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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.