A guest essay by Maria Alva
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Thursday, July 7, 2022 | The Latest Research, Commentary, And News From
Health Affairs

Dear John,

Today's newsletter is written by Maria Alva, an assistant research
professor at the Massive Data Institute at Georgetown University's
McCourt School of Public Policy.

Alva works on impact evaluations, cost-effectiveness, health service
research, and preventive health. Her latest research

focuses on healthcare gaps.

For more curated newsletters by health policy experts, join Health
Affairs Insider
.

Diabetes Prevention Gap

I led this month's Health Affairs study on the diabetes prevention gap

and what to do about it.

Despite almost 96 million people in the U.S. living with prediabetes,
covered prevention benefits remain woefully undersupplied and underused.

This year marks the twentieth anniversary of the dissemination of the
Diabetes Prevention Program (DPP) clinical trial findings examining the
efficacy of an intensive lifestyle versus pharmacological intervention
(metformin) to prevent or delay diabetes development in at-at risk
population.

Compared with placebo, an intensive lifestyle (defined as increased
physical activity of at least 150 minutes per week and lower calorie
intake achieved via taught behavioral self-management strategies) and
metformin reduced the development of diabetes by 58 percent and 31
percent, respectively.

In 2010, Congress authorized the Centers for Disease Control and
Prevention (CDC) to establish and lead the National DPP with the goal of
certifying providers to offer this lifestyle intervention for one year,
consisting of sixteen weekly classes followed by monthly maintenance
sessions.

There are now almost 2,100 National Diabetes Prevention Program
suppliers , but only 40 percent have full
CDC recognition status, which is achieved when program milestones such
as mean participant weight loss of 5 percent are met.

Approximately 50 percent of National DPP providers are membership or
employer-based and therefore unavailable to the general public.

Healthcare and prevention gaps-defined as the difference between the
recommended clinical best practices and the care patients receive in
practice-are attributable to all kinds of factors like lack of
coverage benefits, economic incentives, and access to providers.

A major gap may arise due to patients' lack of knowledge about
available and covered benefits. Navigating a fragmented and confusing
healthcare system is particularly onerous for low-income patients.

In our paper, we argue that even if the number of National DPP sites
increases, testing rates improve (currently, testing rates are below 65
percent across most demographic groups), and referrals to the National
DPP increase (according to the latest data, they're 5 percent), a
year-long lifestyle program requires both time and affordable,
nutritious food.

Pharmacological interventions and shorter diet and exercise programs
could widen access to preventive services. Metformin is a leading
pharmacological candidate for diabetes prevention because of its
effectiveness and long-term safety.

The ADA has recommended metformin for diabetes prevention since 2008,
but it is currently in formularies only for patients with type 2
diabetes, as it has not been approved by the Food and Drug
Administration for diabetes prevention.

Medical nutrition therapy is reimbursed by most payers for the treatment
of gestational diabetes and for diabetes self-management and training,
but not for prediabetes.

We suggest three actions to augment prevention efforts:

1. Increase payment for prevention interventions to incentivize supply.
Currently, the costs of delivering the National DPP outweigh
reimbursement amounts.

2. Improve data integration and patient follow-up to better identify
people who are at risk. Universal screening for gestational diabetes
during pregnancy, for example, affords a unique opportunity to identify
women at risk of developing type 2 diabetes with adequate follow-up.

3. Extend the breadth and depth of coverage for preventive
interventions. This also includes waiving coverage limits for preventive
services, which improve the sustainability of health behavior change and
outcomes.

Or it could include implementing population-level interventions
alongside individual-level programs, like building better public
infrastructure or regulating food consumption, reaching more people even
if with a lower impact.

Healthcare gaps can arise in various contexts, not just limited to
diabetes. A market-based healthcare system requires regulations,
especially when it is not profitable due to high churn rates to support
coverage for evidence-based preventive services that require continuity
of engagement and have a long breakeven time horizon.

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, July
8, from 12:00-1:15 p.m. ET for a panel discussion of several recent
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Elsewhere At Health Affairs

Today in Health Affairs Forefront, Megan Coffinbargar and coauthors
discuss how community health workers

have greater visibility recently as the field has placed heightened
attention on the role of social determinants of health in reducing
health disparities.

Richard Hughes IV writes that Justice Gorsuch's message

to states about vaccine mandates may be interpreted to mean that a state
must always offer religious exemptions, which would negate the success
of public health in dramatically reducing the threat of
vaccine-preventable diseases.

Currently, more than 70 percent of our content is freely available -
and we'd like to keep it that way. With your support
,
we can continue to keep our digital publication Forefront and podcasts
free for everyone.

Daily Digest

The Diabetes Prevention Gap And Opportunities To Increase Participation
In Effective Interventions

Maria L. Alva et al.

Risks And Benefits To Community Health Worker Certification
Megan
Coffinbargar et al.

The Supreme Court And The Future Of State Vaccine Requirements

Richard Hughes IV

 

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