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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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About Health Affairs

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

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