CHANGING THE PARADIGM FROM
TREATMENT TO PREVENTION:
A DIABETES CASE MODEL
CONTEXT
by
Marsha Gold, Sc.D.
Senior Fellow
Presentation at the AcademyHealth National Health Policy
Conference
February 4, 2008
Context for This Session
1

Diabetes is a serious and costly illness both in
human and economic terms.

The burden is expected to grow even more
substantial in the future.

The prevalence of diabetes and extent of
complications are to some extent preventable.

What are we learning about ways to shift the
paradigm? What stands in the way of greater
progress?
Illustrating the Challenges from the 60,000
Foot Level: Federal Programs, Policy and
Spending Relevant to Diabetes
2
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The logic model
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Federal department roles and responsibilities
relevant to diabetes

Federal spending on treatment and disability
payments for those with diabetes (compared to
those without)

Other relevant spending: prevention, research
and regulation, food assistance
Acknowledgements and Caveats
3

Work funded with support of Novo Nordisk’s
National Changing Diabetes Program

Large team of staff from MPR

To “think big” we had to make simplifying
assumptions

Results likely to be “roughly right” in overview
but details may lack precision and
comprehensiveness.
Diabetes Contributes Substantially to
Federal Costs
4

$79.7 billion in extra federal medical spending
and $2.5 billion I SSDI/SSI disability payments

We estimated the extra medical spending is 12
percent of all federal health spending in FY 2005
(one in eight dollars)
Diabetes Treatment Related Costs by
Agency
Additional Federal Spending on Medical Care for Those With Diabetes vs. Without, FY 2005
DOD
4%
VA
7%
Other
<1%
FEHB
3%
Medicaid
(fed share)
6%
Medicare
79%
Total federal program spending = $77.2 billion
Source: MPR analysis using cost of illness approach.
Note:
5
Excludes any spending on prevention and screening that is the same for those with and without
diabetes.
The Federal Case for a Reframed
Paradigm
6

Because of the epidemiology of diabetes, federal
programs (especially covering aged and
disabled) bear a disproportionate share of fiscal
burden of diabetes.

The federal government has many ways in which
programs can influence the development and
progression of diabetes.

However many activities go under-recognized
and uncoordinated. (e.g., CDC’s budget is only
11 percent of total relevant prevention funds.)
Logic Model
7

Primary focus is on people and the progression of
diabetes

Progression influenced by (1) individual
characteristics, (2) the broader social system in
which they reside (family, community, broader
environment), and (3) by health care system
characteristics

Prevention: central role of nutrition, physical
activity, and obesity for general and high risk groups

Screening to detect and treat diabetes early to
manage care and avoid complications
Logic Model - II
8

Ongoing treatment of diabetes and support for
people who have impaired functioning due to
diabetes

Individual, health system, and social/environmental
system variables influence success and ability to
avoid disability and other adverse outcomes
(including disability and death)

Programs that account for different subgroups of the
population at special risk

Context: overall policy and social environment, level
of knowledge (research/surveillance)
Federal Activity Relevant
to Diabetes - I
9

Prevention, Education and Assistance Programs:
Diabetes focused work concentrated in CDC, NIH, and
the Indian Health Service. Broader efforts at disease
prevention and health promotion are more widely
distributed (HHS, USDA, DOT, HUD, DOI, etc.) and not
specific to diabetes.

Medical Treatment and Disability Compensation:
Medicare, Medicaid/SCHIP, Veterans Health
Administration, DoD’s TRICARE, FEHBP, Indian Health
Service, Social Security Administration and others.
Federal Activity Relevant
to Diabetes - II

Policy and Regulatory Authority: Dietary guidelines
(USDA/HHS); ERISA, Family and Medical Leave Act and
disability policy (DOL); health claims and advertising
(FTC); food and drugs (FDA); personal and business
income tax policy (IRS).

Research and Monitoring: NIH (various Institutes);
other HHS agencies, USDA, VA, and DoD; national data
systems (NCHS, AHRQ, Census Bureau, Labor and
others); and FDA and other regulatory efforts.
10
Distribution of Prevention Spending
Diabetes Specific
6%
USDA
23%
Other
19%
a
CDC
11%
Other HHS
41%
Total = $3.9 billion, including $3.7 billion in other programs
related to physical activity, diet, and obesity. a
Source: MPR analysis of federal spending, FY 2005.
aIn
addition, a portion of NIH’s $1.1 billion spending in diabetes research goes to support diabetes education and prevention. These funds
are included in other parts of the estimates.
11
$3.1 Billion in Federal Funds Supports
Research, Monitoring, and Regulation
Relevant to Diabetes
RESEARCH AND MONITORING (in billions)
$3.053
Research
$2.604
NIH diabetes related researcha
$1.055
NIH research on related risk factors for diabetes
$0.814
Other relevant research in HHS (AHRQ, CMS, CDC)
$0.076
Other relevant research outside HHS (USDA, Other)
$0.659
Statistical Systems to Support Monitoring
$0.159
Related regulation (e.g., FDA, FTC, Commerce)
$0.290
Source: MPR analysis of federal spending, FY 2005.
aIncludes
12
NIH spending for diabetes education and prevention.
Federal Spending on Food
Assistance Programs
13

About $48.9 billion is spent, mainly by USDA, on
food programs (in addition to nutrition guidance).

$16.5 billion is directly for food and $32.4 billion is
spent on food stamps.

Key programs include Food Stamps, WIC, Child
Nutrition Programs (e.g., School Meals), HHS’
Nutrition Services for Older Persons, and others.
Opportunities at Multiple Points

Integrate prevention and effective care into treatment
programs to reduce complications.

Leverage families, communities, schools, and the
workplace to encourage prevention, detection, and
early treatment of diabetes.

Use existing federal funds in housing,
transportation, and other programs to build
environments that encourage physical activity.

Draw upon the large amount spent on food
assistance programs to promote healthy eating and
physical activity.
14
Areas for Future Consideration
1.
The federal government should take steps to get
the most out of current spending in medical and
treatment programs.
2.
The federal government should lead by example
and effectively promote the health of its workforce.
3.
The federal government should enhance
interdepartmental coordination and more
effectively apply its resources to reduce the risk
factors for and complications of diabetes within the
U.S. population.
15
Logic Model for Diabetes
Presentation
Characteristics
Health Care System
Insurance Coverage
Access to Healthcare
Provider Supply and
Mix

Primary Care
Provider Knowledge

Policies regarding
Reimbursements/
Incentives
Federal and State Policies, Regulations, Surveillance, and Other Activities
(e.g., agriculture, transportation, etc.)
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People
Age
Race/Ethnic Group
Immigration Status
SES/Insurance
Coverage
Family History
Obesity Status
Pregnancy Status
Nutrition
Physical Activity
Family/Community/
Built Environment
Community Wealth
Availabiilty of
Healthy, Culturally
Appropriate Food
Neighborhood
Walkability/Safety
Nutrition/Physical
Activity in Schools
Family Policy/
Support
Socialization of New
Immigrants
Transportation
Diabetes Prevention
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Physician Incentives
Benefits for
Preventative Care
Reimbursement for
Obesity Counseling/
Treatment
Provider Education
Diabetes Prevention
Programs
Nutrition Programs
Physical Activity
Programs
Obesity Prevention
Programs
Screening/Counseling
Programs
Advertising/Health
Promotion
School Nutrition
Policies
Physical Activity
Programs in Schools
Nutrition Education/
Healthy Food in Food
Assistance Programs
Workplace Physical
Activity Promotion
Diabetes Detection
Diabetes Treatment
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Physician Incentives
Reimbursement for
Screening
Provider Education
Clinical Guidelines
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Screening and
Detection Programs
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Community Health
Fairs
Workplace Screening
Programs
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Provider Education
Payment Policy
Subsidized Services
Chronic Care
Management
Clinical Guidelines
Differences in
Treatment by
Provider Type
Medication
Compliance
Self Monitoring
Physician Monitoring
Co-morbidities
Campaigns to
Reduce Stigma
Patient and Family
Empowerment
Policies
Workplace
Accomodations
Assistance from
Charitable
Organizations
Research on Effective Interventions within Settings and Populations
Source: Mathematica Policy Research, Inc.
16
Management of
Diabetes with
Complications

Adverse Events


Disability
Death

Income and Disability
Policy
Where to get information:
http://www.mathematica-mpr.com/health/diabetes.asp
Reports

“Study of Federal Spending on Diabetes: An Opportunity for Change”
(June 2007)

“Study of Federal Spending on Diabetes: An Opportunity for
Change—Executive Summary” (June 2007)

“Study of Federal Spending on Diabetes: An Opportunity for Change”
(PowerPoint presentation, June 2007)

Study of Federal Spending on Diabetes: Summaries of Federal
Government Agencies and Their Relevant Activities. Working Papers”
(January 2007)
White Paper

17
“Federal Medical and Disability Program Costs Associated with
Diabetes, 2005” (September 2007): Provides a focused looked at the
construction of the $79 billion estimates of medical and disability
costs that were included in the main study.