CHANGING THE PARADIGM FROM TREATMENT TO PREVENTION:

A DIABETES CASE MODEL CONTEXT

CHANGING THE PARADIGM FROM TREATMENT TO PREVENTION:

A DIABETES CASE MODEL CONTEXT

by

Marsha Gold, Sc.D. Senior Fellow

Presentation at the AcademyHealth National Health Policy Conference

February 4, 2008

by

Marsha Gold, Sc.D. Senior Fellow

Presentation at the AcademyHealth National Health Policy Conference

February 4, 2008

2

Context for This SessionContext for This Session

Diabetes is a serious and costly illness both in human and economic terms.

The burden is expected to grow even more substantial in the future.

The prevalence of diabetes and extent of complications are to some extent preventable.

What are we learning about ways to shift the paradigm? What stands in the way of greater progress?

Diabetes is a serious and costly illness both in human and economic terms.

The burden is expected to grow even more substantial in the future.

The prevalence of diabetes and extent of complications are to some extent preventable.

What are we learning about ways to shift the paradigm? What stands in the way of greater progress?

3

Illustrating the Challenges from the 60,000 Foot Level: Federal Programs, Policy and

Spending Relevant to Diabetes

Illustrating the Challenges from the 60,000 Foot Level: Federal Programs, Policy and

Spending Relevant to Diabetes

The logic model

Federal department roles and responsibilities relevant to diabetes

Federal spending on treatment and disability payments for those with diabetes (compared to those without)

Other relevant spending: prevention, research and regulation, food assistance

The logic model

Federal department roles and responsibilities relevant to diabetes

Federal spending on treatment and disability payments for those with diabetes (compared to those without)

Other relevant spending: prevention, research and regulation, food assistance

4

Acknowledgements and CaveatsAcknowledgements and Caveats

Work funded with support of Novo Nordisk’s National Changing Diabetes Program

Large team of staff from MPR

To “think big” we had to make simplifying assumptions

Results likely to be “roughly right” in overview but details may lack precision and comprehensiveness.

Work funded with support of Novo Nordisk’s National Changing Diabetes Program

Large team of staff from MPR

To “think big” we had to make simplifying assumptions

Results likely to be “roughly right” in overview but details may lack precision and comprehensiveness.

5

Diabetes Contributes Substantially to Federal Costs

Diabetes Contributes Substantially to Federal Costs

$79.7 billion in extra federal medical spending and $2.5 billion I SSDI/SSI disability payments

We estimated the extra medical spending is 12 percent of all federal health spending in FY 2005 (one in eight dollars)

$79.7 billion in extra federal medical spending and $2.5 billion I SSDI/SSI disability payments

We estimated the extra medical spending is 12 percent of all federal health spending in FY 2005 (one in eight dollars)

6

Diabetes Treatment Related Costs by Agency

Diabetes Treatment Related Costs by Agency

Medicare79%

VA7% Other

<1%DOD4%

Medicaid (fed share)

6%

FEHB3%

Total federal program spending = $77.2 billion

Source: MPR analysis using cost of illness approach.

Note: Excludes any spending on prevention and screening that is the same for those with and without diabetes.

Additional Federal Spending on Medical Care for Those With Diabetes vs. Without, FY 2005

7

The Federal Case for a Reframed Paradigm

The Federal Case for a Reframed Paradigm

Because of the epidemiology of diabetes, federal programs (especially covering aged and disabled) bear a disproportionate share of fiscal burden of diabetes.

The federal government has many ways in which programs can influence the development and progression of diabetes.

However many activities go under-recognized and uncoordinated. (e.g., CDC’s budget is only 11 percent of total relevant prevention funds.)

Because of the epidemiology of diabetes, federal programs (especially covering aged and disabled) bear a disproportionate share of fiscal burden of diabetes.

The federal government has many ways in which programs can influence the development and progression of diabetes.

However many activities go under-recognized and uncoordinated. (e.g., CDC’s budget is only 11 percent of total relevant prevention funds.)

8

Logic ModelLogic Model

Primary focus is on people and the progression of diabetes

Progression influenced by (1) individual characteristics, (2) the broader social system in which they reside (family, community, broader environment), and (3) by health care system characteristics

Prevention: central role of nutrition, physical activity, and obesity for general and high risk groups

Screening to detect and treat diabetes early to manage care and avoid complications

Primary focus is on people and the progression of diabetes

Progression influenced by (1) individual characteristics, (2) the broader social system in which they reside (family, community, broader environment), and (3) by health care system characteristics

Prevention: central role of nutrition, physical activity, and obesity for general and high risk groups

Screening to detect and treat diabetes early to manage care and avoid complications

9

Logic Model - IILogic Model - II

Ongoing treatment of diabetes and support for people who have impaired functioning due to diabetes

Individual, health system, and social/environmental system variables influence success and ability to avoid disability and other adverse outcomes (including disability and death)

Programs that account for different subgroups of the population at special risk

Context: overall policy and social environment, level of knowledge (research/surveillance)

Ongoing treatment of diabetes and support for people who have impaired functioning due to diabetes

Individual, health system, and social/environmental system variables influence success and ability to avoid disability and other adverse outcomes (including disability and death)

Programs that account for different subgroups of the population at special risk

Context: overall policy and social environment, level of knowledge (research/surveillance)

10

Federal Activity Relevant to Diabetes - I

Federal Activity Relevant to Diabetes - I

Prevention, Education and Assistance Programs: Diabetes focused work concentrated in CDC, NIH, and the Indian Health Service. Broader efforts at disease prevention and health promotion are more widely distributed (HHS, USDA, DOT, HUD, DOI, etc.) and not specific to diabetes.

Medical Treatment and Disability Compensation: Medicare, Medicaid/SCHIP, Veterans Health Administration, DoD’s TRICARE, FEHBP, Indian Health Service, Social Security Administration and others.

Prevention, Education and Assistance Programs: Diabetes focused work concentrated in CDC, NIH, and the Indian Health Service. Broader efforts at disease prevention and health promotion are more widely distributed (HHS, USDA, DOT, HUD, DOI, etc.) and not specific to diabetes.

Medical Treatment and Disability Compensation: Medicare, Medicaid/SCHIP, Veterans Health Administration, DoD’s TRICARE, FEHBP, Indian Health Service, Social Security Administration and others.

11

Federal Activity Relevant to Diabetes - II

Federal Activity Relevant to Diabetes - II

Policy and Regulatory Authority: Dietary guidelines (USDA/HHS); ERISA, Family and Medical Leave Act and disability policy (DOL); health claims and advertising (FTC); food and drugs (FDA); personal and business income tax policy (IRS).

Research and Monitoring: NIH (various Institutes); other HHS agencies, USDA, VA, and DoD; national data systems (NCHS, AHRQ, Census Bureau, Labor and others); and FDA and other regulatory efforts.

Policy and Regulatory Authority: Dietary guidelines (USDA/HHS); ERISA, Family and Medical Leave Act and disability policy (DOL); health claims and advertising (FTC); food and drugs (FDA); personal and business income tax policy (IRS).

Research and Monitoring: NIH (various Institutes); other HHS agencies, USDA, VA, and DoD; national data systems (NCHS, AHRQ, Census Bureau, Labor and others); and FDA and other regulatory efforts.

12

Distribution of Prevention SpendingDistribution of Prevention Spending

Other HHS41%

Other 19%

USDA23%

Diabetes Specific6%

CDC11%

Total = $3.9 billion, including $3.7 billion in other programs

related to physical activity, diet, and obesity.a

Source: MPR analysis of federal spending, FY 2005.

aIn addition, a portion of NIH’s $1.1 billion spending in diabetes research goes to support diabetes education and prevention. These funds are included in other parts of the estimates.

a

13

$3.1 Billion in Federal Funds Supports Research, Monitoring, and Regulation

Relevant to Diabetes

$3.1 Billion in Federal Funds Supports Research, Monitoring, and Regulation

Relevant to DiabetesRESEARCH AND MONITORING (in billions) $3.053

Research $2.604

NIH diabetes related researcha $1.055

NIH research on related risk factors for diabetes $0.814

Other relevant research in HHS (AHRQ, CMS, CDC) $0.076

Other relevant research outside HHS (USDA, Other) $0.659

Statistical Systems to Support Monitoring $0.159

Related regulation (e.g., FDA, FTC, Commerce) $0.290

Source: MPR analysis of federal spending, FY 2005.

aIncludes NIH spending for diabetes education and prevention.

14

Federal Spending on Food Assistance Programs

Federal Spending on Food Assistance Programs

About $48.9 billion is spent, mainly by USDA, on food programs (in addition to nutrition guidance).

$16.5 billion is directly for food and $32.4 billion is spent on food stamps.

Key programs include Food Stamps, WIC, Child Nutrition Programs (e.g., School Meals), HHS’ Nutrition Services for Older Persons, and others.

About $48.9 billion is spent, mainly by USDA, on food programs (in addition to nutrition guidance).

$16.5 billion is directly for food and $32.4 billion is spent on food stamps.

Key programs include Food Stamps, WIC, Child Nutrition Programs (e.g., School Meals), HHS’ Nutrition Services for Older Persons, and others.

15

Opportunities at Multiple PointsOpportunities at Multiple Points

Integrate prevention and effective care into treatment programs to reduce complications.

Leverage families, communities, schools, and the workplace to encourage prevention, detection, and early treatment of diabetes.

Use existing federal funds in housing, transportation, and other programs to build environments that encourage physical activity.

Draw upon the large amount spent on food assistance programs to promote healthy eating and physical activity.

Integrate prevention and effective care into treatment programs to reduce complications.

Leverage families, communities, schools, and the workplace to encourage prevention, detection, and early treatment of diabetes.

Use existing federal funds in housing, transportation, and other programs to build environments that encourage physical activity.

Draw upon the large amount spent on food assistance programs to promote healthy eating and physical activity.

16

Areas for Future ConsiderationAreas for Future Consideration

1. The federal government should take steps to get the most out of current spending in medical and treatment programs.

2. The federal government should lead by example and effectively promote the health of its workforce.

3. The federal government should enhance interdepartmental coordination and more effectively apply its resources to reduce the risk factors for and complications of diabetes within the U.S. population.

1. The federal government should take steps to get the most out of current spending in medical and treatment programs.

2. The federal government should lead by example and effectively promote the health of its workforce.

3. The federal government should enhance interdepartmental coordination and more effectively apply its resources to reduce the risk factors for and complications of diabetes within the U.S. population.

17

Logic Model for Diabetes Presentation

Logic Model for Diabetes Presentation

Health Care System Insurance Coverage Access to Healthcare Provider Supply and

Mix Primary Care

Provider Knowledge Policies regarding

Reimbursements/Incentives

Physician Incentives Benefits for

Preventative Care Reimbursement for

Obesity Counseling/Treatment

Provider Education

Physician Incentives Reimbursement for

Screening Provider Education Clinical Guidelines

Provider Education Payment Policy Subsidized Services Chronic Care

Management Clinical Guidelines Differences in

Treatment byProvider Type

People Age Race/Ethnic Group Immigration Status SES/Insurance

Coverage Family History Obesity Status Pregnancy Status Nutrition Physical Activity

Diabetes PreventionPrograms

Nutrition Programs Physical Activity

Programs Obesity Prevention

Programs Screening/Counseling

Programs Advertising/Health

Promotion

Screening andDetection Programs

MedicationCompliance

Self Monitoring Physician Monitoring Co-morbidities

Adverse Events

Disability Death

Campaigns toReduce Stigma

Patient and FamilyEmpowermentPolicies

WorkplaceAccomodations

Assistance fromCharitableOrganizations

Income and DisabilityPolicy

Family/Community/Built Environment

Community Wealth Availabiilty of

Healthy, CulturallyAppropriate Food

NeighborhoodWalkability/Safety

Nutrition/PhysicalActivity in Schools

Family Policy/Support

Socialization of NewImmigrants

Transportation

School NutritionPolicies

Physical ActivityPrograms in Schools

Nutrition Education/Healthy Food in FoodAssistance Programs

Workplace PhysicalActivity Promotion

Research on Effective Interventions within Settings and Populations

Fed

eral

and

Sta

te P

olic

ies,

Reg

ulat

ions

, S

urve

illan

ce,

and

Oth

er A

ctiv

ities

(e.g

., a

gric

ultu

re,

tran

spor

tatio

n, e

tc.)

Characteristics Diabetes Prevention Diabetes Detection Diabetes Treatment

Management ofDiabetes withComplications

Community HealthFairs

Workplace ScreeningPrograms

Source: Mathematica Policy Research, Inc.

18

Where to get information:Where to get information:

http://www.mathematica-mpr.com/health/diabetes.asp

Reports “Study of Federal Spending on Diabetes: An Opportunity for Change” (June 2007) “Study of Federal Spending on Diabetes: An Opportunity for Change—Executive

Summary” (June 2007) “Study of Federal Spending on Diabetes: An Opportunity for Change” (PowerPoint

presentation, June 2007) Study of Federal Spending on Diabetes: Summaries of Federal Government

Agencies and Their Relevant Activities. Working Papers” (January 2007)

White Paper “Federal Medical and Disability Program Costs Associated with Diabetes, 2005”

(September 2007): Provides a focused looked at the construction of the $79 billion estimates of medical and disability costs that were included in the main study.

http://www.mathematica-mpr.com/health/diabetes.asp

Reports “Study of Federal Spending on Diabetes: An Opportunity for Change” (June 2007) “Study of Federal Spending on Diabetes: An Opportunity for Change—Executive

Summary” (June 2007) “Study of Federal Spending on Diabetes: An Opportunity for Change” (PowerPoint

presentation, June 2007) Study of Federal Spending on Diabetes: Summaries of Federal Government

Agencies and Their Relevant Activities. Working Papers” (January 2007)

White Paper “Federal Medical and Disability Program Costs Associated with Diabetes, 2005”

(September 2007): Provides a focused looked at the construction of the $79 billion estimates of medical and disability costs that were included in the main study.