Panel Discussion: Prediabetes: Real World Implementation of the National Diabetes Prevention Program

Ann Albright, PhD, RDN Friday, February 9, 2018

1:45 p.m. – 3:00 p.m.

Past, Present and Future of the National Diabetes Prevention Program

This presentation will briefly review the history of the National Diabetes Prevention Program (National DPP), the current status of the nationwide implementation and results to date, along with new things that are coming soon.

The Centers for Disease Control and Prevention (CDC) initiated the National DPP in 2009 with Congressional authorization in 2010. The National DPP serves as the framework for implementing the evidence-based lifestyle change intervention. It is the largest national effort to mobilize and bring the program to communities across the country. It brings together health care professionals, community-based organizations, faith-based organizations, employers, payers, government, academic institutions and many others to help those with prediabetes or at high risk for type 2 diabetes prevent or delay onset of the condition. Together these organizations work to (1) build the workforce to effectively deliver the program, (2) ensure quality and standardized reporting, (3) deliver the lifestyle change program through organizations nationwide, and (3) increase referrals to and participation in the program.

The National DPP has four overarching strategic goals: 1) increase the supply of quality programs, 2) increase coverage and reimbursement for participants, 3) increase referrals from healthcare providers, and 4) increase demand for the National DPP among eligible participants. This presentation will provide the current status in each of these goals, including the changes in the 2018 Standards for CDC recognition and Medicare supplier eligibility. In addition, new tools, services, and campaigns will be described.

References

1. www.cdc.gov/diabetes/prevention2. www.doIhaveprediabetes.org3. Centers for Disease Control and Prevention, National diabetes statistics report: estimates of diabetes

and its burden in the United States, 2017. Atlanta, GA: Centers for Disease Control and Prevention,U.S. Dept of Health and Human Services; 2017.

4. Ely, EK, Gruss SM, Luman ET, Gregg, EW, Ali ML, Nhim K, Rolka DB, Albright AL. A national effort toprevent type 2 diabetes: Participant-level valuation of CDC’s National Diabetes Prevention Program.Diabetes Care 2017: 1331-1341.

5. The Community Guide. Diabetes prevention and control: combined diet and physical activitypromotion programs to prevent type 2 diabetes among people at increased risk [online]. 2014.[cited 2015 Aug 3]. Available from: http:// www.thecommunityguide.org/diabetes/combineddietandpa.html.

Centers for Disease Control and Prevention

Past, Present, and Future of the National Diabetes Prevention Program

Ann Albright, PhD, RDN

Director, Division of Diabetes Translation

National Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

Our Public Health Challenge…

30 million Americans have diabetes

84 million Americans have prediabetes

9 out of 10 adults with prediabetes don’t know they

have it

Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2014. Atlanta, GA; US Department of Health and Human Services, Centers for Disease Control and Prevention, 2014. https://www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html

BASIC SCIENCE

EFFICACY

EFFECTIVENESS

EFFICIENCY

AVAILABILITY

DISTRIBUTION

Molecular/

physiological

Ideal

settings

Real world

settings

Biggest effect on

most people

Supply

Diffusion of

interventions

Adapted from information in Sinclair JC, et al. N Engl J Med. 1981;305:489–494. and Detsky AS, et al. Ann Intern Med. 1990;113:147-154.

Why Now? Transitioning From Science to Widespread Practice

Largest national effort to mobilize and bring effective lifestyle change programs to communities across the country!

National Diabetes Prevention Program

Overview of the National Diabetes Prevention Program

1

2

At the core of the National Diabetes Prevention Program (National DPP) is a CDC-recognized, year-long lifestyle change program that offers participants:

To successfully implement these lifestyle change programs, the National DPP relies upon a variety of public-private partnerships with community organizations, private and public insurers, employers, health care organizations, faith-based organizations, and government agencies. Together, these organizations work to:

http://www.cdc.gov/diabetes/prevention/pdf/ndpp_infographic.pdf

National DPP Research into Practice – Key Milestones

▪2002: Diabetes Prevention Program (DPP) research trial

• Showed LCP reduced development of type 2 diabetes in those with IGT by 58% (71% if 60 years of age or older) compared to 31% for metformin.

▪2008-2012: Translation studies

• Showed effective delivery by trained lay people in various community settings at reduced cost from research trials.

▪2008: Initial National DPP framework and partner convening

• CDC developed a framework for the National DPP and convened key stakeholders(University of Indiana, Y-USA, insurers, state health depts., CMS, Agency for Healthcare Research and Quality) to seek input to inform nationwide implementation.

• CDC, the Y-USA, and UnitedHealth Group began initial work to establish, scale, and secure coverage for the program.

▪2009: CDC partnership with Y-USA

• CDC funded the Y-USA to offer the lifestyle change program in Louisville, KY and to expand to communities across the country as part of a staged roll-out plan

National DPP Research into Practice – Key Milestones

▪2010: Congress authorized CDC to establish the National DPP

▪2011-12: CDC Diabetes Prevention Recognition Program (DPRP) established

• CDC worked with partners to develop first set of national quality standards for the National DPP

• CDC DPRP officially launched

▪2011: CDC funded Emory University to develop first lifestyle coach training program

▪2012: Evidence-based, year-long curriculum developed for use by CDC-recognized organizations

▪2012: Six national organizations funded by CDC to establish and sustain new CDC-recognized programs across multiple states

National DPP Research into Practice – Key Milestones

▪2012-16: Center for Medicare and Medicaid Innovation (CMMI) model test conducted

▪2012 and 2017: Diabetes Prevention Program Outcomes Study

▪2015: CDC DPRP Standards revised to allow virtual program delivery

▪2015: CDC and the American Medical Association (AMA) partnered to launch a rally cry to Prevent Diabetes STAT - Screen, Test, Act -Today™

▪2015: Medicaid Demonstration Project

• CDC funded a demonstration project in Maryland and Oregon—through the National Association of Chronic Disease Directors—to test the feasibility and effectiveness of different models to obtain Medicaid coverage for the National DPP lifestyle change program.

▪2016: Multi-year national prediabetes awareness campaign launched by CDC, Ad Council, AMA, and American Diabetes Association

National DPP Research into Practice – Key Milestones

▪2016: HHS Secretary announced expansion of the National DPP into Medicare

▪2017: National DPP lifestyle change program included as a covered health benefit for state/public employees in 12 states

▪2017: CMS rulemaking completed to establish the Medicare Diabetes Prevention Program (MDPP)

▪2017: CDC funds work to reach underserved areas and populations

▪2018: Initial CDC-recognized organizations enroll as Medicare suppliers to deliver the MDPP

▪2018: CDC DPRP Standards revised a second time to align with CMS MDPP model expansion

▪2018: CDC launches National DPP Customer Service Center to support CDC-recognized organizations and all National DPP stakeholders

National DPP Strategic Goals

Increase the supply

of quality programs

Increase

coverage among public and

private payers

$Coverage &

Reimbursement

Increase referrals

from healthcare providers

Increase demand for

the National DPP among people at risk

Demand From ParticipantsReferrals

Quality Programs

Increase the Supply of Quality Programs

Increase the Supply of Quality ProgramsThe number of CDC-recognized organizations has increased substantially since the program’s inception.

1: CDC Diabetes Prevention Recognition Program

CDC-Recognized Diabetes Prevention Programs Across the U.S.

480 477 512 522644

720

953

1,237

1,4561,531

1628

0

200

400

600

800

1000

1200

1400

1600

1800

Jun 2013 Dec 2013 Jun 2014 Dec 2014 Jun 2015 Dec 2015 Jul 2016 Dec 2016 Jul 2017 Oct 2017 Jan 2018

CDC Recognition: Overview

Recognition involves…

assuring quality by developing and maintaining a registry of organizations recognized (by CDC’s Diabetes Prevention Recognition Program) for their ability to deliver effective type 2 diabetes lifestyle interventions

Quality Standards

▪ DPRP Standards and Operating Procedures

▪ Updated every 3 years

Registry of Organizations

▪ Online registry and program locator map

Data Systems

▪ Data analysis and reporting▪ Feedback/technical

assistance for CDC-recognized organizations

Key Activities

The CDC National Diabetes Prevention Program

►2018 Diabetes Prevention Recognition Program (DPRP) Standards

Key Revisions

National Center for Chronic Disease Prevention and Health PromotionDivision of Diabetes Translation ■ www.cdc.gov/diabetes

New Application Data Elements

4 Delivery Modes with one application per delivery mode required:

1. In-person (delivery is 100% in-person)

2. Online (delivery is 100% online)

3. Distance learning (new):

Delivered 100% by trained Lifestyle Coaches via remote classroom or telehealth (i.e., conference call or Skype) where the Lifestyle Coach is present in one location and participants are calling or video-conferencing in from another location.

4. Combination (new):

Delivered as a combination of any of the previously defined delivery modes for all participants by trained Lifestyle Coaches

Participant Eligibility Changes

BMI thresholds:▪ Non-Asian: BMI of greater than or equal to 25 kg/m2

▪ Asian-American: BMI of greater than or equal to 23 kg/m2

Blood test eligibility:

▪ A minimum of 35% of all participants in a cohort must be eligible for the lifestyle change program based on either a blood test indicating prediabetes or a history of GDM; 65% may come in on a risk test

▪ 100% of Medicare Diabetes Prevention Program participants must come in on a blood test

3 Categories of Recognition

1. Pending

Awarded upon approval of application

2. Preliminary

New recognition status that aligns with the final Centers for Medicare and Medicaid Services MDPP expanded model rule

Is attendance-based since data indicate that attendance past the first 6 months drives weight loss

Minimum required to become an MDPP supplier

3. Full

Highest level of CDC recognition awarded when an organization meets all DPRP Standards requirements

Organizations in Full can also apply to become MDPP suppliers

Data Submission Timeline and Evaluation Data submission now occurs every 6 months; organizations will

receive progress/evaluation reports accordingly

Numerators and denominators for evaluation toward Preliminary and Full recognition have been liberalized to help organizations serving all populations succeed

Six new data elements collected for more thorough evaluation:

1. Enrollment source (how a participant was referred to the program)

2. Payer type (reimbursement source)

3. Education (proxy for socioeconomic status)

4. Delivery mode (per session to account for how make-up sessions are delivered and to track combination modes)

5. Session ID (tracks session number by first 6 months, second 6 months, and for on-going maintenance sessions delivered in Year 2 by MDPP suppliers)

6. Session type (denotes if a session is core, core maintenance, ongoing maintenance, or make-up)

Increase Demand for the Program Among People at Risk

Increase Demand for the Program Among People at Risk

1. CDC Diabetes Prevention Recognition Program

160,378 individuals have enrolled in the National DPP as of Jan. 12, 20181

27,468 33,306

79,45592,761

106,219

152,551 160,378

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

Cumulative Number of Individuals Enrolled in the National DPP1

Award-Winning Prediabetes Awareness Campaign Ad Council, AMA, ADA, CDC

Puppies –A Perfect Way to Spend a Minute

Hedgehogs on Vacation –A Perfect Way to Spend a Minute

Your Health with Joan Lunden and CDCcdc.gov/DiabetesTV

Increase Referrals from Health Care Providers

Increase Referrals from Health Care ProvidersCDC works with numerous partners to help identify and refer at-risk individuals to CDC-recognized diabetes prevention programs. Examples include:

Y-USA

Partnership with the Y-USA to explore bi-directional e-referral models for use by health care systems and CDC-recognized diabetes prevention programs to screen and refer people at high risk for type 2 diabetes (retrospectively or at point of contact).

American College of Preventive Medicine

Partnership with the ACPM to increase health care provider screening/testing/referrals through training, developing local champions, and testing and evaluating approaches in the field.

American Medical Association

Partnership with AMA to increase health care provider screening/testing/referrals by engaging and activating state medical societies.

State Grantees

Partnership with state health departments to work with local health care organizations to develop referral protocols/policies/systems.

Increase Coverage and Reimbursement for the Program

$ Increase Program Coverage & ReimbursementMany public and private insurers are offering the National DPP as a covered benefit.

$

Commercial Insurers State Coverage

▪ Colorado

▪ Kentucky

▪ Louisiana

▪ Maine

▪ Minnesota

▪ New Hampshire

▪ AmeriHealth Caritas

▪ Anthem

▪ BCBS Florida

▪ BS California

▪ BCBS Louisiana

▪ Denver Health Managed Care: Medicaid, Medicare, Public Employees

▪ Emblem Health: NY

▪ GEHA

▪ Humana

▪ Kaiser: CO & GA

▪ LA Care: Medicaid

▪ MVP’s Medicare Advantage

▪ Priority Health: MI

▪ United Health Care: National, State, Local, Private, and Public Employees

Many commercial health plans provide some coverage for the National DPP. Examples

include:

Over 3 million public employees/dependents in the following 12 states have the National DPP

as a covered benefit:

The following states have approved coverage for Medicaid

beneficiaries:

▪ New York

▪ Rhode Island

▪ Washington

▪ Oregon (Educators)

▪ California

▪ Texas

▪ Minnesota

▪ Montana

▪ New Jersey (in 2018)

▪ California (in 2018)

Medicaid Demonstration ProjectCDC launched a demonstration project in Maryland and Oregon to design, evaluate, and implement a Medicaid coverage model in value-based plans.

Successful models will be translated for use by other states

Goal: to achieve sustainable coverage of the National DPP for Medicaid beneficiaries under existing Medicaid authorities

The Plan

July 1, 2016 – June 30, 2018

▪ Maryland and Oregon developed and implementing a delivery model for the National DPP through either Medicaid managed care organizations or accountable care organizations

▪ The delivery model includes the following components:

o Screening, referring, and enrolling eligible Medicaid beneficiaries in CDC-recognized programs (in-person and virtual)

o Implementing a value-based coverage and reimbursement model

o Providing support to participants to ensure successful completion of the program

▪ Maryland and Oregon are participating in a comprehensive evaluation which will include:

o Costs

o Participant outcomes

Tools & Resources

Resources for CDC-recognized Organizationshttps://www.cdc.gov/diabetes/prevention/lifestyle-program/keys-to-success/index.html

Tool Description

DPRP Welcome Kit / Video▪ Description of the DPRP, advantages of CDC

recognition, and key characteristics of successful CDC-recognized organizations

3 Toolkits for CDC-recognized organizations • Working with Medicaid beneficiaries• Working with Medicare beneficiaries• Working with Employers/Insurers

▪ Tailored materials for CDC-recognized organizations working with specific populations

Videos for CDC-Recognized Organizations

▪ Videos include:

‒ “Assessing Your Capacity to Offer a CDC-Recognized Diabetes Prevention Program”

‒ “Learning the DPRP National Standards”‒ “Making Required Data Submissions”‒ “Improving Outcomes Using the 12-Month

Data Submission”

Supplemental Training for Lifestyle Coaches ▪ Additional online videos / webinars

Tip Sheets▪ Tip sheets based on practical lessons learned from

national organizations and their affiliates funded under cooperative agreement 1212

Emerging Practices in Diabetes SeriesThe CDC compiles information on innovative approaches taken by grantees and other partners to inform other organizations’ approaches.

http://www.cdc.gov/diabetes/programs/stateandlocal/results.html

Emerging Practices Document Case Studies Used

Promoting the National DPP as a Covered Benefit for State Employees

▪ Kentucky, Minnesota, and Washington

Approaches to Promoting Referrals to DSME and CDC-Recognized Diabetes Prevention Program Sites

▪ Delaware, Kentucky, Maine, and New York State/ NYC

Approaches Taken by State and Local Health Departments to Market the National DPP to Populations At-Risk and to Health Care Providers

▪ California, Montana, and New Mexico

Approaches to Employer Coverage of the National DPP for Employees At Risk for Type 2 Diabetes

▪ Costco, General Dynamics Bath Iron Works, Latham & Watkins, University of Michigan, and NYC

Resources for States, Employers, and Insurers Diabetes Prevention Impact Toolkit

https://nccd.cdc.gov/Toolkit/Diabetesburden/

https://nccd.cdc.gov/Toolkit/Diabetesimpact/

• Online resource to support Medicaid, Medicare Advantage, and commercial health plans that are considering covering or implementing the National DPP lifestyle change program

• Covers topics such as contracting, delivery options, coding & billing, data & reporting

http://nationaldppcoveragetoolkit.org/

• Developed by the National Association of Chronic Disease Directors (NACDD), Leavitt Partners, and the Centers for Disease Control and Prevention (CDC)

• Includes special sections on how to obtain Medicaid coverage and draw down federal funds

Quick Facts

National DPP Customer Service CenterCDC expects to launch the Customer Service Center in late April 2018.

Purpose: Provide a hub for resources, training, and technical assistance for CDC-recognized program delivery organizations and other National DPP stakeholder groups

Find Resources and Info

• Quickly and easily find relevant resources and events (FAQs, toolkits, training videos, webinars

• Discuss opportunities and challenges with the National DPP community

Receive Technical Assistance Provide Feedback and Input

• Engage with technical assistance coordinators and subject matter experts via the web-based platform or email

• View the status of and update existing technical assistance requests

• Submit feedback on your satisfaction with the technical assistance, resources, and web-based platform

• Share success stories and suggest additional resources