention Act of 2013. H. R. 962, 113th Cong. (2013).

Medicare Diabetes Prevention Act of 2013 [MDPA]. S. 452, 113th Cong. (2013).

Michigan Department of Community Health. (2011). The impact of diabetes in Michigan: The diabetes burden report and the Michigan diabetes action plan 2011-2014. Retrieved from http://www.michigan.gov/documents/mdch/2011_Impact_of_Diabetes_365234_7.pdf

National Diabetes Education Program (2011a). Diabetes prevention program fact sheet. Retrieved from http://www.ndep.nih.gov/media/dpp-fact-sheet-508.pdf

National Diabetes Education Program (2011b). Power to Prevent: A Family Lifestyle Approach to Diabetes Prevention. Retrieved from http://www.ndep.nih.gov/media/power-to-prevent-508.pdf

Orleans, C. T., & Cassidy, E. F. (2011). Health and behavior. In A. R. Kovner & J. R. Knickman (Eds.), Jonas & Kovners health care delivery in the United States. (pp. 205-231). NY: Springer Publishing Company. 12References continuedRockefeller, J. (2012a). Rockefeller takes aim at diabetes in WV - Bill would extend new prevention program to Medicare. Retrieved from http://votesmart.org/public-statement/733500/rockefeller-takes-aim-at-diabetes-in-wv-bill-would-extend-new-prevention-program-to-medicare#.UVhCjpOcfUV

Rockefeller, J., IV. (2012b). Statements on introduced bills and joint resolutions. Retrieved from http://votesmart.org/public-statement/732727/statements-on-introduced-bills-and-joint-resolutions#.UU8u7ByW_ng

UnitedHealth Center for Health Reform & Modernization. (2010, November). The United States of diabetes: Challenges and opportunities in the decade ahead (Working Paper No. 5). Minnetonka, MN: UnitedHealth Group. Retrieved from http://www.unitedhealthgroup.com/hrm/UNH_WorkingPaper5.pdf

U.S. Department of Health & Human Services [HHS]. (2004). Diabetes: A national plan for action. Retrieved from http://aspe.hhs.gov/health/ndap/ndap04.pdf13