The $174 Billion Question: How to Reduce Diabetes and
Obesity
Alliance for Health Reform
July 23, 2010
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
2
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
[START RECORDING]
ED HOWARD:
Good afternoon.
My name’s Ed Howard.
I’m
with the Alliance for Health Reform and on behalf of Senator
Rockefeller and Senator Collins and our board of directors, I
want to welcome you to our program to look at how we deal with
one of the most insidious threats to good health in the United
States and that’s diabetes but one of the premises of the
recent health reform law is that we need to get a handle on
health care costs.
Where do we find the bulk of spending on health care
among those with chronic conditions like diabetes?
Today’s
program’s a close look at a program built around combating
diabetes at the community level by intervening to prevent those
at high risk of contracting diabetes from doing so in the first
place.
We’re going to be looking at broader lessons and I hope
about broader chronic disease questions raised by this case
example and the proper roles for the private and public sectors
in all this.
Our partner in sponsoring this briefing is the United
Health Foundation, a program associated with the United Health
Group, which has more than a passing interest in preventing the
number of people under their care from developing diabetes.
In the interest of full disclosure, the executive Vice
President of United Healthcare is Reid Tuxson who, by the way,
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
3
has been on the board of the Alliance for a lot longer than
he’s been at United.
So we’re happy to claim him from you.
Here today from United is Dr. Deneen Vojta who’s the
Senior Vice President of their Center for Health Reform and
Modernization.
She’ll be sharing the moderator duties with me
and we’ve asked her to start us off by briefly describing why
we care and maybe why we should care more about preventing and
treating diabetes.
Dr. Vojta?
DENEEN VOJTA:
Thank you.
Can you all see the picture?
This is why we’re here and I ask you to think about this
picture.
This is reality for far too many children in our
country and frankly around the world now.
If we do not address
this issue, there is no way we’ll ever get control of health
care costs unless we reduce health risk and specifically
obesity and pre-diabetes.
Here’s some of the numbers.
Those of you who’re in the
space know this far too well but those of you that don’t,
diabetes is in Lancet, in June of this year, reported that
diabetes doubled around the world to 285 million people just
from the year 2000 to 2010.
What one of the authors wrote was that this was a
public health humiliation and although that’s a strong word,
it’s probably correct.
It doesn’t mean that we need to lay
blame but it means that we have not focused on this huge public
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
4
health issue with the same degree of rigor and intensity that
we have focused on more acute care conditions.
As a result, we know now that children born in the year
2000, one in three of them will develop diabetes in their
lifetime.
Children of certain ethnic groups, the number’s one
in two so sort of striking numbers and again, going back to
this picture, this is a reality for far too many children in
our country.
These children end up becoming young adults who
have children who are employees.
So the cycle, it truly is a
vicious cycle.
So what is the role of a health plan in our new world
of managing health risk?
I’ll start by saying the first
historically, we and others, payers and providers, have done a
really good job of focusing on acute care.
We really get it.
We really get how to manage cancer.
We know how to pay for cancer.
We know how to organize care
for people living with cancer.
We know how to pay for care for
survivors of cancer but what we haven’t done well again is
focus on prevention.
In 1921, Dr. Jocelyn wrote in The New England Journal
of Medicine that physicians should take pride in preventing
diabetes to the same degree that they take pride in preventing
small pox and tuberculosis and that was in this country.
Needless to say those two more overt clinical issues are not a
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
5
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
problem anymore in this country.
What I’m here to say, you’ll
start seeing health plans take pride in preventing diabetes as
well.
Next, we must focus on health outcomes.
If we don’t
reduce health risks, we will never get to fulfilling the
promise of the increased access we got with health reform and
ultimately you will have this iceberg that we’re all going to
hit and the cost continue to rise.
Many of you, if you look at
a lot of health cost statistics, cardiovascular disease is
always at the top.
That’s because, in this country, we tend to
designate cost by service.
So if I go in the hospital and have a heart attack that
gets coded as a cardiovascular service but we re-ran our data
at United Health Care, our commercial insurance company and
instead of running it by service, we ran it by the people.
are the people who are having these services?
Who
In our
commercial book of business, people living with diabetes and
pre-diabetes accounted for 44-percent of the spend.
That’s a big number.
It makes sense because people
with diabetes are the ones having strokes and heart attacks and
amputations and kidney failures and blindness.
Again if we’re
going to get to the root of this problem, we must address this
today.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
6
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
The good news is that we, as payers, are in a unique
position to do that.
We have impressive technology platforms.
We have the population health data we’ll need to work with our
public health partners in making this a reality.
We have
structures to incentivize physicians and consumers to take
better care of themselves and to pay for that care but we also
must think about how we do this and that will take innovation.
Now we all know that if this was a drug or a device
type of issue, we know how to innovate and if we publish
something on a device or drug innovation tomorrow in JAMA or
The New England Journal of Medicine , our colleagues in China
will be using those same services tomorrow but when it’s a more
health service innovation, it takes longer for that reality to
get across the world.
I’ll give you a concrete example.
In 1754, somebody made the connection between Vitamin C
and lemons and scurvy.
It took 41 years before the first Navy
instituted policies to leverage that understanding.
So we know
that because diabetes prevention program and evidence-based
intervention that you’re going to be hearing about later, we
know that works.
What we have to figure out jointly, in a public-private
partnership, is how to execute that across this country.
cannot do it alone.
We
We do have a lot of assets but we must
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
7
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
partner with the community and the public health world to
execute on this.
So we actually have begun this process specifically
partnering and leveraging the assets of the CDC and the YMCA in
the communities to deliver the National Diabetes Prevention
Program.
What that means, briefly, is that we enroll our
commercial and potentially our Medicaid and Medicare lives and
not just United Healthcare branded membership.
This is open to all payers, all insurers and in fact in
the state of Minnesota, Medica was the first non-UHC plan to
participate in this effort.
We enrolled the members.
We
provide the national underlying technology to make sure that
this delivered in the way it was designed and then we can
attract these folks over time.
So what’s really innovative about it?
evidence-based.
This is
Again if the DPP was a pill, it would have
flown through the FDA and we’d all be taking it.
successful.
It was that
There was a 58-percent reduction of conversion
from pre-diabetes to diabetes.
This is preventive care.
is the Diabetes Prevention Program.
This
This prevents people who
have a very high risk of diabetes that is they have prediabetes from converting to diabetes.
So it’s covered under their preventive care benefits.
We are instituting a pay-for-performance so that is our
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
8
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
partners, our community partners, are paid for better outcomes.
Again, this commitment from United Health Group is to go well
beyond the United Healthcare members but also to include other
people from around the nation.
ED HOWARD:
Thank you.
Let me just follow up on something before
we go any further Deneen.
This is very useful to me but one of
the points that we heard over and over in the reform debate is
that unless you reform payments at all levels, you’re not going
to be able to change the way care is actually delivered.
You
may have to do some other things as well.
While you talk about paying for performance to the
people you’re contracting with, what about the people who are
paying you?
What kind of level of understanding of
participation are you getting from employers?
DENEEN VOJTA:
So great questions.
First let me
comment and probably one of the most unique features of this
public/private partnership is the fact that we are paying the
YMCA as a provider.
So we are paying a community-based entity
to provide an evidence-based service, sort of groundbreaking .
So I don’t know if you’ve seen in Health Affairs in
May, they talked a lot about the medical home and different
challenges in executing the medical home across the country and
how you need physician extenders and other community-based
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
resources to make that a reality.
9
Well one of the issues that
comes up in every article in that journal is reimbursement.
So the first answer to your question, I would say is
that we are actually reimbursing the Y as a claim for this
preventive, evidence-based, proven service.
Second question is
how are we changing the payment system?
So when we presented this to most of our employer
partners and our own fully insured United Healthcare, the
evidence is so compelling that everybody has bought into that
we must pay for this preventive care service if we can reduce
the incidence by 58-percent.
So one by one, they are turning
on this network to their members.
ED HOWARD:
Very good, thank you very much.
Let me
just do a little logistical homework before we get to the rest
of our program.
You have in your packets, some important
information including speaker biographical information more
extensive than I have time to give them or that they deserve.
You will also find the PowerPoint presentations of those who
have them, lots more background available on our website at
allhealth.org.
Web cast and pod cast of this briefing available
probably Monday at kff.org thanks to the Kaiser Family
Foundation and it’s providing that service for all of our
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
10
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
briefings and in a few days, you’ll be able to read a
transcript of the briefing on our website, allhealth.org.
You have in the packets a green question card that you
can use at the appropriate time.
There are also floor mics
once we get to the Q&A part and a blue evaluation form that we
respectfully request that you fill out before you leave so that
we can help improve these programs as we go along.
One other logistical note, often in this room we find
ourselves at a temperature that is uncomfortably cool.
there anybody who is uncomfortably cool today?
you’ve been outvoted [laughter].
Two.
Is
I think
I would urge you to borrow a
sweater so that we can keep it as a respite from whatever
degree day of heat it is out there.
We have a terrific panel for you today and we’ll hear
some brief presentations and then open it up to questions.
Leading off is Dr. Ronald Ackermann.
He’s an Associate
Professor at the Indiana University School of Medicine.
He’s
involved in the leadership of several different programs at the
university including their Center for Diabetes Translational
Research.
He’s a general internist by training with advanced
training in a bunch of different fields.
He’s consulted for
every imaginable governmental agency involved in this issue and
has also not coincidentally done the definitive evaluation of
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
11
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
the Diabetes Prevention Program that you’re hearing about
today.
So Ron thank you for being with us.
We look forward to
hearing from you.
RON ACKERMANN:
Great, thank you.
So I’ll dive right
in and I have this first slide and the purpose of it is to
really make the connection, first, between diabetes and the
obesity epidemic that’s plaguing our entire population.
First
and foremost, I think we all recognize that the obesity and
overweight problem is a population problem.
There’s no escape from it.
It really is affecting all
corners of our nation and at the bottom of the funnel, diabetes
and heart disease and stroke are the types of conditions that
we clearly need to become better at managing in the health care
sector but most people would recognize that the health care
sector has a clear position in trying to or a clear lever in
trying to impact the care of individuals who already have those
chronic conditions.
Certainly there are many of them.
In between is this continuum of really the development
of obesity-related complications and there are many.
arthritis.
There’s hypertension.
There’s depression.
There are
There’s high cholesterol.
There’s, you name it but diabetes is
perhaps the most connected to obesity.
If you look at the trends in overweight and obesity
over the last 40 years, diabetes is the chronic condition
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
12
that’s really most connected to the development of the shape of
that curve.
In between prior to the development of diabetes is this
condition we now call pre-diabetes.
high-risk.
We’re also calling it
That is one way to describe very high-risk of
obesity-related complications.
I just want to make clear that
when we talk about pre-diabetes or talk about that high -risk,
we’re not just talking about a little bit of sugar.
These individuals are, tend to be on averag e,
overweight or obese.
They have high cholesterol, high blood
pressure and are at a very high-risk of a chronic condition in
the near future somewhere between around 30-percent of those
individuals will develop diabetes in a five-to-seven year
period.
It’s not a small problem.
There are 80 million to 85 million individuals who now
meet either the fasting, the two-hour glucose or the A1C
criteria that ADA now uses for defining high-risk.
problem.
It’s also population-based.
care sector.
It’s a big
It transcends the health
We really must find a path that bridges the
health care and other sectors to identify and manage this
problem.
I should say just a few things about the diabetes
prevention program itself.
The DPP clinical trial was funded
by NIH, by the CDC, and other partners.
It was a national
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
13
comparative effectiveness trial in 27 centers with over 3,000
participants.
They were all overweight or obese and had pre-
diabetes.
What the study found is that in comparing just basic
advice that you might get at the doctor’s office once a year or
twice a year to a pill, actually using a diabetes pill, to
intensive lifestyle intervention.
It was the intensive
lifestyle intervention that worked the best.
It prevented more than half of the new cases of
diabetes.
groups.
It worked for all age and economic and racial
It worked across the United States and those findings
have now been replicated worldwide with more than 5,000 total
individuals.
It’s important to understand what the lifestyle
intervention is.
Just saying it’s a lifestyle intervention or
that it was intensive doesn’t mean a whole lot.
I think the
main message is that obesity and weight loss literature have
shown that the types of interventions that work and work the
best and tend to be most cost effective are those that combine
both diet and physical activity.
So they’re setting behavioral goals for both of those.
They tend to meet on an average every week to two weeks for an
acute phase.
For the DPP, it was the first four to six months.
Then they continue.
They don’t stop.
You don’t graduate from
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
your behavioral change.
support.
14
You actually do continue to need
So the DPP is a continuous intervention that meets
monthly.
It was a one-on-one coaching intervention.
important to recognize.
That’s
The goal was not 40 pounds of weight
loss or 50 pounds of weight loss, which is a lot of what my
patients tell me they want when we start to discuss weight loss
interventions.
It was seven-percent of body weight, which
amounted to about 13-14 pounds on average.
It’s an ongoing
support structure not just teaching didactically but actually
supporting with a social structure.
It’s important to recognize that in the DPP, one did
not need to lose 50 pounds to be successful in preventing
diabetes.
Many people think boy, weight loss, yes it’s not
going to happen in the real world.
It’s too hard.
People
won’t do it.
In the DPP, half of the people, only half, achieved the
goal of just seven-percent of their weight loss but on a whole,
the whole population regardless of that weight loss, over half,
58-percent of those cases were prevented by this intervention.
Just one kilogram or two pounds of weight loss reduces the risk
of diabetes by 16-percent or about a sixth.
So it’s important
that small change is important and complete success is not
essential.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
15
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
On the DPP, I like this slide because it talks about
really all of the benefits on one slide, not all of them but
many of them that I think our society values.
to recognize these.
It’s important
So if we were to deliver the DPP or just
to offer it to 100 high-risk adults, so people with pre diabetes at age 50, it’s about the average age of the DPP, for
three years that’s the duration of the DPP, it would prevent 15
new cases of Type II diabetes, 162 missed work days.
It would avoid the need for any blood pressure or
cholesterol pills in 11 people, would avoid the equivalent of
$91,400 in health care costs.
That’s in 2008, U.S. dollars and
it adds the equivalent of 20 perfect years of health, all
things that I think we value as a society.
So that was published, those results, not in this
format but were published in 2002, why is there not a DPP
franchise on every street corner?
costly.
It’s first and foremost too
If you put it in terms of 2008-2009 U.S. dollars, it’s
about $1,800-1,900 just in the first year and about half of
that more in each subsequent year per person.
It’s also very intensive to deliver this one-on-one
format, the DPP occurred in research settings on academic
campuses by masters level dieticians and physiatrists and
people with a lot of training.
So the overhead is high.
The
delivery model is not particularly efficient and it’s not
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
something that intensive of an intervention.
16
It’s not
something we routinely deliver in health care or in most
community settings.
So those were some major challenges.
So we embarked, in 2003, on the development with the
YMCA of developing a model for DPP delivery that could address
those barriers.
Our approach was not to say great, lifestyle
prevents diabetes.
Let’s put four sessions on a web module and
fling it out to everybody.
We knew that we needed to maintain
fidelity to the DPP approach.
We know that it needed to be
intensive.
There needed to be relationships and it needed to be
continuous over time.
However we needed to find a way to
minimize the intervention costs and our challenge was then to
see if we could deliver those 16 core sessions and those
monthly maintenance sessions in a group format.
So instead of delivering it in one-on-one fashion,
could we do it in a group of 10 on average?
We also felt that
it was important to think about the future scaling of this
intervention.
So working with the Y as a national organization
made a lot of sense.
We also made the decision rather to not involve masters
level physiatrists and dieticians in the delivery of the
intervention but wellness instructors at the Y who were hourly
employees and that were lay people in the community who were
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
17
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
trained to deliver this in a structured way but did not have
sort of this same cost that it would be to deliver the DPP in
its original format.
What we have found and this summarizes a lot of work
over seven years across actually about five studies on one
slide, but these studies have all involved co mmunity
comparative effectiveness trials delivering the group DPP in
partnership with the YMCA versus more standard lifestyle advice
like the DPP initially something like an hour a year at most of
education.
What we have found is that in those randomized
experiments out in the community, when we offer people the YMCA
intervention free of cost, about 70-percent of people actually
decide to go at least once or participate in that program.
So
that’s good just to show that people actually get to the Y and
do participate.
The average weight loss among those who do attend at
least once is five-percent to 6.8-percent and that’s a range
across our studies thus far.
So that is very much consistent
with the DPP where the average with this one-on-one more costly
intervention was more in the range of seven -percent.
We also, in a study that we hope to have published very
soon, weight losses we’ve now observed almost three years, twoand-a-half years and still maintaining 4.8-percent weight loss.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
18
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
So people frequently say yes you can do it but they’ll never
keep it off.
This intervention does work.
continue it but it does work.
You have to
The cost of the DPP delivery,
important to recognize in the study, was about an eighth of the
original DPP, so far less expensive and that you can imagine
that it becomes more sustainable and more scalable.
So this is my recipe for DPP translation or scaling.
It involves finding the right people.
right point in time.
You have to be at the
These are the people at-risk for obesity-
related complications now.
It’s not that we don’t need
interventions to deal with the obesity epidemic at other levels
but this intervention, which is much more intensive needs to be
focused at the right population at the right time.
We need to have the right intervention that can’t be
distilled down to let’s do it four sessions, let’s do it over
the web.
That needs to still be studied.
if that will work.
We just don’t know
It’s a great question to ask but we’re not
sure.
So it needs to involve modest weight loss goals,
lifestyle, both diet and activity changes, and ongoing support.
Then we need to channel like the YMCA which is national.
It
does not reach everybody but it does reach 2,700 sites and
10,000 communities across the United States potentially.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
19
That channel should be accessible to people, the costs
included in that, and it needs to be coordinated with the
patient-centered medical home.
So I don’t mean to
overmedicalize the issue but finding pre-diabetes today
requires a glucose test to really nail it down and the best
place we think to do that is in the clinical sector.
At the same time even in the best of circumstances,
people that do very well in the DPP program, some of them will
still develop diabetes and they need to have access to their
usual medical care so that that care can pick up for the
management of their chronic condition.
So with those ingredients, I think that we build the
potential for a sustainable and valuable service for the entire
country.
I won’t talk about this last slide in the interest of
time but there is a handout that you have but it may be the
focus of some of our conversation at the end, really what we
could do or what agencies could do to help to promote this
process and help it to move forward so that we can scale this
really cost effective program.
ED HOWARD:
Terrific.
Thanks very much Ron.
are pleased to welcome Lynne Vaughan.
Next we
She’s the Senior Vice
President and Chief Innovation Officer of the YMCA of the
U.S.A., which sort of has a rhythm to it doesn’t it?
The
Village People could do something with that.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
LYNNE VAUGHAN:
ED HOWARD:
20
I think they’ve already done something .
Lynne’s been in charge of finding and
getting running for the Y a whole slew of major initiatives
over the last few years.
She’s developed programs specifically
dealing with overweight children while at the Y in Milwaukee
and she led the project aimed at transforming the Y itself to
address the current health care crisis in the United States.
So we’re really pleased to have you with us today.
LYNNE VAUGHAN:
Thank you so much.
This is a little
bit like the gathering of the family in our partners up here
and some new friends as well.
I am very pleased to be here
today, on behalf of our nation’s YMCAs and the fact that every
day in those communities, they are helping kids, families, and
adults thrive in improving the life and the quality of life in
that community and that’s what this is really all about.
How can we collectively be sure that we can improve the
quality of life for people who are at-risk who struggle every
single day with lifestyle health issues and making those every
day healthy choices that allow us to be healthy and whole and
really have a quality of life that we deserve and were put on
this earth to have.
Those of you in this room have a lot to do with some of
how that can happen as you advocate on behalf of this kind of
work and the work that you do every single day.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
21
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
What I’m going to share with you a little bit is how we
are going to take this to scale in the Y with our partners and
with the systems and processes and policies that we have in
place in the Y but with a recognition that it is clear that no
single entity can do this alone.
This is something that really when I think it was
Hillary Clinton said, it takes a village, this one, it really
does.
happen.
It really is going to take all of us to make this
What I’m going to do is cover these topics very
quickly and make sure that you have a sense of how we’re going
to move forward in this initial phase of the dissemination of
the DPP through the YMCA.
One of the things that you might ask is well why the Y?
the fact that the YMCA has been a pioneer in healthy living for
over 160 years and when we begin to think about the Y and our
mission and our values and the work that we do, we have been a
social innovator who continually looks at how we can improve
what we do based on the needs on community and neighborhoods to
make sure that we are improving the quality of life for
everybody.
It’s interesting the things that are up there that we
have been pioneers with are very much purposefully done.
One
of the things you may or may not know is that the YMCA invented
basketball.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
22
Well when James Nay Smith tacked that peach basket to a
ladder in a YMCA college where he was training youth workers,
it wasn’t because he knew he was inventing something that the
NBA would make a whole lot of money on.
It was because we were
teaching young men how to work together to be able to reach
greater goals for themselves.
When we looked at resident camping, it wasn’t that we
wanted these pristine places out in the wilderness that the
YMCA could just have and bring people to, is that we knew that
young people needed healthy living in the out of doors,
learning to live with other young people in a cooperative
environment so that they would learn the values and the
cooperation and the collaboration skills that would then
benefit them for a lifetime.
When the YMCA started after school childcare, it wasn’t
because we thought gosh these kids, we can do something fun and
play with kids and keep them in a place after school.
It was
because working mothers, for the first time, were entering the
workforce and families needed us to be able to make sure that
their children were safe and that they could go and be
productive for their families.
So through the years, this innovation, this social
innovation that has become the YMCA continually calls us in
different ways to do different things and the Diabetes
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
23
Prevention Program, the work that Ron has done, the work that
Deneen speaks of, is calling us to really think about the work
of the Y in a new and different way.
The work that we’ve been doing over the last eight
years in the YMCA is we have looked at this lifestyle health
crisis and focused on people who need us most has been very
much about how do we make sure that what we do every day helps
people reach their fullest potential and engages them in the
behavior change that’s going to require for them to make
everyday healthy choices and therefore those kids, their
families, and the adults actually have that healthy life.
So millions of children, adults, and families are
receiving the kind of support for healthy living and when we
begin to think about the next generation, when somebody’s up
here in another five to 10 years and talking about the Y as a
social innovator, they’re going to talk about the Diabetes
Prevention Program because it is placing us in the forefront of
this public health issue in a way that is calling on us as a
community-based organization to help really galvanize and bring
together the community and work together with the medical
community, the for-profit community, the government to be able
to make this happen across our country.
We have an amazing footprint.
a goal.
Our goal is this.
Ma ke no mistake, we have
We want the Diabetes Prevention
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
24
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
Program to be offered in every YMCA in this nation.
When Ron
Ackermann and David Marrero began to work many years ago at the
Indianapolis YMCA to do these early studies, we knew that the
potential of this was amazing.
We hoped that the kind of results that they would get
would really give us the confidence to be able to take this
nationwide.
We are at this amazing place right now.
Can you
imagine if this program was offered in all of these communities
across the country and was accessible to so many people in all
kinds of communities in all kinds of neighborhoods?
Now what’s amazing about the YMCA, it’s not just our
footprint and the community-based nature of what we do.
It’s
the fact for us to be able to scale this, obviously we need our
partners and we’re going to talk a little bit about that but we
also know that we have the systems in place and the processes
in place to make sure that we can train with fidelity that we
can develop the systems to provide the oversight that this
isn’t just about the dissemination of the program.
This is the dissemination of an evidence-based program
that we need to make sure continues to have the fidelity every
place it is held so that we can help build the confidence of
providers, of our providers at CDC, and of those individuals
who’ve been doing this program for a long time at Indiana
University that we’re going to be able to do this with
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
fidelity.
25
We have a network that’s committed and connected and
the learning inside of that network is amazing.
Ron talked about the beginning of the DPP, the history
of the DPP, but a few things I want to just lift up.
So the
federal investment to date in this has been $200 million and
still it has not been delivered to that many people across our
country.
It’s not gone to scale because in its original format
it’s just too expensive.
Well now we have an evidence-based,
cost effective, community-based intervention that the nation’s
largest nonprofit community-based organization is ready to
deliver on but we cannot do it alone and it’s going to take all
of us.
It’s a dream that we are so close to having the reality
of that in place.
We know that we can do this and we know that
community is ready and that there is no doubt after Deneen
talked and Ron talked about the need for this in our country.
As we have developed plans to take this, the stars
began to align when we began to talk with our partners at
United and that for the first time, we began to look at what an
important part of our puzzle this was and how important it was
to have a payer at the table.
This is, and Deneen said it, the first time that there
has been a partnership of this kind that there has been the
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
26
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
kind of reimbursement that we’re describing here and that we
are beginning to slowly roll this out across the country.
You
can see the seven communities where we’re beginning but the key
ingredients and the reason this is so important and so much of
a hallmark for public health is that it’s sustainable because
of the people who are involved in this.
It’s evidence-based because of the good work that Ron
Ackermann and Indiana University has done.
It’s available to
all and that this is something that is important that it is
connected to every part of our communities with the racial
disparities that we see related to health care.
It does ensure
agnostic in that there are many places where other insurance
companies, as Deneen referenced, can access this.
It is
performance-based.
We, at the Y, get paid by United if we can deliver on
the weight loss that’s required to really make this program
effective in the lives of people and that there are quality
assurances in place through a data system and through the
national oversight that the YMCA of the U.S.A., our national
office for the Y is going to have to make sure that it is
again, there’s fidelity and there’s performance as we work with
our YMCAs.
Our other partner for this is the CDC and the CDC has
recently been, over the last number, I think probably a year
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
27
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
more working on the National Diabetes Prevention Program.
Ed
actually already asked us earlier on, well wait a minute, this
is the National Diabetes Prevention Program we’re talking about
and then the CDC has a National Diabetes Prevention Program
that’s already in Congress and it’s an act and everything.
So
is it the same and well you know, it’s the same name used for
two different things.
It is a program and one of the things that we’ve been
working on over the last little bit of time is that we worked
with Senators Frankin and Luger to secure an amendment to
health care reform to establish the National Diabetes
Prevention Program at CDC.
It really is the way in which the
Centers for Disease Control, the Diabetes Division of CDC, is
going to have a national training and recognition program for
community-based DPPs, that has quality insurance, applied
research, and model sites as a part of it.
Why this is important is that there needs to be a level
of quality assurance for this program.
Ron made kind of a joke
and said surprise that there’s not on every street corner one
of these program because it is something that’s effective.
It’s something we should get out there but how do you know that
on every street corner that that program has the fidelity and
is really the standards are in place for that?
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
28
Well that’s what the CDC is going to be developing, the
kind of system that is going to provide the oversight and
recognition to programs that begin and entities that begin to
offer the Diabetes Prevention Program nationwide.
It’s going
to provide the payers an opportunity to understand that they
can have confidence in this and it’s going to attract others to
this.
We are beginning to work, and have for a while, with
the CDC on some model sites to make sure that we can begin to
look at how we spread this, it’s kind of pilots for them in
this work.
We’re starting small with the CDC.
We’re starting
small with United Health Care and this is where we’re going.
Remember that map I showed you with all those dots?
This is the way we’re starting.
We’re starting in a
very measured approach to make sure that we’re going to
continue to get the results that were gotten at the very
beginning at Indiana University, the translation, the
replication, and the dissemination between the YMCA working
with the Centers for Disease Control and the United Health
Group.
Our goal is that ultimately the YMCA is delivering this
in the 100 largest MSAs in the country and that we are able to
bring this to scale over time.
Rest assured, we know that we
will not be the only provider for this program ultimately.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
29
There will be many more programs that will pop up but
we are there early on with our partners.
It will be many more
that will follow but what we’re doing is we’re paving the way
with fidelity and making sure but we cannot do this alone and
we cannot do this without the support of the federal
government.
We need the government’s help to make sure that
this spreads with fidelity.
We need to make sure that we fully
fund the National Diabetes Prevention Program.
The Urban Institute has said that making this program
available nationwide with organizations like the Y, we can save
$190 billion over 10 years.
In order to be able to do this, we
need to be able to scale the DPP, which means that we’re going
to need $80 million a year and we need this from the mandatory
prevention funds that are already there.
We know that you work in this world and that you have
an interest in making sure this happens.
which we can begin to move forward.
we have the CDC’s training.
This is the ways in
It’s going to ensure that
It’s going to ensure that we have
the public education in place.
It’s going to ensure that we can begin to build the
capacity in our YMCAs and the 100 largest MSAs where, by the
way, 50 million of the 57 million people with pre-diabetes
live.
It’s going to be able to activate referral networks.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
30
This is the next step to be able to have the resources in place
to make this happen.
So we’re taking it to scale in the Y.
with our partners.
We’re doing it
We’re very serious about making sure that
this lives in every community that the YMCA is and helping pave
the way for others in partnership wit the CDC, Indiana
University, and United Health and hopefully you in the room who
want to advocate on behalf of getting the resources to be able
to take this to scale.
The other thing we’re doing is we are building
something that can be used as we move down the road in looking
at the other public health issues like childhood obesity.
ED HOWARD:
Great.
Thank you Lynne.
As it turns out,
we’re going to check your footnotes because we have the author
of that Urban Institute paper or at least lead author, as our
final panelist.
We’re gong to hear from Dr. Robert Berenson.
He’s a Fellow at the Urban Institute and I’m pleased to say, a
frequent panelist on Alliance panels.
Bob’s also an internist by training.
in the D.C. area.
He ran a PPO here
He’s Vice Chair of the Medicare Payment
Advisory Commission.
He’s held senior positions in a couple of
administrations here in Washington including as Chief of the
Medicare Payment Policy at CMS in the late 90s.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
31
He happens to be one of the most thoughtful policy
analysts around.
He has just returned recently from a visit to
look at diabetes programs in Germany and even more recently,
he’s returned from the West Coast on the red eye.
So we’re
really appreciative that you made it back for our program.
Bob, thanks very much.
ROBERT BERENSON:
I actually got four hours’ sleep and
you think it’s hot in Washington, you should go to Phoenix
[laughter] where I’ve just been for four days.
for the frying pan into the fire as they say.
be back in cool Washington [laughter].
It’s like going
So I’m happy to
The purpose of what I’m
doing here is not to give a presentation but to start some
commentary, which I hope we can then get into dialogue and get
some Qs and As going.
This was a very impressive set of presentations and I’m
reminded of a quote, well from an article recently from Bob
Kane who’s a Professor of public health at the University of
Minnesota who’s a long-term veteran in looking at chronic care
programs.
He wrote, in a recent review, asking whether chronic
care management programs works for people with chronic
conditions is like asking whether antibiotics in general work
for infections in general.
There’s the policy community still talks in sort of
this generalities when you need to bring the kind of precision
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
32
that you heard about today, a program that is targeted to prediabetics or early diabetics related to weight loss is a
different kind of a program than one might envision or develop
for somebody who’s had diabetes for 20 years and has renal
failure and maybe has had a stroke and it may be different from
somebody who maybe has multiple chronic conditions and is frail
elderly and the idea that we still analyze disease management
work as a general question is just something we need to put
behind us.
You’re hearing about a very specific intervention,
evidence-based, and we should be moving to a stage of policy
development where we can say that program works under these
circumstances and it doesn’t mean that it’s going to work for
other conditions or in other circumstances.
appreciate that.
So I very much
A related issue is the question that gets
raised a lot, does prevention save money?
You heard that the Urban Institute, in a paper that I
was the lead author but actually one of my colleagues did most
of the investigative work in this particular topic, found that
diabetes prevention saves money.
Vaccines save a lot of money.
Colorectal screening
probably doesn’t save a lot of money but it’s probably a good
thing to be doing.
It’s again we need to get beyond sort of
this does prevention save money.
It’s the kind of analysis
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
33
[inaudible] these kinds of programs [inaudible] management
because it’s relevant in a couple ways.
I didn’t come with slides.
Perhaps later in the year
when I actually have written something up, maybe it would be
worth laying it out more formally but I think there’s some
interesting lessons.
I went over there because for, I’ve been sort of
toiling in the field of chronic care management for almost a
decade since I left CMS and I had been hearing about German
disease management.
It became part of their statutory health
insurance program meaning that it became a universal program in
Germany.
I’ve been looking and others have been looking at sort
of the U.S. model of disease management, which typically means
either whether based in the health plan or usually with a stand
alone vendor, nurses and call centers establishing
relationships with patients often on the phone around
particular conditions and trying to motivate behavior
improvement but importantly for some conditions like congestive
heart failure identifying early deviation from normal
functioning, say in heart failure, weight gain so that you
could do an immediate intervention to prevent it from getting
out of control.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
In Germany they don’t do it that way.
34
Their disease
management, what they mean by disease management is very much
embedded in the physician clinical practice.
So one issue this
brings up is we just have a terminology issue and it would be
nice if there was some agreement on what everybody meant by
these things.
Essentially what happened in Germany was that in the
early part of the century, they were moving towards a more
competitive model of delivery with sickness funds, which are
the equivalent of our health insurers being able to compete for
patients as opposed to in the past where they tended to have
patients who would have their sickness fund associated with
their particular job.
They opened all of that up so that
individuals could choose across sickness funds, a form of
managed competition, but what they lacked was a risk adjustor.
So as in insurance models all over without risk
adjustment, insurers want healthy people and they don’t want
sick people.
They didn’t, at that point in Germany, physicians
were not providing codes that are used to do the risk
adjustment.
That’s what we now do in the U.S. for Medicare
Advantage, so a very creative legislator who was actually a
physician who entered the legislature said we got two problems.
One is we need a risk adjustor and two, he and his
colleagues at the University of Colon had been studying
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
35
deficiencies in care for diabetics and said let’s put the two
together.
For health plans or sickness funds that have disease
management programs for diabetics and they defined what that
meant in terms of what the physician practices had to do to get
extra money, they would pay those sickness funds extra money.
So it was a crude form of risk adjustment.
The plans had an incentive.
incentive to do disease management.
The sickness funds had an
So he would solve two
problems at once getting some start at the risk adjustment,
two, get some programs in place to improve diabetes care and
it’s actually pretty basic.
You have to understand that in
Germany, one of their problems is that physicians, we talk
about hamsters on a treadmill describing the life of primary
care physicians.
In Germany, a GP who’s the equivalent of our
family physicians, sees 60 or 70 patients a day not the 25 or
30 that American docs are complaining about and what would
happen is they would be reactive to patients coming in because
they were so busy they would frequently not schedule follow-up
appointments.
They would frequently not do hemoglobin A1C levels and
monitor and most importantly, at least in the view of the
researchers at Colon, they often weren’t doing blood pressure
checks on their diabetics, which may be the biggest pay off at
all is to control blood pressure in patients with diabetes
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
36
because of the synergistic harmful effects of hypertension and
diabetes.
So they created a very basic set of expectations for
what the physicians’ practices had to do to get extra money.
It looks like it was tremendously successful.
I should add the
program was voluntary for patients and voluntary for physicians
and about two-thirds of patients with diabetes signed up and
about two-thirds or three-quarters of doctors signed up.
Unfortunately they didn’t, at that point, sort of randomize
anybody.
So it’s hard to have a control group.
They’ve attempted to match the patients and there’s
probably some significant bias in terms of the doctors who
signed up and the doctors who did not sign up, the nature of
their care but they are showing in their early findings
dramatic reductions in mortality in diabetics.
This is diabetes, not number one diabetes, number two.
This is the condition that tends to be associated with obesity
and where the complications are usually supposed to develop
over many years that are already finding reduced mortality and
cost with in about a six or seven-year window.
The point of all of this is to make this point is that
they acted very opportunistically and very targeted.
What we
had an opportunity of doing about five-six years ago when all
the big sort of attention to pay for performance developed was
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
37
to pick a few conditions like diabetes, have some very specific
concrete measures for performance, work with those clinicians
and those providers, hospitals, and others who have a role to
play in diabetes management and target those efforts to improve
care.
We chose basically not to do that.
We said let’s have
all doctors of all kinds have performance measures and we
diffused the whole program.
I think this is no time for me to
fully develop the argument but I think we would be much better
off if we picked the areas where we know we can make a big
difference and really do something very strategically as a
value-based purchaser to improve the care in those areas.
Diabetes seems to be that one such area.
We now have
some evidence of success so that we were able to write in our
report that a real attention to diabetes could result not only
in improved care but in savings.
I’m just about out of time.
I wanted to raise just a
couple of, put a couple of questions on the table for my
colleagues if I could and then I’ll stop.
One for Deneen is
the issue that we’ve heard over the years of do health plans
invest in prevention if there’s no return on investment over a
relatively short period of time, the theory or the concern
being that investment might benefit some other payer down the
road but it might not reward our work right now.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
38
So I guess my question is to what extent is United
convinced that there’s an immediate return on investment and
that’s why it was something that United has engaged in if there
hadn’t been an immediate return but that the return was five or
10 or 20 years down the road, would the organization have
thought differently about what sounds like a very innovative
approach.
I guess my question for Lynne is to what extent, at
this point, the Y has direct relationships with schools where
it seems to me a real opportunity around physical education,
nutrition, and those kinds of things where I mean I am, as
somebody said earlier, there’s an absolute role for the health
care system but to some extent we don’t want to medicalize
everything.
There’s clearly a role for schools and the broader sort
of social institutions we have around this obesity epidemic and
it seems to me the Y is perfectly positioned as sort of move in
both directions in this area and with that, I’ll stop.
ED HOWARD:
Two very good questions.
We’ll have three
moderators I think. Deneen, you want to try to respond to Bob’s
first question?
DENEEN VOJTA:
Sure thank you and thank you for a great
presentation especially on four hours’ sleep.
about you but I’m pretty impressed.
I don’ t know
Certainly the issue of
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
39
return on investment comes up a lot from our plan sponsors,
etc.
I think at United Health Group and payers across the
country, what we are beginning to see an adoption of is the
philosophy is that we pay for evidence-based care.
So that is really critical because once you sort of
make that commitment and you partner with the government
agencies who make some of those decisions whether it’s the
USPSTF Taskforce, etc., and so experts in their field in a very
narrow and focused way, they tend to go out to very specific
experts to decide what is evidence-based care.
Historically we’ve all thought about that in the more
acute care guidelines but now with the attention on preventive
care, I think you’ll see payers like us regardless of the ROI
focus on what works.
So another specific example will be the
recent attention to child obesity as a B recommendation both
for the screening and referral for intervention for children
who are overweight and obese.
ED HOWARD:
Yes, Lynne you want to address the other
question about relationships with schools?
LYNNE VAUGHAN:
Yes.
So one of the things that you may
or may not know about the YMCA that nationwide, we are the
largest provider of after school childcare and the majority of
those programs are actually in the school system.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
40
We have a very strong program and after school and have
worked with the Harvard School of Public Health to create the
environmental guidelines that we’ve put in place to ensure that
there are healthy snacks, adequate physical activity, and the
kind of relationships and environments that support healthy
living in those sites.
In addition to that, we have 10 million children a year
that are involved in our programs.
So many of those programs
are physically active programs where it is about teaching kids
to swim, being engaged in new sports leagues, being in our day
and resident camps and those activities really then do actually
contribute to the prevention of childhood obesity as we’re
teaching children the benefits of playing.
Lastly one of the things that we are seeing in urban
communities in particular, there are YMCAs who are going and
actually offering physical education in the schools where the
school has maybe had to cut that and looking at unique ways in
which we can ensure that that is happening.
So our
relationship, in fact our number one partner in most
communities, is the school.
ED HOWARD:
We’re getting a bunch of questions.
Deneen’s got one in her hand that actually’s pretty intriguing.
Why don’t you go ahead and read it?
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
41
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
DENEEN VOJTA:
Sure.
Just one more comment to Lynne’s
response would be that as you know, many school nurses now,
it’s interesting to look at the training they receive and
really are becoming public health officials for their
community.
They’re beginning to be trained in statistics and
evidence-based medicine.
councils, etc.
They’re actively joining wellness
So I think in the future, there’ll be more and
more opportunity to work closely with those organizations.
So
we have a question.
I’m curious about the 43-percent of the population who
does not live near a Y or one population that comes to mind are
Native Americans who are at very high risk for diabetes but
little private insurance.
What is being done to test and lower
cost model interventions of DPP in a population where there’s
no Y or no private insurance?
Ron, do you want to start
talking about the Indian health services participation?
RON ACKERMANN:
Sure.
So Lynne can comment on this too
but the Indian health service certainly has done a lot of
really excellent work in diabetes prevention.
It’s clearly at
the focus of issues that are extremely important to Native
Americans across the country.
There are currently efforts
across IHS to build a diabetes prevention program nationally
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
42
and the challenges are great because it’s not always that you
can coordinate people in one place.
Native Americans live throughout the country and the
services they receive need to be accessible from where they
live.
So there is a lot of effort being put in led by Kelly
Actin and others in the IHS.
I know that there is some work
developing actually with the YMCA and other partners to develop
that.
There is evidence the same as with other participants in
the DPP.
The DPP involved three to four Native American sites so
there was actually an oversample of Native Americans who
participated in the DPP and it was an effective intervention in
that group as well.
So it’s a very important question,
important target community and there are initiatives going on
that I’m not completely familiar with the details of all of
them.
LYNNE VAUGHAN:
One of the things that just recently
has happened at the head of our government relations office
here in Washington, D.C., Audrey Haynes was just at a meeting
of attorney generals where there were some conversations about
how can the Y and United Health Service begin to work together
particularly with those populations that are near some of our
urban centers.
So it’s an interest we have in making sure that
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
again we’re portable with this program.
43
It really can go many,
many places.
ED HOWARD:
Well nice segue way to a follow up question
from another person in the audience wanted to know whether this
plan could plausibly extend into rural communities.
I noticed
that it was a much higher concentration of those little dots on
the right hand side that on the left hand side, can this still
be effective and even cost effective in sparsely populated
communities?
RON ACKERMANN:
Let me begin by just saying that since
we began this, our work in the area of translating the DPP
seven and a half years ago, we have worked very closely with
the YMCA.
on the map.
They are a wonderful partner.
There’s a lot of dots
They have an extraordinary commitment to this.
The program of DPP in the community has no requisite to be
delivered by the YMCA.
It can be delivered by many other community partners.
The challenge is maintaining that fidelity and that consistency
with really a few, our partnering with a health plan or with
the medical community in the area, is it still something worth
paying for?
Has it got diabetes prevention in the name but we’re
not sure what we’re getting or is it this type of program that
has structure and is based on evidence.
That’s what the CDC is
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
44
tasked to achieve and their resources are somewhat limited in
scope given the enormity of the problem but the training and
sort of recognition of organizations that would deliver groupbased community DPP is not YMCA specific.
ED HOWARD:
One other related question that is being
raised about this aspect and it’s nominally directed to Dr.
Ackermann and I have a related question from a trainer at my
gym [laughter].
The question on the card, any controls in the research
for socioeconomic resources for participants that do class and
neighborhood have a relationship to healthy food access, the
presence of any health community centers.
I got this email
from a trainer in our gym today.
Anyone heading off to the supermarket with a shopping
list of the best recommendations for a healthy diet is in for a
bit of sticker shock.
The University of Washington study recently tracked
the cost of nutrient-dense foods, good foods versus energy dense foods, junk foods and the study found that getting your
average 2,000 calories a day from the junk food side costs
$3.52.
Getting it from the nutrient -dense cuisine would cost
$36.32.
It raises the question of how you continue and maybe
this part of it is better directed to Lynne, how do you make
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
45
sure there is continued compliance or whatever the current word
is with the diet part of this program when you have situations
like this?
RON ACKERMANN:
Yes.
It’s an extraordinary challenge
and you can imagine when you’re teaching somebody and modeling
how you read or interpret a food label, there’s an interaction
there with literacy, with educational attainment.
there’s rural/urban challenge.
Certainly
There is cultural differences
in communities about eating preferences.
So there is a lot of
background that interacts with the achievement, average
achievement one might expect, from just basic content delivered
vis-a-vi the DPP program.
In the DPP study and in many of our studies, we
included people from across those populations and we do see
that the intervention works differentially depending on
people’s food access and people’s ability to walk safely in
their communities.
You can tell people that but if it’s not
going to happen in the real world, it’s not a reasonable thing
to teach.
So even in delivering this in a group setting, you must
individualize the content and understand, there must be a
connection between the organization and the group instructor in
that group in that one understands the culture and the reality
of what these people face in their daily lives.
You can
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
46
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
imagine that that’s why it’s so important that we don’t try to
scale this in a vacuum.
Delivering and disseminating something like the DPP as
a preventive program, partnering community with the clinical
sector across the country will work much better if we have food
and nutritional policies that make food access more available
in underserved areas that make physical activity more feasible
and more safe for individuals and more normative culturally.
So we need those other policies that transcends maybe the
discussion here but it’s so connected and it is important that
we continue on all of those fronts.
LYNNE VAUGHN:
So the way we look at this and approach
it in the Y and it’s something that’s what you live in this
community too, the program is one thing but there are policy
and environmental factors that have to be taken into
consideration and that it’s not the program in the vacuum from
all of those other things.
So looking at the community, looking at where the
community change and the policy change actu ally needs to happen
and to make sure that we’re really operating on all of those
fronts is really critical.
BARBARA PRIMLOW:
Barbara Primlow, the American
Association or People with Disabilities and I was wondering if
this program is accessible to people with disabilities.
One
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
47
concern is people with intellectual disabilities, as you
mentioned, and the other would be people with mobility
impairments.
RON ACKERMANN:
So in our studies, there is some
limitation to the involvement of individuals with cognitive
impairment at baseline because most of the IRBs do not allow us
to involve participants with severe cognitive disabilities at
baseline in this type of program because of the difficulty in
communicating risks and benefits of the research and that’s the
pure and only reason.
We do have several individuals in our studies and as
did the DPP who have physical disabilities.
We have had to
develop policies over time about what does the Y or what does
the program look like for those individuals.
That’s why it’s
partly why it’s important that it is both a program of food and
of activity behavior.
There are physical activities certainly that people
with disabilities participate in and can participate in
regularly.
There has to be an understanding of what’s safe and
what an individual can achieve and it has to be tailored at
that level but most of the dietary changes certainly are
translatable to those populations as well.
So it might be that in some circumstances the program
shifts its goals more towards food as a means to achieve the
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
48
weight loss goal as opposed to certain activities but we try to
continue to do both and we have had many people with physical
disabilities and some that have developed cognitive
disabilities in our programs in Indianapolis.
BARABAR PRIMLOW:
We’d be happy to serve as a resource
for you if you want to try and approach an IRB with a risks and
benefits at a lower reading level.
RON ACKERMANN:
That would be wonderful and maybe we
could talk more too because we had gone to the, maybe I
shouldn’t throw things at other people but we have gone to some
groups and actually not had a very good, it wasn’t a bad
experience but they really didn’t have anything to give us that
said this is how you assess safety for physical activities.
BARBARA PRIMLOW:
give resources.
We’d be happy to work with you and
I’ll talk to you after this.
RON ACKERMANN:
ED HOWARD:
Thank you.
That would be wonderful.
Thank you.
Yes, go ahead.
GRETCHEN YOUSEF:
Hi, I’m Gretchen Yousef.
I work for
MedStar Diabetes Institute here in Washington, D.C. and I
actually manage the DPP here in D.C. and I just wanted to talk
a little bit about the model that we set up.
I’ve been doing
the DPP in our community since 2008 and we love the idea of the
Y and I applaud the Y for taking this on and I think it’s
fantastic but in the district, there isn’t a Y in every ward.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
49
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
So we are going to be placing and working with the
Department of Health and so far we’ve placed the DPP in one rec
center in ward five, which is appeared near the hospital center
and we’ve been doing that for almost two years now and in this
fall, we’ll be starting one in ward seven.
So we feel like it’s right there in the community.
What’s great about placing very similar to the Y is that they
have free exercise programs so people who are not exercising,
come in join the program, start exercising and people who are
there already come for the service.
So if anybody’s interested here in the group in seeing
the DPP actually implemented, you’re welcome to contact me.
I’ll be back here and you can come out and visit our site.
ED HOWARD:
program comes from?
Could I just ask where the support for your
Is it internal to MedStar?
GRETCHEN YOUSEF:
Well it was actually my first gr ant
was through the Department of Health for my first 226
participants and after the money ran out and ended, we just
continued doing it.
I just got additional funding.
So we have
funding for one more year to implement it but I didn’t want to
step out when we got it started.
It was such a great response
from the community.
ROBERT BERENSON:
Ed can I just make a comment?
I mean
it will be interesting when health reform is successful and we
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
50
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
cover more than 30 million more people for not-for-profit
hospitals to sort of justify their not-for-profit status
providing community benefits.
This is the example of an excellent community benefit
that we would expect not-for-profit hospitals to be doing, in
some cases on their own dime rather than needing specific
funding.
So it suggests that there’s various sources of
support for these kinds of programs.
hospital would be doing it.
I think it’s great that a
I think that was the point I
wanted to make.
ED HOWARD:
Yes, you and then in the back.
FEMALE SPEAKER:
[Inaudible] from the American Medical
Association just following up on the two points that were made.
I echoed that in terms of the success of the program being run
through MedStar because there was a series in the New York
Times last year, I think it was, about diabetes programs that
had been run by various non-profit institutions, hospitals, and
they stopped them not because they weren’t successful.
It was
a very similar model and they were very successful but because
they lost money.
ED HOWARD:
Because they were successful [laughter].
ROBERT BERENSON:
I mean I remember that was a very
powerful set of articles and I mean it does go to the perverse
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
51
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
incentives that hospitals in particular face for doing the
right thing.
Their business models, they keep beds full.
A lot of them are able to rise above that at times but
when it directly goes to the bottom line and there’s a major
loss on the books, the CFO tends to become more important and
the medical director tends to become less important than those
internal discussions.
That’s why some of the some of the
payment models and organizational models in the health reform
were that important to see if we can get that right where
hospitals.
To me the real test of whether we’ve come up with a
good payment model will be whether a hospital actually does
well by keeping somebody out of the hospital rather than the
current situation because we can’t just rely on good will.
So
that’s the test.
So accountable care organizations seems to be the major
one but also related to the new payment for avoidable
readmissions.
I mean we’re beginning to sort of identify and
see if we can change those payment incentives but I agree
they’re very important too.
A mission-based hospital can’t do its mission if it
doesn’t have a positive bottom line.
I think sometimes that’s
an easy excuse sometimes but that Times article I’d recommend to
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
52
anybody to sort of get a picture of the day-to-day reasons why
the right things aren’t done even when they work.
LYNNE VAUGHAN:
Don’t you agree Bob, unfortunately if
you try to run a program like the DPP in the cost structure of
today’s hospitals, it makes the situation even just more
expensive.
So for example, one could imagine a partnership
between a hospital and a local YMCA or another community-based
provider because the original DPP, it’s not that the results
didn’t work, it’s that it was $1,800 a participant in the first
year.
There are 57 million folks, U.S. citizens, with prediabetes.
The math just doesn’t work out.
The really exciting
part and again about the good work the CDC and the Y did was
they were able to translate this into an intervention at a
price point of between $250 and $300.
Now we have a financial model and the link to an
evidence-based intervention.
So I’m not sure that ultimately
the hospitals themselves will be the ones delivering the DPP
but certainly in their relationships, the medical homes and the
ACOs referring to community-based providers.
ROBERT BERENSON:
I think that’s right.
I think that
Times article was referring to sicker diabetics who were
getting interventions that were preventing hospitalization not
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
53
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
the early diabetic or the pre.
I mean that’s the point of
bringing some precision to the intervention.
I think you’re absolutely right for what the Y is doing
right, where the Y exists.
It may be that the hospital
shouldn’t try to replicate it but the previous commenter made
the point that the Y wasn’t everywhere.
for the hospital to be doing that.
So it was a good thing
So I mean health care is
local and the solutions will be variable but I generally agree
with your point.
NAIVA THOMPSON:
Hi.
My name’s Naiva Thompson.
I’m a
preventive medicine physician who initially trained in internal
medicine and saw first hand why programs like this are needed.
I think just would like to ask you any suggestions for, I know
my colleagues and myself were looking for positions that allow
us in the community to do this population-based prevention,
chronic disease prevention, and like you’re saying it’s not, we
can’t bill for it.
We can’t do the group meetings and just suggestions as
a provider, what we can do to further this work or where we can
be helpful because individual level of medicine is important
but a lot of us know that population level medicine is also
very important but unfortunately there’s not as many
opportunities for us to do that so just any guidance you might
have.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
DENEEN VOJTA:
54
I think one of the first things is that
we have 85-percent of people living with pre -diabetes and 25percent of people with full blown diabetes are unaware of their
condition.
We have got to get people screened and how do we,
per the guidelines, etc., and how do we work with physicians
like yourself who get that to get our colleagues, I’m a
physician as well, how do we get that word out because it just
doesn’t seem to happen.
The second major role for physicians beyond everything
else they do is to begin to recognize the power of the Y and
actually make referrals just like we made to a cardiologist or
to an oncologist but to a Y?
David Williams, former CDC
director for diabetes translation wrote an article called The
One Minute Brief or something and said today if a primary care
physician identifies somebody with pre-diabetes, the standard
calls for them to give three to five minutes of brief
counseling on exercise and diet.
That’s usually of an average of a 10-minute visit.
It’s too hard to happen but what if, instead, they could take
30 seconds and write a prescription to the Y but that sounds
good.
So I think we’d love to think with people like you about
how do we execute on that?
How do we engage the physician
community and make those, it seemed easy for the sailors to eat
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
lemons, right, but that didn’t happen for 41 years.
55
Hopefully
we can figure these two pieces out in less than 41 years.
ROBERT BERENSON:
a lot of work to do.
At least theoretically, we have again
The patient-centered medical home would
have at least a mixed payment stream where physicians are
continuing to get paid for their face-to-face visits with
patients.
And some kinds of education can be done there, but that
there would be a per member or per person, they’re not members,
there’s no enrollment, per person per month payment to the
practice to have the kind of team in place where if no t you
perhaps you.
But perhaps somebody trained in the practice would be
able to be supported for spending the necessary time or
alternatively and there’s Vermont, North Carolina, some other
places are testing the model in which that capability resides
in the community, the Community Care Network approach in North
Carolina and that the physicians would then have in the
community, not in some call center on a phone somewhere but in
the community, immediate referral centers.
But if I were practicing today, I would love to know
that the Y had an evidence-based success and would be writing
that prescription all sorts of times.
I mean that was one of
the most frustrating.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
56
I won’t say it’s the reason I gave up practice but one
of the major reasons I gave up practice was the frustration of
not having the skills or the time to deal with lifestyle
issues, to deal with true prevention, to have patients taking
responsibility.
I wasn’t trained to know how to do that and
I’m glad there are people who do know how to do that in the
community.
ED HOWARD:
Before we go to this questioner, let me
just remind you we’re moving through the Q&A session and if you
would make sure that as you go through this, you pull that blue
evaluation form out and start to fill it out.
appreciate it.
We’d very much
Yes Bob?
BOB GRIST:
Bob Grist with the Institute of Social
Medicine and Community Health.
The panel has been talking
about this particular evidence-based model for which is cost
effective for a highly selected, targeted population.
You’re
saying that public health is good for other people but this
particular program can be shown to be cost effective for this
high-risk population.
I can see why it would appeal to a health provider
who’s on the hook for medical expenses for that population but
I’m not sure I understand how this model is going to defuse
into a more active public health approach in this country.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
57
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
Bob Berenson contrasted the German approach with the
American one, which seemed to be defusing more the guidelines
for appropriate diabetes treatment.
I’m thinking that so many
of the health conditions, which show up in the health care
system are preventable.
The literature says it’s more effective to invest in
that than it is to invest in quality health care even.
I don’t
see how this demonstration is going to further strengthen our
public health approach to chronic conditions.
ED HOWARD:
Good question.
Is this a model to build on
or is it specific to a particular condition? Ron?
RON ACKERMANN:
I think it’s both of those things.
I
think that it doesn’t solve the societal problems of
deterioration, so to speak, and lifestyle behaviors of physical
inactivity and of unhealthy eating.
It addresses an issue, as
I pointed out, before 30-percent of people in this 80 milli onperson group, 30-percent of them will develop diabetes in a
five to seven-year period.
Not only is that an issue of cost and the costs are
burdened by those individuals, are burdened by the health
system, they’re also burdened by everybody else whose health
premiums increase as costs of care increase with the prevalence
of chronic conditions.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
58
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
So it’s an issue that has to be addressed specifically.
It’s important to address it.
We don’t think one can wait
until the long-term policies, programs that do need to be
developed to address the societal and cultural sort of deepseated issues that transcend us.
They go well beyond the issue of people with prediabetes.
Those need to continue.
You don’t do this first and
then wait because something else is a long-term payoff.
it’s a long-term payoff, you got to begin it now.
planting a tree.
If
It’s like
If it’s going to take 20 years to grow, you
don’t wait 20 years to plant it.
So I think we need to do those things.
We need to find
out what are the specific levers that are most going to have
the biggest impact and are going to be the most cost effective
and are feasible to begin to implement today.
I’m not sure for
a lot of those things we know that.
If you go to the Community Preventive Services
Taskforce website who reviews a lot of environmental and policy
interventions and you click on obesity, they’ve reviewed
school-based programs and given it insufficient evidence.
There’s a lot of other things that have been attempted
and we’ve got to begin sorting through this and figuring out
what we can do at a more societal level but I do think this
model, which is specific does set a model.
It’s not the only.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
59
It’s in our disease management, Bob used the example of
disease management, I think there are examples within the
disease management realm for congestive heart failure and
particularly for individuals who’ve been hospitalized recently
where you can have a very strong, immediate impact that’s cost
effective.
You can also have a longer-term impact on things.
So I think we do need to be precise.
We do need to be
dealing with issues at hand now today with dedicated programs
if it’s feasible to sustain the added funding.
intensive program.
This is an
It requires a lot of additional resources.
To whom do we direct those resources now to have the
biggest bang for the buck?
Your point is well taken and I
think that we need those initiatives as well and they need the
current parallel.
ROBERT BERENSON:
points.
My only comment would be just two
One is this one is so important that even if it was a
unique program, I think we should do it.
As I said earlier, we
diluted the potential impact of getting physicians involved
with this by sort of coming up with three measures for every
physician, some of which aren’t scientifically based on
anything rather than sort of targeting a major societal issue
where we could actually make some improvements.
So I would do
this.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
60
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
My concern, which I suggested in my question was, cost
effective isn’t necessarily the same as cost reducing.
I mean
this apparently is effective at accomplishing the outcome that
is being, it’s efficient achieving the outcome that the program
is designed for.
My hat is off to United if they are truly doing
evidence-based policy making.
I still have a concern that in
our system the things that have a positive benefit but are
costly will be not done and the things that do have an
immediate return on investment will be the ones that we do,
which is better than nothing but still we can’t, I mean I think
your point is pretty well taken.
I met with some French insurers a couple weeks ago and
there they provide sort of supplemental wraparound insurance
because it’s a social insurance system but they had a concept
and I wish I remembered the exact terminology they use,
something like a social compact of cross-insurers that they
would sort of all agree to invest in activities that helps
society even the particular return on investment for an
individual company might not be strong.
It seems to me that within the constraints of anti trust rules and stuff, we could probably be doing or we should
be doing something like that.
Payment matters.
So I think we
could get payment better too.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
ED HOWARD:
Good.
JANET GORWITZ:
61
Go right ahead.
Hi, I’m Janet Gorwitz, I’m a health
policy fellow at the Center for the Study of Presidency and
Congress.
I’m a rising second year medical student.
So I’m
really excited to see where medicine could be going in the
future if these kinds of things work.
I had just a quick
technical question.
Are you paying the YMCA for success in achieving
outcomes, for instance, in losing weight or are you paying them
for implementing the program for a particular person?
For
instance, we said that it doesn’t work for everyone and no
program works for everyone but are they still going to get paid
for the time that they’re investing.
DENEEN VOJTA:
model.
Great question and it’s a combined
So there’s a service element payment for enrollment and
completion but there’s also an outcomes payment for the fivepercent weight loss that we knew led to the 58-percent
reduction but there’s another nuance of the study and help me
here Ron but at nine-percent weight loss, there’s an 80 -percent
risk reduction.
So there’s a fourth payment as well.
ED HOWARD:
Is the weight reduction measurement, on
average, across the enrolled population, is it not on a personto-person basis?
DENEEN VOJTA:
Person-to-person basis.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
62
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
ED HOWARD:
I’m sorry, person-by-person.
failure and we don’t get any payment for you.
You’re a
You only lost
four-percent.
DENEEN VOJTA:
I think in year one, first of all, as I
said to Lynne, we’re putting in the rounds.
We’ve made a
tremendous financial investment and people investment in really
trying to get this wheel’s up.
How do we execute on and
operationalize a 16-session lifestyle intervention that’s being
delivered in the community, so pretty hard.
So I’ll say for year one, we came to an agreement as is
and I think that our goal was certainly to make the Y whole for
their costs but to absolutely use the power of incentives both
for members and for providers to see if we can even do better
than that 58-percent.
Remember that was a five-percent weight loss on the
average so not everybody got to that five-percent but the way
the payment structure is designed on the other half is that
nobody will lose in this methodology.
We just think that
there’s more to gain and that we should share in that gain.
LYNNE VAUGHAN:
The systems that are going to be in
place or that are in place to be able to do this as we roll it
out are very much around our ability to be able to watch and
learn.
That’s the other thing about this whole project.
When
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
63
we began to think about this specific program, we have taken it
from what Indiana University had done.
We are now taking it to scale but the commitment is to
continue to learn, to continue to monitor the data that’s
coming in and make sure that we have the fidelity to the
program in all of our Ys.
This is a partnership not only
between all of us but also with our YMCAs as they’re delivering
in the sites that we’re beginning to do this with.
DENEEN VOJTA:
We’ve also taken a lot of the costs out
of the system by using technology and leveraging platforms and
point-of-service adjudication and all that stuff that United
Health Group can bring to the table.
to the administration.
So it’ll make it easier
Difficulties in cost become less of a
barrier to providing the actual care.
ED HOWARD:
I think you were here first and then we’ll
go to the back.
LAUREN FISHKIN:
Thank you all for a very interesting
and informative panel today.
You all mentioned many different
stakeholder groups, federal agencies, insurance companies,
clinicians, community groups and the steps that they’re taking
to prevent diabetes but lacking was mentioned of the role of
individual patient accountability and motivation.
So we all know that obviously healthy diet, a healthy
active lifestyle is very effective in helping to prevent
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
diabetes.
64
So my question is what is different about your DPP
program that it will be effective where it’s not just providing
resources to a community but it’s actually engaging an entire
community and individual patients to have a lasting commitment
to change lifestyle?
ED HOWARD:
Do you want to identify yourself?
LAUREN FISHKIN:
I’m Lauren Fishkin, recent Georgetown
graduate.
RON ACKERMANN:
I would say that first of all that’s a
great question and it’s the reason why the DPP is so
structured.
There’s been countless weight and lifestyle change
interventions that preceded the DPP many of which found that as
you reduce the number of support sessions. You reduce the
content.
You reduce the duration of time you spend within a
relationship with supporting somebody who’s trying a lifestyle
change the less you achieve,
the more the weight regain.
So that is why it’s individual accountability and the
struggles that they faced in their sociocultural context they
go back to their lives when they leave that setting and they’re
faced with all of those things, which are the inertia that led
them to get to that place in the first place.
So you need to be intensive.
You need to be ongoing
and I don’t think there’s anything particularly magical about
what the DPP does except for the fact, aside from other maybe
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
65
weight management or lifestyle programs other than it’s added
intensity and support structure.
However the one thing that we do find is that in the
DPP and in our subsequent studies when you find somebody who
meets this, one of these definitions of pre-diabetes, about
two-thirds of those individuals have a first -degree family
member with diabetes.
So family history is pretty common.
It’s common anyway but it is something that when you
talk to an individual, it resonates with them.
They’re there
to prevent their diabetes and there is this commitment too,
which makes it a bit different that you can move around this
issue of you’re here and you’re doing these things to prevent a
chronic condition you don’t want.
They’ve seen first hand the potential complications of
the disease, the complexity of the disease and for the most
part don’t want it.
So it’s, in and of itself, focusing on
this population, having a conversation around the prevention of
diabetes as a reason is something that is additionally
motivating for this group but regardless of that, we do need to
have focus on the ongoing structure and intensity of the
program.
DENEEN VOJTA:
The other thing I would add is that our
approach that we’re taking is very holistic in that we
recognize that this program that the Y is going to be doing is
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
66
done within the context of our organization and very portable.
So we have a very much of a commitment to behavior change and
healthy living in the broadest most holistic perspective.
We work at the community level with our healthier
community work to make sure that we begin to look at the
policies and practices of a community and the programs that
exist outside that so that that individual and their families
actually are supported wherever they go in that community with
the ability to make everyday healthy choices because that’s
what it really does come down to, you’re right.
DEBORAH OUTLAW:
Educators.
Hi, Deborah Outlaw with the Diabetes
I think we all certainly agree that we’ve got to
get more prevention programs into the community and away from
this hospital-based centers that are closing every 30 minutes.
My question, because this certainly has a lot of potential as a
great model, but what I’m not hearing is any utilization of the
specialized diabetes licensed providers like diabetes
educators.
So my question is if you’re not using CDEs at all who
work with diabetes and pre-diabetes then who exactly is
training these quote hourly lay workers at the Y?
RON ACKERMANN:
Yes so one of the reasons why early on
we departed from having this delivered by CDEs was in part the
cost.
The other was the availability of CDEs.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
67
So I’m a part of the largest provider network in
Indiana, the whole state and the part of the provider group I’m
affiliated with has several hundred providers and we had only
CDEs and they were both centered only in the endocrine
practice, which primarily for our practice sees very, very
difficult to treat type II diabetes and Type Is.
So they
weren’t available to us for the intervention delivery.
As we look beyond, it seemed to be the case as well.
Registered dieticians and other potential persons in the
clinical workforce that could play an instrumental role here is
not ubiquitous as well.
If you look across different registered dieticians,
they have very different backgrounds.
So you can get
registered dieticians who know a lot about pre-diabetes and
some that would recommend a meter and carb counting and there’s
not a lot of literature that that prevents diabetes although
that’s what you do in part for somebody with diabetes.
So we lack the knowledge for what to do for prediabetes in our clinical sector when we began this work and it
made more sense to really work with these community lay
professionals.
To answer your question about who’s training them, what
we have done is and this is a work in development, is a need
that becomes when you begin to scale it, now who’s going to
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
train them?
68
When we trained them initially, we can use
researchers who are very familiar with the program to train
these individuals and provide a support structure.
That’s the way the DPP did it initially.
that now.
We are doing
We are building a train-the-trainer program that
will be facilitated through the CDC and supervised and
supported by the CDC.
The train-the-trainer program begins
with basically those DPP investigators who had a lot of
expertise developing the DPP.
They’ve trained a number of people who have taught the
program.
They’ve undergone fidelity monitoring.
We could talk
about later maybe the ways that we do that and eventually
people can become master trainers and we’re at the point now, I
don’t know how many we have, six or maybe more than that,
master trainers who are training cadres of lifestyle
instructors in individual Ys and non-Y professionals in the
community as well.
So I hope that answers your question but that’s the
whole purpose of the CDC structure and it’s in part, the
training mechanism but then it’s also the quality monitoring
and perhaps public reporting of some of the outcome goals and
participation rates that we’ll see evolve over time as a part
of this program that’ll tell us if we’re doing a good job
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
69
teaching the curriculum to the instructors and getting it out
there in a way that ensures fidelity.
Edward Howard:
I know this will be a great question
and I don’t want to put any pressure on you but it looks like
you’ll be the last person from the microphone.
JANET PHOENIX:
I’m Janet Phoenix.
I’m in the school
of public health at George Washington University and my
question has to do with the need for preventive services to be
based in the community that are focused on a number of health
outcomes and perhaps on bundling the ability to provide
services to families that could cut across the gamut of a
number of health conditions.
For example, as a resource that could provide
assistance to families who are at risk for having a child who
could develop asthma or who already have an asthmatic child who
need to increase their ability to have good medical management
and keep their child out of the emergency room, those families
could use access to community-based resources that provide, for
example, mattress covers, pillow covers, integrated past
management and something that could allow them to put resources
into their home that could prevent those triggers that lead
into more expensive care like emergency room utilization.
It seems to me that we need to really be focusing on
creating that community-based prevention capacity and hosting a
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
70
variety of services that could be bundled and that are not
specific to a single disease but that really assess what the
need is in that community and what the needs are in a
particular family or individuals’ environment and can provide
that in the community basis because it’s simply not cost
effective or easy to provide those services in a clinical
setting such as a doctor’s office or a hospital facility.
So I’m wondering if the panel could comment on that
because it seems to me that our prevention messages need to
kind of go beyond a single disease approach and we really need
to be providing a comprehensive set of preventive services for
people.
LYNNE VAUGHN:
I can just speak to that from the
perspective of healthier community work, which is actually
getting at just the thing that you were talking about is how do
you take a look at a neighborhood or community and begin to
identify what those needs are or those gaps in service that
really tie to some of the chronic disease in that community.
In that community work that we’re a part of and t hat
CDC has funded a tremendous amount if you’re familiar with it,
they do go into a community and they look at it from a very
holistic perspective and then they begin to look at how they
can, based on those immediate needs, tackle that.
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
71
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
The bundling thing, we’ve actually talked a little bit
about that with our CDC partners particularly on the healthier
community because when you look at some of this work, you can
take and look at well so hypertension and pre-diabetes and are
there ways to look at that but what we have to really follow
right now, which is where we are, is we’re following the
evidence.
What we know is the evidence related to this, we do a
tremendous amount in those assessment and really looking at
community issues but in this case with this kind of
dissemination, we’re taking the approach with pre-diabetes but
with our healthier community work, it’s very much from the
perspective of looking at the community and then going where
the need in that community is to be able to make sure we are
looking at it holistically.
DENEEN VOJTA:
One last question, Ron I hate to keep
pickling on you but I think it’s worth mentioning.
How will
people with pre-diabetes be identified and referred to DPP
programs since the USPSTF does not recommend screening for prediabetes or diabetes unless they are adults with high blood
pressure.
RON ACKERMANN:
Yes that’s a very good question.
So
the U.S. Preventive Services Taskforce reviewed diabetes
screening a few years ago now and didn’t see direct evidence
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
72
that screening for diabetes in a general population that it
prevents heart health outcomes and so there wasn’t a
recommendation to screen individuals without diabetes with a
glucose test unless they had another condition for which the
management would change if diabetes were detected.
That was the statement of the review and that one could
dream up that that would apply also to high cholesterol and
some other conditions but the statement they released only
mentioned hypertension.
So I think there’s a slight disconnect
there in the wording and it needs to be revisited.
It is an important distinction but even with targeted
testing for diabetes among people with other risk factors that
is a large proportion of the individuals who are impacted
today.
There would be a lot of people with pre-diabetes that
would remain undetected but if we tested everybody with
hypertension and/or high cholesterol for diabetes at an annual
health visit that would be a drastic improvement over what we
have today, which is about seven-percent of individuals saying
with pre-diabetes saying that they’ve been told that they have
pre-diabetes.
So largely this condition remains undiagnosed.
It’s a big problem.
The USPSTF is one organization that sets preventive
recommendations.
Medicare, of course has, through the Medicare
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
73
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
Modernization Act has recommended diabetes screening, which I
think was implemented in ‘08.
It’s to use a fasting glucose
test.
As a provider, I can tell you it’s challenging to
document and code what needs to be coded to perform that test
but it’s there as a potential mechanism.
It certainly is
something that still remains underutilized.
So why is that?
I
think it’s a message that even with U.S. Preventive Services
Taskforce recommendations or Medicare recommendations or
payment policies, it doesn’t make providers necessarily go out
and find these conditions unless there’s a reason, unless
there’s something they can do about it.
In some cases during the phase of sort of making that
change or getting early adoption by health care providers, I
think that one might need to consider the potential other
mechanisms that might incent or reward the finding of targeted
high-risk people who have this condition.
I think we also need to revisit the issue as the ADA
did and recommended this year that we might use a more
practical and more widely available test such as the A1C.
It
does raise a lot of issues and conversation that’s beyond this
panel but I think that’s a more practical strategy.
It doesn’t require an overnight fast.
It’s done in
almost every primary health care center in the country, so
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.
The $174 Billion Question: How to Reduce Diabetes and Obesity
Alliance for Health Reform
7/23/10
74
another mechanism that we might revisit but that is a lever.
That is an important area and there’s several ways where I
think that the provider community’s role in identifying and
documenting that test result will become very important.
ED HOWARD:
Deneen, do you have the final word?
DENEEN VOJTA:
Well first of all I want to thank you
all for staying as late as you have on a Friday afternoon in
the summer.
I wonder how many people would take off for the
Maryland shore human by human here and I hope that you all have
heard us that this is a big issue.
day no pun intended.
It’s getting bigger by the
It’s going to require all of us to focus
on this if we’re going to be successful.
time today.
We do appreciate your
Thank you [APPLAUSE].
ED HOWARD:
Great.
Thank you.
[END RECORDING]
The Alliance makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded
material, this transcript may contain errors or incomplete content. The Alliance cannot be held responsible for the consequences of
the use of the transcript. If you wish to take direct quotes from the transcript, please use the webcast of this briefing to confirm their
accuracy.