PUBLIC HEALTH
THE DIABETES Tsunami
Tom James, MD
Nearly every morning, Pittsburgh TV station, KDKA * presents a five-minute infomercial produced by the Center for Disease Control( CDC) featuring former Good Morning America anchor Joan Lunden talking about diabetes and more recently, pre-diabetes. It struck me that as clinicians we have a hard enough time with getting compliance from people with frank type-2 diabetes; how can we expect people who are at risk but don’ t have diabetes to change their ways? After all isn’ t that akin to trying to persuade people at risk for other conditions to actually engage in prevention programs? We have all had problems getting the salt shaker out of the hands of our patients with hypertension, let alone convincing the 30-something who has a strong family history of early heart disease to put down the pizza and pick up the running shoes. After all, I have moved to Pittsburgh, the land of pierogis, beer and self-driving Ubers. Healthy diets, reduced alcohol, and walking are just not a part of the lexicon of the region.
So, I greeted the CDC pronouncements through its spokesperson, Joan Lunden, with more than a pinch of skepticism. However, curiosity did get to me. In 2014, the most recent year for the evaluation, the Center for Disease Control( 1.) estimated that there are 29 million people in the US with diabetes. The CDC started the Diabetes Prevention Project after it estimated that there are 86 million people in the United States with pre-diabetes. So, if pre-diabetes is the pipeline to frank diabetes, then this pre-diabetes population represents a tsunami of people likely to increase the number of diabetics in the country at a time that resources are being strained. Looking at it in a different angle, nearly nine percent of the US population has type-2 diabetes. Add in the pre-diabetic population and we are talking about 35 percent of the population( scary). Worse still, if the pre-adolescent population is excluded, then four out of six people have diabetes or pre-diabetes. This country is far from fit.
While the CDC has made clear distinctions between diabetes and pre-diabetes to make it easier for the public, the American Heart Association, the American Association of Clinical Endocrinologists, the American College of Preventive Medicine and other specialty societies see this as a spectrum disease. Even for people with pre-diabetes, there is a recognized increase in cardiovascular and renal disease at a level much higher than the general population— even if they never progress to frank diabetes.
The numbers are so startling and the potential implications for taxing the health care system( and the financing vehicles) have attracted a lot of attention. The American Medical Association has praised efforts to develop formalized diabetes prevention programs
( 2.) noting that the cost of diabetes in the United States will exceed 2 trillion dollars over the next 10 years. The American College of Physicians, representing internal medicine doctors, has developed a series of well-developed informational pieces for patients on pre-diabetes( 3.) Seems that everyone has gotten on-board with preventing diabetes. The YMCA has taken a lead with developing programs that meet the CDC recommendations. Academic medical centers and community hospitals have developed CDC certified programs. In Kentucky, Baptist Health has certified programs in Louisville and Lexington. Owensboro Health- inBalance Diabetes Education Program and the Diabetes Resource Center in Hopkinsville round out the certified centers in the Commonwealth beyond those at the YMCAs.
Since the concept of the continuum of disease and the real concern of potential increase in health care costs, pre-diabetes has now become a condition being addressed by the professional societies and now by Medicare. Effective January 1, 2018, Medicare will begin coverage of certified Diabetes Prevention Programs for Medicare beneficiaries who meet eligibility requirements( see Table on page 15). The Centers for Medicare and Medicaid Services( CMS) is so concerned about the impending huge wave of new patients with diabetic / pre-diabetic complications that it has determined that a new benefit would more than pay for itself. This is now a Medicare version of the CDC program and is aimed at reducing the impact of diabetes-related morbidity more than the cost of administering a program. Since this new benefit is being rolled out without direct physician input, it is even more important that doctors who deal with diabetes and its complications are aware of it. While this program is being rolled out for traditional Medicare beneficiaries, it must apply to the Medicare Advantage carriers such as Humana, Anthem, United and Baptist Health Plan.
The program provides 12 months of an intervention program with at least 16 weekly one-hour motivational and educational sessions over months 1-6 of the program and at least six monthly maintenance sessions over the next six months.( 4.) Those individuals who lose at least five percent of their body weight are eligible for continued maintenance at three month intervals to reinforce their positive efforts. There are no copayments for eligible patients. However this is a one-time benefit with a one year maintenance reinforcement plan as currently proposed. Some commercial health plans are likely going to emulate that and may allow more repeat sessions since the longevity of a commercial member will exceed that of a Medicare beneficiary on average.
Medicare beneficiaries are covered only at CDC diabetes Prevention Recognition Program( DPRP) programs. The list is likely
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