Health and Economic Impacts of Coverage Requirements and Health System-Community Coordination for Diabetes Prevention

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Project Summary Currently, 86 million Americans have prediabetes, but 9 in 10 of them remain unaware. Randomized trials have demonstrated that more than half of all new cases of type 2 diabetes can be prevented or delayed when high risk adults are offered resource-intensive lifestyle intervention programs, such as the Diabetes Prevention Program (DPP). While numerous organizations have engaged in efforts to expand screening and subsequent access to interventions for adults with prediabetes, those services are far from routine in clinical and public health practice. However, implementation efforts in this arena are expected to accelerate rapidly during the next 3 years as several forthcoming policies will catalyze efforts to identify and intervene upon prediabetes. The US Preventive Services Task Force (USPSTF) recently issued a grade B recommendation that all overweight or obese adults with cardiovascular risk conditions (including prediabetes) be offered intensive lifestyle interventions, specifically referencing the DPP as a case example. This recommendation, together with Affordable Care Act (ACA) legislation requiring commercial and public payers to provide coverage of USPSTF A and B recommendations, has led payers to begin structuring coverage policies that will include a mix of clinical and community intervention services. In parallel, key stakeholders such as YMCA of the USA and the American Medical Association (AMA) have engineered a series of strategic regional initiatives to strengthen healthcare-community linkages for the screening and diagnosis of prediabetes, as well as the coordination of referrals to community-based interventions, and the billing and payment for delivery of those interventions. In close collaboration with these stakeholders, we propose this natural experiment, employing a mix of qualitative and quantitative research methods, and leveraging available data from the Health Care Cost Institute (HCCI), OptumHealth Care Solutions, and other accessible sources to evaluate the reach, implementation, effectiveness, and costs of these interrelated policies likely to impact the prevention of type 2 diabetes for potentially several million Americans over the next 5 to 10 years. Our proposal aims to: (1) evaluate and compare the impacts of large-scale, regional healthcare-community linkages on changing rates of prediabetes screening, diagnosis, and National DPP intervention attendance following enactment of USPSTF recommendations for those services; (2) describe implementation features and elicit barriers and facilitators of implementation, replication, and future scaling of large-scale regional initiatives; and (3) compare the effects of exposure to the YMCA’s DPP on healthcare costs and utilization for different subgroups of patients with prediabetes. This evaluation will provide critical information about whether particular strategies should be discontinued, refined, or replicated on a larger scale to achieve maximal impact over the coming decade.