Today’s Managing Health Care Costs Number is 5%
It’s not easy to design and implement a successful medical management program. Such programs must first identify the right participants – they must be at high risk of something, and they must be at least a little bit motivated. The program must then enroll participants – not easy in a world where many of us only answer phone calls from phone numbers we already recognize, and many mailed letters go unopened straight into recycle. Then the program must deliver an intervention – and these interventions often depend on highly trained coaches or other professionals. These interventions are hard to scale, expensive, and highly-touted results on small pilot groups are often not successfully replicated.
Finally, a medical management program must measure its results. These programs are rarely subjected to randomized controlled trials, and these interventions are often modified “on the fly.” Measurement is often plagued by selection bias (comparing participants with refuseniks), regression to the mean (those with especially high costs might have lower costs the next year even without an intervention), and survival bias (reporting on only those participants who persisted with the program – which makes the program look more successful than measuring on the basis of intention to treat). Reporting bias is also rife – it’s rare to see published accounts of medical management programs that fail.
And then there is the Diabetes Prevention Program. The DPP targets those with “prediabetes,” who are at high risk to convert to diabetes in subsequent years. The program is a 16 hour, four month in-person curriculum – often administered at YMCAs. Participants on average lose 5% of their body weight, and the program has been shown to reduce progression to diabetes by 58%. The DPP was initially validated with a randomized control trial with over 3000 participants – and subsequent studies have continued to show it to be wildly beneficial. The DPP worked even better than Metformin, a drug used to delay the onset of diabetes.
The DPP is also “open source.” The entire curriculum is posted on the Centers for Disease Control and Prevention website. The CDC offers a recognition program – and while dieticians and diabetes educators can teach the course, such certification is not a requirement. A number of commercial companies have built interventions based on the DPP, including Omada Health, Newtopia, and United Health Care’s Real Appeal.I’ve previously criticized an article claiming that widespread adoption of the DPP could save $7 billion a year – but perhaps I judged too quickly. Even if it wouldn’t save $7 billion – keeping diabetes at bay can save hundreds of thousands from heart attacks, strokes, kidney failure, blindness and amputations.
Aaron Carroll has an appreciation of the Diabetes Prevention Program in yesterday’s New York Times’ Upshot. He points out that CMS has just announced that it will provide reimbursement for programs like this – and important step to offering this well-proven program to more Americans.
