Memorandum

AMA urges all public and private insurance to cover Diabetes Prevention Program – June 21, 2016

Executive Highlights

  • In a recently-adopted policy, the American Medical Association (AMA) is calling on all public and private healthcare payers to offer coverage for the Diabetes Prevention Program (DPP).
  • This is exciting news that will hopefully result in widespread access to DPP for the 86 million Americans with prediabetes and for other patients at risk for type 2 diabetes. We’re happy to see the AMA’s continuing commitment to type 2 diabetes prevention, and look forward to a specific action plan for the rollout of DPP coverage among private payers, who may be more reluctant.

The American Medical Association (AMA) recently adopted a new policy advocating for coverage of the Diabetes Prevention Program (DPP) from all public and private health insurance providers. This is tremendous news that gives an extra nudge to payers, many of which are reviewing DPP and considering coverage. The AMA plans to coordinate with the American Hospital Association and similar organizations to educate hospitals and health systems on how to implement in-person or digital DPP and to clarify how existing community benefit dollars can be allocated toward offering DPP to all patients. The AMA has yet to announce actionable steps that can be taken to put pressure on private payers to cover DPP. We expect commercial payers will be among the most reluctant to answer the AMA’s call for nationwide DPP coverage as the long-term cost savings of the program may be realized for a different payer if patients switch insurance plans. This AMA policy comes on the heels of a recent announcement by the US Department of Health and Human Services, stating plans to authorize DPP coverage for Medicare beneficiaries at high risk for type 2 diabetes – this was a landmark decision and we so hope it is implemented well.

Previously, the AMA, in partnership with the CDC, also created a diabetes prevention toolkit and a diabetes prevention cost-saving calculator, which should help make the case for DPP coverage to payers. This is a big deal and goes a long way toward making the health economic case for diabetes prevention efforts. We’re elated to see the AMA also making type 2 diabetes prevention a key aspect of its agenda, and we’re especially encouraged to see major powerhouse health policy institutions teaming up to deliver this unified message on the benefits of prevention. It will be so very important to see their specific advocacy strategy on this front.  While the AMA support for the policy does not directly translate into actionable steps for expanded DPP coverage, the AMA announcement does give voice to the power of preventative healthcare. It puts additional pressure on payers to reimburse this low-cost, evidence-based program, which we hope will translate into widespread access to DPP and a noticeable decrease in progression from prediabetes to type 2 diabetes.

  • “I think their support is positive, and symbolic, but holds limited weight.” Obesity expert Dr. Barbara Troupin (San Diego, CA) pointed out that the way in which DPP coverage is implemented by specific payers will be key to determining the program’s success. With regards to Medicare reimbursement of DPP, for example, Dr. Troupin posed the questions of which specific types of healthcare professionals would be reimbursed for offering DPP and what would be the specific reimbursement level. Ideally, we’d like to see support for a standardized DPP reimbursement process across all public and private payers, offering the opportunity for (i) DPP reimbursement for primary care physicians, endocrinologists, diabetes educators, nurse practitioners, and more and (ii) a level of reimbursement that makes it possible for health systems to offer the program from a value proposition standpoint.
  • Other key diabetes prevention experts praised the AMA’s announcement for drawing much-needed attention to diabetes prevention among patients, providers, and payers – a crucial first step in expanding DPP. Diabetes self-management education is severely underutilized, and this endorsement of DPP is as important for patients as it is for payers. As we see momentum toward increasing payer coverage, Dr. Adam Kaufman (Canary Health, Los Angeles, CA) pointed out that we must also spread awareness among consumers so that they’re ready to participate actively in DPP and yield maximum benefits from the program. According to Dr. Donna Ryan (Pennington Research Center, Baton Rouge, LA), the most meaningful aspect of the AMA’s new policy is the message that realistic, modest weight loss can have life-changing impact.
    • Modest weight loss (~5%) can achieve a return on investment in the short-term – only 15 months – but can be quite difficult for most people to achieve. This degree of weight loss often times requires significant behavioral change including self-monitoring, cognitive restructuring, increased physical activity, and decreased calorie intake. As noted by Dr. Ryan, to be success with weight loss efforts we need skilled coaches who can actually deliver the degree of intervention DPP can provide.

Close Concerns Questions

Q: What strategies does the AMA have in store to get both public and private payers on board?

Q: Will other health professional organizations make similar statements in support of payer coverage of DPP?

Q: When can we reasonably expect to see DPP well-reimbursed and well-utilized across the country?

Q: Given that settings other than a typical medical establishment – such as the YMCA – could play a pivotal role in scaling DPP, how will these nontraditional healthcare workers be factored into reimbursement?

Q: What will be the impact of expanded DPP access on diabetes incidence rates? What sort of decrease in diabetes incidence should we look to as a sign of success?

Q: How can we continue increasing awareness of prediabetes and preventative healthcare? Could coverage of DPP leader providers to screen for prediabetes more broadly?

-- by Payal Marathe, Helen Gao, Sarah Odeh, and Kelly Close