NCCC Releases Recommendations to Improve Federal Response to Diabetes Epidemic

More than 37 million Americans currently have diabetes; of these, 8.5 million are undiagnosed. In addition, more than 1 in 3 Americans currently have prediabetes—or higher than normal blood sugar levels and the precursor to type 2 diabetes (T2D)—but more than 80% of this population is unaware they even have the condition.

Obesity is a key risk factor for T2D and data from 2018 show 42.4% of the United States population is obese, compared with 30.5% in 2000.

The American Diabetes Association estimates diagnosed diabetes alone costs the country $327 billion annually, with Medicare and Medicaid paying a large portion of this sum.

All of these factors underscore the urgency with which diabetes prevention needs to be addressed on a national level—not only from a clinical standpoint, but also an economic one.

As part of the National Clinical Care Commission (NCCC) Act passed in 2017, HHS was directed to convene a committee to evaluate and make recommendations to Congress on diabetes prevention. Specifically, the NCCC was tasked with raising awareness and providing education to health care professionals and the public around diabetes, and identify opportunities to consolidate overlapping or duplicative programs, among other efforts.

Today, the NCCC released its report summary, published in Annals of Internal Medicine, outlining steps to improve federal programs impacting diabetes prevention and care, with a particular focus on the role of internal medicine specialists.

The 23 NCCC members submitted their final report to Congress on January 5, 2022. In it, experts on epidemiology, public health, clinical care, patient advocacy, health policy, and regulation listed critical steps that will help reduce the current burden of diabetes in the United States and prevent future worsening of the epidemic.

Social and environmental factors including access to healthy food and housing greatly influence diabetes risk and contribute to wide racial disparities in US diabetes incidence. Despite advancements in diabetes prevention and treatment, “translation into practice has been slow and benefits have been experienced unequally,” the authors wrote.

Furthermore, “the national response to diabetes has focused on clinical aspects. It is critical that the epidemic be addressed via multisector societal, environmental, and public health approaches,” they stressed.

In total, the NCCC crafted 39 recommendations that incorporate both health-related and non-health related federal agencies, each of which require administrative action by these agencies or legislation from congress. Among these strategies is creating an office entirely dedicated to this mission, the Office of National Diabetes Policy, which will work across federal agencies and departments to streamline efforts.

National Diabetes Prevention Program

The National Diabetes Prevention Program (NDPP) is a landmark program which established implementation of an intensive lifestyle program or metformin treatment reduces diabetes onset in high-risk individuals by 58% and 31%, respectively, compared with placebo.

In the years since it started in 2010, the program continues to yield beneficial results in those at risk of developing diabetes.

But despite its proven efficacy and safety, successful implementation of the NDPP—especially among Medicare beneficiaries—remains a challenge. Nationally, only 3600 beneficiaries have enrolled in the program as of November 2021.

Metformin has also not received FDA approval for T2D prevention, although it can be prescribed off-label for this purpose.

However, “in this setting [metformin] may not be reimbursed by insurers,” said Paul R. Conlin, MD, an author of the NCCC report and chief of medical service at the VA Boston Healthcare System, in an email to The American Journal of Managed Care® (AJMC®). “The Commission recommended that [the National Institutes of Health] summarize data from the Diabetes Prevention Program study on the effectiveness of metformin, to support a request to the FDA to approve an indication for metformin in type 2 diabetes prevention.”

When it comes to the NDPP, Medicare began covering the program in 2018, but several challenges have plagued its uptake among beneficiaries, one of which is the program’s financial structure.

A recent study published in AJMC® found the structure and requirements for Medicare reimbursement of DPP (MDPP) “make it difficult for health systems and community-based providers to implement and promote this benefit.”

Researchers carried out semi-structured interviews with 12 delivery system stakeholders at Kaiser Permanente Northwest. The majority of Medicare patients in this system had Medicare Advantage plans with a capitated payment structure.

“Medicare did not offer any increase in the capitated rate for implementing MDPP. Unlike in the fee-for-service setting, this creates a short-term financial disincentive to wide implementation of the program for comprehensive medical systems, even if in the long-term costs are decreased,” researchers explained.

They also found the need to achieve a balanced budget annually outweighed long-term benefits, and the introduction of a third-party vendor to connect beneficiaries to the CDC program complicated efforts.

Concerns were also raised on achieving the CDC’s program recognition requirement of meeting a weight loss threshold of 5% or more among participants. Although CMS has tied higher payment to this metric, only a minority of patients may achieve it, and evidence has shown less weight loss can lead to significant reductions in glycated hemoglobin and subsequently lower diabetes risk, Health Affairs reports.

Lack of awareness and knowledge of the MDPP on both the provider and beneficiary sides also impeded enrollment efforts, while no online version of the MDPP existed prior to COVID-19, and it is currently only available online due to the pandemic’s emergency period. When this period ends, coverage for online programming will cease.

To address these hurdles, the NCCC recommends:

• Streamlining the CDC recognition process for the NDPP and CMS payment process for the MDPP while maintaining quality and reducing or eliminating differences in program eligibility and duration.
• Supporting the testing of new payment models that allow for greater upfront payments, equitable risk sharing between CMS and MDPP delivery organizations, and increasing payment levels to allow such programs to be financially sustainable.
• Providing financial incentives to state Medicaid programs to cover the NDPP and other evidence-based interventions that meet or exceed those of the NDPP quality standards, including in-person, online, distance learning, or telehealth interventions.

Improved uptake of the DPP and other established methods will require “increased availability and awareness of such programs and reduced administrative and financial burdens to organizations and participants,” authors wrote.

“A significant gap in diabetes prevention and treatment is the mismatch between available resources and the ability of people with diabetes to access those resources,” they said, adding insurers should cover key elements of T2D prevention and diabetes treatment.

Aligning the MDPP and the NDPP will aid providers as they will be able to more easily deliver both programs, Conlin explained.

“For example, obtaining full or preliminary CDC recognition allows National DPP organizations to enroll as Medicare DPP suppliers,” he said. “However, some organizations, particularly in rural and underserved areas, experience challenges achieving CDC recognition and becoming Medicare DPP suppliers due to administrative burdens.”

Affordability

Another main theme of the NCCC report was affordability, not just for insulin, but for diabetes services and treatments in general. One recommendation reads: “Require insurers to cover (pre-deductible) high-value diabetes services and treatments that prevent or delay progression of diabetes complications.”

Uninsured and underinsured individuals with hypertension and diabetes often forgo effective treatments that can improve outcomes.

Although the Affordable Care Act does require coverage of Grade A or B primary prevention services specified by the United States Preventive Services Task Force at no cost to the patient, “Secondary prevention strategies (e.g., diabetes self-management education and support) and tertiary prevention strategies (e.g., eye exams and laser treatment for retinopathy) are not treated similarly,” explained Conlin.

For most patients these services will require cost sharing, while for those with lower incomes and high-deductible plans, this will significantly reduce treatment adherence.

“Providing pre-deductible coverage (i.e., coverage at no cost to the patient) for some of the most critical secondary and tertiary prevention services for diabetes offers an opportunity to close gaps in care and reduce the human and financial costs of diabetes complications,” Conlin said.

Enhancing the USDA Supplemental Nutrition Assistance Program is also critical to improving nutrition sufficiency and reducing food insecurity, the NCCC wrote.

Disparities

In addition to broadening access to proven diabetes prevention methods and increasing affordability, an additional component of the NCCC report is working to close racial and geographic disparities in diabetes.

The HHS Office of Minority Health reports American Indian/Alaska Native adults are almost 3 times more likely than non-Hispanic White adults to be diagnosed with diabetes; in 2018, these populations were 2.3 times more likely to die from diabetes than their White counterparts.

Furthermore, American Indian/Alaska Native adolescents are 30% more likely than their White peers to be obese, while for adults, this risk rises to 50%.

The Special Diabetes Program for Indians (SDPI), coordinated by the Indian Health Service (IHS) Division of Diabetes, was created in 1997 by Congress to provide funds for diabetes prevention and treatment services. It also recieves guidance from the Tribal Leaders Diabetes Committee.

The SDPI "provides funds for diabetes treatment and prevention to IHS, Tribal, and urban Indian health programs across the US,” Conlin explained. “With funds from the SDPI, the prevalence of diabetes in American Indian and Alaska Native adults has been reduced. However, funding for this program has not increased since 2004.”

To increase the program's financial stability, the NCCC recommends funding the SDPI “in 5-year increments with annual increases addressing inflation costs and increase funding to HRSA [Health Resources and Services Administration] Delta States Network Grant Program to include diabetes prevention as a focus.”

Diabetes prevalence varies by education level, income, and race, but is also influenced by location, with the highest rates seen in Southeast America and in Appalachia. Rural regions also tend to have less medical infrastructure compared with urban areas, Conlin explained.

One method of addressing these geographical hurdles is to direct resources to HRSA’s Delta States Rural Development Network Grant Program, to allow the program to include T2D prevention as a focus area, he added.

Currently, the program “provides network development grants to 8 states in the Mississippi Delta for network and rural health infrastructure development.”

Authors also recommended the department of Housing and Urban Development work to increase affordable housing options for low-income individuals to increase health-promoting environments.

Overall, NCCC concluded more research is needed on the social and environmental conditions associated with diabetes, barriers to uptake of self-management education and support, and implementation of team-based care models.

“The NCCC strongly encourages Congress and the HHS Secretary to swiftly implement its recommendations. It is imperative that a national diabetes strategy be established to coordinate and monitor trans-agency collaboration and progress toward achieving these goals,” they wrote.

“These combined efforts will further leverage and maximize federal resources focused on diabetes prevention and treatment of the benefit of the US population.”

Reference

Conlin PR, Greenlee C, Schillinger D, et al. The national clinical care commission report: improving federal programs that impact diabetes prevention and care. Ann Intern Med. Published online February 14, 2022. doi:10.7326/M21-4175