>> Good afternoon, good
evening, or good morning,
depending on from when and
where you are joining us.
I'm Dr. Phoebe Thorpe and it's
my pleasure to welcome you
to CDC Public Health Grand
Rounds for November 2018.
The National Diabetes Prevention
Program: Changing Lifestyles
to Prevent Type 2 Diabetes.
We have an exciting
session-- oops--
but first a few housekeeping
slides.
Public Health Grand Rounds has
continuing education available
for physicians, nurses,
pharmacists,
veterinarians, and others.
Please check out our
website for more information.
The course code is PHG10 and
this is our disclosure slide.
Grand Rounds is available
on all your favorite web
and social media sites.
Please send the questions
to grandrounds@cdc.gov
and we will try to include your
question in the Q and A today.
Want to know more about
prediabetes and preventing it?
We have a featured
video segment on YouTube
and our website called
Beyond the Data,
which is posted after
the session.
This month's segment features my
interview with Dr. Ann Albright.
We have also partnered with
the CDC public health library
to feature scientific
articles about the topic.
The full listing is available
at cdc.gov/scienceclips.
Here is a preview of our
upcoming Grand Rounds topics.
Please join us if you can.
In addition to our
outstanding speakers--
which I will give a special
thank you to Dr. Pryor
who is joining us
from California,
he had to evacuate his
home due to wildfires--
I'd also like to acknowledge
the important contributions
of the individuals listed here.
Thank you.
And now for a few words
from CDC's Deputy
Director, Dr. Schuchat.
>> Today, 30 million
Americans have diabetes
and another 84 million Americans
or 1 in 3 adults
have prediabetes.
You may never have heard of
this, but today you'll find
out why prediabetes matters and
what you can do about it if you
or a loved one has it.
Prediabetes is characterized
by blood glucose levels
that are higher than
normal, but not high enough
to be diagnosed with diabetes.
People with prediabetes
have an increased risk
of developing type 2 diabetes,
heart disease, and stroke.
Prediabetes does not mean
an inevitable progression
to diabetes.
Research shows that people
with prediabetes who take part
in a structured lifestyle change
program can cut their risk
of developing type 2
diabetes by more than half.
People over 60 can cut
their risk by nearly 3/4.
The National Diabetes Prevention
Program or DPP is designed
to help people make changes in
diet, exercise, and behavior.
The program starts with weekly
lessons the first 16 weeks,
then monthly for
another 6 months.
These can lead to lasting
health improvement.
The goals are to lose
5-7% of body weight
through healthier eating
and to get 150 minutes
of physical activity a week.
It doesn't take a radical weight
loss to make a big impact.
The impact of this
program can last for years.
Research has found that
even 10 years later people
who completed a diabetes
prevention lifestyle change
program were 1/3 less likely
to develop type 2 diabetes.
Most people who have
prediabetes are not aware of it.
Increasing screening is key.
The CDC-led National Diabetes
Prevention Program is a
partnership working collectively
to prevent or delay onset
of type 2 diabetes in
adults through the delivery
of an evidence-based
lifestyle change program.
Today we will hear about how
partners are delivering this
program across the
U.S. and how private
and public health care insurance
providers are supporting
this effort.
The national levels of type 2
diabetes have been increasing
along with the obesity
epidemic and make scaling
up the DPP an urgent
national priority.
Working together, we can
make it easier for people
with prediabetes to participate
in evidence-based, affordable,
high quality lifestyle change
programs to reduce their risk
of type 2 diabetes and
improve their overall health.
>> And now for our first
speaker, Dr. Ann Albright.
>> Thanks, Phoebe.
It's really a pleasure to
be with all of you today.
As you heard, there are
over 30 million people
who have diabetes.
That's about 9.4% of
the U.S. population.
It's expensive; 237 billion
in direct costs and 90 billion
in reduced productivity
and disability.
Prediabetes is a condition
where blood sugar is higher
than normal, but not high enough
yet to constitute type 2
diabetes, but as was noted,
it does put you at
increased risk
for other serious
health problems,
including heart attack
and stroke.
Prediabetes really is a
significant health issue
in our nation.
So, as we work to improve
the outcomes for those
who already have
diabetes, it is imperative
that we really do
focus and invest
in preventing new cases
of type 2 diabetes.
Fortunately, we have
strong evidence that--
for the prevention or
delay of type 2 diabetes
in those at high risk.
We have multiple
randomized controlled trials
that have been done in the
U.S. and around the world.
The most preeminent one done
in the U.S. is referred to--
is known as the Diabetes
Prevention Program Research
Study, which was led by NIH
with critical support
from CDC and others.
The trial was done in
adults and about half
of the study participants were
from high-risk ethnic groups.
The intervention tested--
the interventions tested
were lifestyle program,
a structured lifestyle program,
the medication metformin,
which has been used-- is used
to treat type 2 diabetes,
and a placebo.
The intensive lifestyle
intervention did consist
of this structured
curriculum that addressed diet,
physical activity, and
behavior change modification.
The intervention did
involve 16 weekly sessions
and then 6 monthly sessions
over the course of a year.
The goal was 7% weight loss
and 150 minutes of
physical activity.
So, let's take a look at the
results from the study briefly.
The lifestyle change program
did reduce the incidence
of type 2 diabetes, as
you heard earlier, by 58%,
31% for those using medication.
The 58% reduction
was seen in those
with a 5-7% weight loss and,
as was noted, those over 60,
71% reduction in the
development of type 2 diabetes.
Exciting is that this is
a long-lasting impact.
Not only have we now been
studying the trial for 10 years,
we now have 15-year
data that shows
that after 15 years there
still is a 27% reduction
in the development
of type 2 diabetes.
So, this shows both
prevention and delay.
Very importantly, though,
we also have research trials
that have been done in the real
world and so that is critical
to allow us now to transition
from these research studies
into the actual implementation
of the lifestyle intervention.
We also, by the way,
have support
from very esteemed bodies
like the U.S. Preventive
Services Taskforce
and the Community Guide who all
recommend this intervention.
So, to implement this proven
lifestyle intervention
nationwide, CDC did establish
the National Diabetes Prevention
Program, officially
called the National DPP.
Congress authorized
CDC to establish it
and so that's good
news for all of us.
The National DPP is the largest
national effort to mobilize
and bring together effective
lifestyle change program
to communities across
the country.
It serves to unite all sectors
so we can really
achieve national scale.
The National DPP has 4
overarching strategic goals;
increase the supply of quality
programs across the U.S.,
increase demand for the National
DPP among people at risk,
increase referrals from
healthcare providers,
and increase coverage among
public and private payers.
All of these critical elements
have to work simultaneously
since all are required.
Let's take a look at where we
are on the progress to achieve--
where we are in achieving the
goals in each of these areas.
So, first let's take a look
at increasing the supply
of quality programs.
As you can see, the trajectory
is showing a significant
increase in the number
of organizations
who are delivering the lifestyle
change since its launch.
There are currently close
to 1800 organizations offering
the program in all 50 states,
in D.C., and in some of
our U.S. territories.
Many of these groups have
multiple delivery sites.
The program is being
delivered in person, online,
and through distance
learning by a whole array
of various kinds
of organizations.
CDC's diabetes prevention
recognition program plays a key
role in assuring the quality
across these many
unique organizations.
It's part of the National DPP.
We award recognition in
3 categories; pending,
preliminary, and full.
The standards are
updated every 3 years.
They are really a critical part
of the recognition program.
They are the heart of
the recognition program
and they are updated every 3
years, both to stay in alignment
with the science of type
2 diabetes prevention,
but also to respond to the
lessons we have learned
through the program delivery
and the analysis of
participant data.
There are many benefits
of CDC recognition.
We have now data that allows
us as a country to look
at how we are doing in program
outcomes across the nation.
It also is very important
now for those
who are providing coverage
for the intervention.
Many of these payers now
require CDC recognition.
It also allows support to be
given to those organizations
who are delivering
the intervention.
We can provide assistance,
training, and resources,
and also can be very effective
part of marketing your program.
So, let's now take a look
at increasing the demand
for the program among
people at risk.
The number of participants
enrolled
in the National DPP lifestyle
change program has really
grown rapidly.
This graph represents trends
in cumulative enrollment
of almost 1/4 million
people who are currently--
for whom we currently have data.
There are many more people
enrolled in the program
but data is not yet
submitted for them.
We do have a system in place
to track these numbers
in real time.
Since 2016, CDC has
worked with the Ad Council,
the American Medical
Association,
and the American
Diabetes Association
to launch the first national
prediabetes awareness campaign
and get people to complete a
brief prediabetes risk test.
We've used humor to engage
people in the campaign.
We've used a comedic
doctor talking to patients,
cute animal videos-- which
we know people watch--
and we also-- which is showing
us now from what we've achieved
so far in the campaign about 3
million people know their risk
for prediabetes as a
result of this campaign.
We're really excited to be
launching the third phase
of this very successful
campaign on November 14th,
tomorrow, World Diabetes Day.
The new campaign assets will
focus on the message of 1
in 3 adults has prediabetes
and will again use humor
to reach people at risk and
encourage them to take action
to know where they stand.
Please take the test yourself.
Share it with everyone
you know and share it
in your social media channels.
So, now let's turn
to increase referrals
from healthcare providers.
CDC works with many different
national partner organizations
to help identify and
refer at-risk individuals
to CDC-recognized programs
who offer the intervention.
Each of these groups is working
with the clinical care community
or implementing systems--
some involving the
electronic health record--
to increase healthcare
provider screening, testing,
and referring people
with prediabetes
to CDC-recognized organizations
around the country.
The role of healthcare
professionals really
is critical.
And now the last strategic goal
is increasing coverage among
public and private payers.
Our goal since the inception
of the National Diabetes
Prevention Program has been all
payer coverage and we have
made significant progress.
Many public and private insurers
are offering the National DPP
lifestyle change program
as a covered benefit
in specific markets
or geographic areas.
There are some examples of these
commercial health plans listed
on the left of your slide, but
these are just some of them.
In addition, another 3.4
million public employees
and their dependents in
19 states have coverage
and other states are
working towards this goal.
We also support work to make the
National DPP lifestyle change
program available as a
covered benefit for Medicaid.
There is a lot of energy
in this area right now.
Currently, there are
9 states who have full
or partial coverage through
Medicaid authorities,
demonstrations, or pilots.
Beginning in April 2018,
the National DPP lifestyle
change program became a covered
service for eligible
Medicare beneficiaries.
It's called the Medicare
Diabetes Prevention Program
or MDPP and is part
of the National DPP.
You will hear more about the
MDPP from our next presenter.
Together, all of this work
has informed the development
of an online toolkit to assist
public and private payers
and employers pursuing
coverage for the program.
We encourage you to
look at that toolkit.
In response to the
program's tremendous growth,
we have recently launched
our newest resource,
the National DPP
Customer Service Center.
The customer service
center really provides a hub
of resources, training,
and technical assistance
for CDC-recognized
delivery organizations
and other national DPP
stakeholders nationwide.
You can access numerous
resources including toolkits,
training videos, and very
importantly connect with others
in the National DPP community.
You can also engage with experts
at CDC and other organizations
for technical assistance.
The National DPP is
bringing all sectors together
to unify efforts and get this
highly effective intervention
implemented nationwide.
In addition to this very
critical intervention,
we also need interventions that
focus on the whole population
because we need fewer people
ever developing prediabetes
and those with prediabetes
will benefit from this as well,
but they are both necessary,
not one or the other.
This really is our opportunity
to make a significant impact
on type 2 diabetes prevention
and the data tells us
we must all succeed.
Please join this
effort and stay tuned
for even more new
exciting developments
that are coming your way.
You will now hear from
Nina Brown-Ashford,
Deputy Director CMS
Innovation Center Prevention
and Population Health Group.
[ Applause ]
>> Good afternoon
and thank you, Ann,
for that overview
and introduction.
I will note I also love
cute animal videos, so very,
very excited about that.
So, I'm going to provide a
little bit of an overview.
As Ann mentioned, we are now
covering the Diabetes Prevention
Program as a covered
service under Medicare,
which we are very excited about.
So, I'll be talking a little
bit about that coverage as well
as addressing some
of the key components
of the MDPP outlined here.
So, we know that MDPP
works to prevent high rates
of type 2 diabetes among older
Americans and so when we look
at how type 2 diabetes is
affecting Americans 65 years
and older, we know that
about 25% are living
with type 2 diabetes and
about 50% of individuals,
older Americans 65 or older
actually have prediabetes.
We estimate that care
for older Americans
with diabetes costs Medicare
about $104 billion annually
and this number is
continuing to grow.
Seeing that this
was a big issue,
the Medicare Diabetes
Prevention Program model test,
which was implemented
by the YUSA
through a Healthcare
Innovation Award,
actually served 7800
Medicare beneficiaries.
And what we saw was that it
was wildly effective in terms
of reducing weight and
allowing beneficiaries
to achieve weight loss as
well as reducing costs.
And so we went through
rule-making
to expand the Diabetes
Prevention Program
as a covered Medicare service
and create a new supplier type
so that these individuals
who deliver DPP could
actually enroll in Medicare
to provide the service.
So, we know that DPP,
as Ann highlighted,
really does a great job of
promoting healthier behaviors
for eligible Medicare
beneficiaries at risk
for type 2 diabetes as well as
decrease overall Medicare costs.
So, I wanted to highlight some
of the specific criteria as far
as which Medicare beneficiaries
are eligible to be able
to receive MDPP services.
So, it is available for Medicare
part B and C beneficiaries
as long as they meet one of the
following eligibility criteria.
So, having a BMI or body mass
index of at least 25 or 23
if self-identified
as an Asian American,
1 of 3 blood test requirements,
and they cannot have any
of the following diagnoses
or conditions listed below.
So, the MDPP covers up
to 2 years of services
for eligible beneficiaries.
So, in that first year--
which is really that core set
of services-- we have
months 0 through 6
and these are 16 sessions that
are available to beneficiaries
that are offered at least a
week apart and they are able
to be attended regardless
of weight loss.
In months 7 through
12, we then move
on to the core maintenance
sessions
and so these are 6 monthly
sessions, again available
to beneficiaries regardless
of the weight loss
that they achieve.
In months 13 through
14, that's where we move
on to the ongoing
maintenance sessions
and these are 12 monthly
maintenance sessions
and in order for
beneficiaries to be able
to attend these sessions, they
must have achieved and maintain
at least a 5% weight
loss as well
as meet the attendance goals
in order to remain eligible.
An important thing to note
is that this was expanded
as an additional preventive
service, so there is no copay
for beneficiaries to
receive this service.
It does leverage the
CDC's approved curriculum
and they can attend
in-person sessions
and there are a limited number
of virtual make-up
sessions that are allowed.
So, what we really try to do
with this service is to make--
develop it with a
performance-based payment.
So, they are really based
on meaningful outcomes
such as beneficiary
attendance and weight loss.
So, as you can see here,
within the first 6 months
of the program, a supplier could
actually receive a reimbursement
of up to $165 if a
beneficiary attends all sessions
and if they meet the weight
loss targets they could achieve
$325 reimbursement.
For the full 12-month
program, if a beneficiary went
through the entire program
but didn't achieve
any weight loss goals,
they could receive $195 or $445
if they achieve all
of the goals.
Sorry about that.
I talked faster than I advanced.
So, one important criteria is
that MDPP suppliers
must actually adhere
to the requirements to establish
and maintain enrollment
as a supplier.
So, CDC recognition is the
crux to their enrollment
and this really has
to happen first.
So, they have to have CDC
preliminary or full recognition
in order to be able and
eligible to enroll in Medicare.
They have to obtain a national--
a national provider identifier
through the national plan and
provider enumeration system,
and then there are a
couple of enrollment options
that they can utilize
to enroll in Medicare.
So, they could use this-- do
this using the online system
that we call PECOS or they could
actually submit a paper form.
I will just note there is about
a 90-day faster turnaround
for them to enroll
using the online system
versus the paper form,
but there are those 2
mechanisms available.
If you are already
enrolled in Medicare,
so you are already providing
services as a Medicare provider,
you must actually reenroll
as an MDPP supplier.
Because this is a new supplier
type, we had to work really hard
to develop enrollment
requirements that would allow us
to be able to identify these
types of suppliers and then
in order to maintain enrollment
in Medicare you actually have
to maintain compliance with the
CDC's recognition requirements--
as I mentioned, that is the
core of the enrollment--
as well as the MDPP supplier
standards, which are outlined
in the physician fee
schedule final rule
in which we expanded a program.
So, one thing that
I like to highlight
because there is a
little bit of confusion.
The MDPP is under the National
Diabetes Prevention Program
umbrella and so we do
like to highlight this.
This really is a joint
partnership between CMS
and the CDC and I always joke
that once the rule was final,
CDC and CMS were married in
holy regulatory matrimony.
And so we worked very closely
with our colleagues at CDC,
they're a wonderful team,
and it's been a really
great experience,
but CMS is really the payment,
enrollment, and oversight arm
of the MDPP program and so
the suppliers receive payment
from CMS and they have to remain
compliant with those criteria
that I outlined earlier.
We really view CDC as the
quality assurance arm.
So, they-- the MDPP
suppliers have to maintain
that CDC recognition, follow
the quality standards,
which includes the use of
that approved curriculum.
We want to make sure that our
beneficiaries are receiving a
quality program and benefit.
So, what can you do to help?
Screen, test, and refer your
at-risk Medicare patients.
So, you can screen them using
the CDC's prediabetes screening
test, there is a link here, you
can use 1 of the 3 blood tests
that Ann highlighted and
are also listed here,
and please do refer your
at-risk Medicare patients
with prediabetes to one of
their nearby MDPP suppliers.
We do have a supplier map on our
CMS website where you can go in,
put your address, and see where
the nearest MDPP supplier is
to you so that you can
enroll either yourself
or refer your beneficiaries
to enroll.
How else can you help?
So, we really need to increase
MDPP supplier capacity.
This is a new service, we know
that new services take time
to roll out and ramp up,
so suppliers were able
to begin billing for the
benefit beginning April first
of this year.
So, we know that there's going
to be a ramp-up period for folks
to get enrolled in Medicare.
So, encourage CDC-recognized
delivery organizations
to enroll as MDPP suppliers.
Encourage organizations to
actually become CDC-recognized
so that they can eventually
enroll once they've met
that preliminary recognition,
and then educate CDC-recognized
delivery organizations
that MDPP is out here and that
there are a ton of resources
on our website available to
help you enroll in Medicare
to be able to bill
for this service.
Lastly, you know, really
work to promote awareness
of prediabetes among
the Medicare population.
As I said, about 50% of Medicare
beneficiaries are prediabetic
and many of them don't know it.
So, you know, have folks get
screened and learn their status,
as well as encourage
providers to screen, test,
and refer patients
to MDPP suppliers.
So, if you want to know
more, there are a number
of resources here both
on our website at CMS
as well as CDC's website.
And now I will turn it over to
Dr. David Pryor, who is calling
in from California and Phoebe
will advance his slides.
Thank you.
[ Applause ]
>> Well, thank you
very much, Nina.
I hope everybody
is able to hear me.
Very much pleased to be here
with you today via the phone.
As was mentioned earlier, I am
right in Southern California
in the midst of all of
the fires and good news is
that after being evacuated from
my home for the last 5 days,
it looks like I'll be
able to return today.
So, that is the good news,
but again I am a regional vice
president medical director
with Anthem Blue Cross.
And, as many of you know,
Anthem is a national insurer
with about 40 million medical
members across the country
and I work in our
California division.
And I wanted to talk a little
bit about our implementation
of the National DPP
lifestyle change program
over the last year or 2 and talk
through some lessons learned
through that, hopefully.
Our journey with the National
DPP program really began
in August of 2014 when the U.S.
Preventative Services Taskforce
issued a recommendation stating
that intense behavioral
counseling intervention could
promote cardiovascular
disease prevention.
And so we took notice of
that and looked around
and were excited to find
that the National DPP lifestyle
change program met all the
requirements for
this recommendation,
so really that's how
it started for us.
And, in August of 2016,
we were able to offer this
as a fully-covered benefit
for our medical members
in California.
And as we go to the
next slide, you know,
this really has been
a tremendous offering
for our employees-- our members.
It's been a win-win situation.
Many of our large health plans
always ask us the same question.
Well, we appreciate what you
do, you provide insurance
for our employees, but how can
we continue to improve health,
you know, bring more
and more quality
to the healthcare experience,
and at the same time,
as a large employer, how can
we save on healthcare costs.
And so what we certainly know
through our data is that members
with diabetes do cost more
than members without diabetes.
Our data tells us that
health plan costs for members
with diabetes a little over
$11,000 as opposed to $4400
with those members that
don't have diabetes.
So, certainly it's
really an easy proposition
that if we can keep
people healthy,
if we can prevent people
from developing diabetes,
we can improve their health,
the quality of their healthcare,
and we can save costs.
So, that was really again
that win-win situation.
So, the next step is,
well, how did we go
about implementing the
National DPP program.
And so we decided early on that
we were going to use vendors
to help us implement the program
and we decided that the best way
to reimburse for this was
to run all of these visits
through our claims system
that we already had in place.
Our claims structure
allowed us to really align
with the CDC quality and
fidelity metrics and,
as I'll talk about in the next
few slides, we have 4 milestones
which we pay our vendors and
it's worked out very well.
So, the next slide
goes into more detail
about these milestones.
So, milestone number 1, when
somebody enrolls in the program,
that's milestone number 1
and we make a reimbursement
to our vendors at that stage.
When they have meaningful
engagement through 4 weeks,
that's milestone number 2.
When they continue that
engagement up to 9 weeks,
they reach milestone number 3.
And then, hopefully, if
everything goes well,
when they're able to reach that
greater than 5% weight loss,
you know, sometime
between milestone 3 and end
of 19 months, right, between
9 weeks and 12 months,
that's milestone 4 and
that is the last payment
that our vendors receive.
And so, obviously, you know,
we didn't want to just kind
of pay a fee and if people
aren't able to continue
with the program, you know,
that money is kind of lost.
So, we-- these milestone
payments really helped us
to manage this relationship
with our vendors.
The other question on the
next slide is, gosh, well,
how do you pick the
right vendors.
And what we found very quickly
with our clients is we
have very diverse needs.
Some of the clients that we
insure and provide insurance
for are large municipalities.
We have large school districts,
but we also have tech companies.
Let's say in the San Francisco
Bay area, for example,
younger employees, very
tech savvy, you know, again,
different ethnicities.
So, we had a lot of different
needs and we realized
that it wasn't going to
be just one size fit all,
not just one provider
that's going to provide DPP,
but that we really
needed to allow choices
so that we could
have the best fit.
And the next slide here
again talks and amplifies
on that just a little bit more.
So, we knew that our
vendors needed to have kind
of a national network
of organizations.
We wanted kind of bricks and
mortar community organizations
as well as the digital solutions
as well and you'll see some
of the vendors here even
from Weight Watchers
to Lark and Sclera.
And so, again, Solera was our
company who has relationships
with many of these vendors
and they're contracted,
so they were our first major
DPP vendor in California
and then we've also
added on Omada,
which is a pure digital solution
that really appeals to a lot
of our tech savvy customers.
And the next slide again
talking about choice.
What we've learned so far is
that choice really does
drive the engagement.
So, really finding the right DPP
provider for the members is one
of the major determinants
of success.
If they're using a
service or a provider
who is not really aligned with
their interests and goals,
it's not going to work.
And so this choice has
been very valuable for us
as we've moved forward.
The next slide now really wanted
to emphasize a little more
of why choice matters and
what's the preferred delivery.
So, our data so far has
shown us the following.
It may not be a big surprise to
many of you, but our younger--
our younger members, let's say
18 to 24, 25 to 34, that range,
they often opt for the
digital or virtual solutions.
OK? As we see our membership
get older and they age,
you'll see a little more mixed,
Weight Watchers becoming more
popular as people get older
and other community
organizations.
And so, overall, I guess as we
kind of distill all of our data,
we found that more people
tend to opt and start
with the digital virtual
provider, if you will,
but that we've actually
had more success in some
of those achieving
those weight loss goals
with the Weight Watchers
or community organizations,
the kind of brick and mortar.
You go in, you check
in, you, you know,
deal with somebody in person.
For us, so far, we've had
a little bit better overall
results in the weight loss, but
I think that continues to evolve
and we kind of really
push to make sure
that our digital providers
are engaging in the right way,
but those are some things
to certainly consider.
I wanted now to go over
just a few case examples
of how we've implemented this.
You know, I work in
our commercial division
and we have different segments.
We have individual
insurer-- individual accounts,
we have small group accounts,
and we have these very large
group accounts with, you know,
hundreds of thousands
of employees
and so we had different
strategies for each segment.
So, this slide here talks
about our small group
case study in California.
Again, small group is
typically those small businesses
with 100 employees or less.
So, in this program, we actually
started and directed individuals
in these small groups to take
the CDC prediabetes risk test
to determine their
type 2 diabetes risk.
We actually ran 4 campaigns
between 2016 and 2018 and more
than 60,000 received a series
of emails referring them
to take this risk test and
find out what their status was.
Here are some of the results.
So, as of August of this
year, we had 1811 members
who actually committed
to the program.
They took the test, they
committed to the program.
Of those members, 65% remained
actively engaged and 24%
of those members had achieved
the 5-7% weight loss goal.
What we found is that
incentives were important.
We actually gave Fitbits
after the completion
of the fourth week.
That helped keep some
of the momentum going.
We also learned that
those employers
who were very engaged--
so it was the vendor
engaging the employee,
but also the employer, right, at
the same time working engaging,
reminding the employees to
take advantage of this benefit.
That seemed to work the best.
Also, our vendor
Solera in this case kind
of used very sophisticated
and slick emails to outreach
and to get the employees
excited.
So, they had a lot of work with
implementing these programs
and learned that you can't just
necessarily send a standard
email out, you have to
sometimes use some animation
and some other little tricks
to get people excited.
And so next steps, we're
going to be the end
of this last quarter sending
out a fifth campaign focusing
on our small group members.
The next slide is a
little case example
from our large group business.
These are often large
employer groups
with over 10,000
employees and wanted
to give you some
highlights there.
The same thing, we
directed the members
to the CDC prediabetes
risk test.
We had different mechanisms,
this was actually a
large school district
that had early retirees,
over 38,000, that we--
they received a newsletter
article linking them giving them
information about this program
and this covered benefit.
We also had another track
for those district employees
who were active employees,
over 60,000,
where they received a series of
emails sent out by the district
in this case encouraging them,
telling them about this benefit,
saying, hey, why don't you
just go and take the risk test
and see where you're at
because we have something
that may be helpful to you.
And now let's talk a
little bit about the results
from this large school district.
As of April 2018, a little
over 5200 district employees
have taken the risk screener,
934 district members were
committed to the program,
and of that 934, 64%
remained actively engaged
and 18% actually achieved
the 5-7% weight loss.
Again, with this group we
provided some incentives,
a $10 gift card just for
completing the 1-minute,
you know, assessment
test and quiz,
and again we gave
them the Fitbits
after they completed
week 4 of the program.
And so, again, it's-- all these
programs when you're talking
about health, wellness,
it's engagement.
How do you engage people?
How do you get them started?
And then, certainly,
how do you, you know,
get them to maintain
that commitment?
Just, again, some of our lessons
learned working with employers
to implement the National
DPP lifestyle program.
That we've had our--
obviously, the best success
with employers who
are very engaged.
When we tell them about the
value proposition, your ability
to improve your employees'
health, also the ability
to save healthcare dollars,
save healthcare costs, right,
that's really what employers
always want, they want both
of those together, then it
seems to be an easier sell.
And then employers are engaged
and they're working
with our vendor.
Certainly, it's raising the
awareness of type 2 diabetes,
the risk and the costs,
and another key is
having this accessible
and available provider network.
Right? Having choice and
many different providers
that can provide the service
certainly was important.
And what we've found is this
need to kind of have initial
and persistent engagement
and so that's something
that we've worked hard on,
it's an ongoing effort, and--
but we've had some success
so far and, like you said,
some of the earlier
presentations,
the more creative you can
get as to engage people,
provide the incentives,
it seems to really help.
Some additional considerations
as you move forward,
especially in the payer space,
it's all about, you know,
how do you continue to
drive program completion
and weight loss.
We certainly feel that--
remember those milestones,
if you complete 4 weeks,
you complete 9 weeks--
I think there are certainly
benefits anywhere along
the pathway.
Obviously, the goal
is to get people
to complete all 4 milestones and
achieve that 5-7% weight loss.
We know that really makes
a significant difference
at decreasing that risk
of developing diabetes.
So, we're constantly
looking at ways trying
to address dropout
and reengagement.
We do have with these vendors
in the contract a pathway back.
So, if somebody starts
the program, you know,
midway through they
just disengage
and they just don't follow up
anymore, they are allowed a way
to come back and
restart the program.
So, that was part of our
contract with the vendors and so
that is something
certainly I would recommend.
And I think the other
part of it is, you know,
culturally appropriate
material--
and we certainly do offer many
of these programs in, you know,
Spanish language,
which is important.
And out here and certainly
in California we need
to even expand that more to
other languages, but, you know,
all those things-- digital, in
person, culturally appropriate--
all certainly very important.
With that being said, I'd
like to turn the presentation
over to Arlene Guindon from
the National Kidney Foundation
of Michigan.
[ Applause ]
>> Great. Thank you, David.
I really appreciate it and
I'm happy to hear you're going
to be able to go back
to your home soon.
So, my goal today is to
provide you with some insight
on what it's like to
deliver the National DPP
and eventually the MDPP
within the community
and why the National
Kidney Foundation
of Michigan is interested
in doing so.
So, really the National
Kidney Foundation
of Michigan is interested
in doing
so because prevention
aligns very,
very well with our mission.
And our mission is to
prevent kidney disease
and improve the quality of
live of those living with it.
For those for chronic kidney
disease, approximately 70%
of chronic kidney disease, the
risk factors that are attributed
to it are diabetes and
hypertension align so well
that if we can offer
evidence-based programs
within the community
and be successful
at individuals adopting
healthy behaviors
and sustaining those behaviors,
we feel like we can really make
an impact within the community.
The next slide actually
shows what it looks like
and what our results
are to date.
We actually owe a new file
and updated results this month
to the Centers for
Disease Control,
but thus far we've served
over 1500 individuals
that have completed our
program, the National DPP.
The average weight loss for
those individuals is 6%.
The recognition factor,
as probably all
of you know here, is 5%.
And the average physical
activity minutes
for those completing the
program is 187 minutes per week.
Now, there's no recognition
factor on it,
although the program goal
is 150 minutes per week
and it's critical really
that both the healthy eating
and the physical
activity go hand in hand.
You really-- although you
could do one with the other,
you can't sustain a healthier
lifestyle without doing both.
One of the things that we also
measure are not only employee
engagement, but are participants
really engaging in the program
and are they confident when
they complete those 12 months
that they're able to sustain
those healthy behaviors once
they leave the program or once
they graduate from the program.
If they're not, then we
really haven't done our job
as well as we could.
If they are, then we feel
like we've really armed them
with the right tools to
move forward and create
that healthy lifestyle.
So, as you see from
the fourth bullet,
90% of participants are very
confident in their ability
to eat healthier and be active
for 150 minutes per
more-- or more per week.
That's a critical
success factor for us.
And as I go through
the presentation,
we'll talk about how
do we collect that
and how do we take checkpoints
of those participants
throughout the program.
So, one of the things in
launching the National DPP
and the MDPP within the
community is there are several
factors we need to look at,
several dots we need to connect.
And on this slide you see 6 of
those dots; community of focus,
finding a host site,
recruit participants,
how will the program be
paid for, who will the--
who will pay and
reimburse participants
for their participation
in the program,
and then what are the
available resources
and is it culturally
appropriate for the community
in which we are launching
the National DPP.
I'm going to go through each
one of these and provide you
with an example of what I
mean specifically in each one.
Each area.
So, the community of focus
is our starting point.
Where are we going to deliver
the National DPP and MDPP?
What communities?
We have offices in southeastern
Michigan in Detroit, in Flint,
in Ann Harbor, and Grand Rapids
and those communities are
very, very, very different.
And some of the ways in which
we select where we're going
to start in all honesty
is funding.
So, if we have a grant and the
grant focuses on Wayne County
and Detroit, that's where
we're going to start our focus
and launch and get the other
dots and connect those.
If we have a demonstration
project, like we might have
with Michigan Medicine, and they
want to add in maybe a different
but parallel slightly
off the National DPP--
maybe a low-carb to see
which one is more successful,
we'll work with them
and we'll offer it
at a Michigan Medicine location.
If we have a food bank
that really wants to--
where there's a food desert in
the community, but they want
to really engage underserved
areas to participate
in the National DPP, then
we'll have our food--
their food truck come
and provide resources
to individuals once
they complete a session.
So, we can begin to really
communicate with the community
and draw them in, but where
we start really is based
on a variety of factors,
funding not
which being the least of them.
So, once we find a community,
who's going to host the event?
So, as easy as this
may seem, it's not,
because we're asking
organizations
in the different communities
to at least give us their space
for 12 months minimum,
continuously,
or 24 months potentially
with the Medicare DPP.
So, that's not easy to do
that from a space perspective,
but some locations
in some communities
like clinics we have
relationships with.
It tends to be for
different clinics we work
with whether it's a
federally-qualified health
center or a large
university system,
we can use their
facilities but after hours.
And so that brings up
other special challenges
of getting people in and out and
making sure that site's secure.
We sometimes look at
recreation centers.
Other times, many of our DPP
workshops are offered in houses
of worship, temples, churches.
We really-- the focus of
where we operate is where--
what's available,
what's easily accessible,
and will participants
feel safe and secure
when they come to that site.
That's our goal no matter
what the community is.
We also offer worksite
wellness, so we'll offer this
in the corporate setting
and usually the corporation
will provide
that space for us to use.
Regardless of who the site is,
all sites we develop what we
call a memo of understanding
and basically it
manages expectations.
What can that site expect from
us when we come in every week
and then in monthly
sessions every other week,
and what can we expect of
them as far as creating a safe
and healthy facility and place
to hold the National DPP.
So, once we have the community,
we have the host site,
we need participants.
Just because we have
those things
in place doesn't mean
participants will come
and this is one of the
most challenging aspects is
to recruit participants.
To recruit them not only to come
to the information session--
so we have the information
session before session 1
and it's to really
tell individuals
about what the program is,
to answer any questions they
might have about funding
and reimbursement,
but also for us
to let them know what our
expectations are from them,
because we hope that
they'll be highly engaged,
and then what they
can expect from us,
the support that they can expect
from us throughout the program.
Sometimes we have host sites
that really engage in marketing
and recruiting with us.
Sometimes we need to do it on
our own through social media,
and other times when
we work with clinics
or federally-qualified health
centers, we have an e-referral
in which they can send
us referrals for patients
who qualify for the National DPP
through a compliance
secured line.
They can go ahead and refer
and then we'll let them know
that we received the referral.
It's most successful
when we receive referrals
from clinicians if they
talk to their patient first.
I know that sounds basic,
but I can tell you how many
times we received referrals
and we're the first contact--
the National Kidney Foundation
of Michigan is the first contact
of calling the patient saying,
hey, we see that you're
interested in the National DPP
and they're like who are you
and how did you get my name.
So, it's really critical
that the healthcare provider
have that first dialogue.
As I briefly mentioned,
funding methods are critical.
We know that grant funding
is-- it ebbs and flows.
In many situations
where grant funding is,
we know that we can
support individuals
within those workshops.
CMS has come onboard with
the Medicare benefit.
That's going to help us
with that proportion
of the population.
We're doing some demonstration
pilots with a few Medicaid plans
in Michigan, so we know
that they're underwriting it
and they can support
that population,
so those individuals
don't have to worry
about the funding perspective.
We have some commercial insurers
that we work with that fund
at a different rate the
individuals participating
in the program as
long as they qualify.
And then some corporations
also will open the doors wider,
so beyond those who qualify,
and let all employees attend--
even those with diabetes.
So, it's very tricky
for us and we work
with our coaches very diligently
to offer the best program
that we can for that population.
Where those mechanisms
aren't in place,
we offer individuals the
opportunity to self-pay.
We-- they can pay in a lump
sum or over a period of time.
And if individuals
can't afford it,
none of these funding mechanisms
align with where they're at,
we have scholarships
that are available
and it's really based on need.
So, we also look at what
are the available resources
in the community because we're
there for a year or 2 years,
depending on the population
we service, and once we leave,
we want to make sure that
those community resources
and those participants can
sustain that healthy behavior.
So, one good example of aligning
available resources is one
of the clinics that we work
with near the Ann Arbor area
actually has a fitness center--
the clinic doesn't own
the fitness center,
but a local community college
owns a state-of-the-art wellness
center and they've allowed
us, the community college,
for anybody that participates
in the National DPP,
as long as they attend,
they get a pass to go ahead
and use the fitness
facility free.
It's really a low-cost one and
in fact we hold session 5--
I also am a lifestyle coach, so
I know by the session number--
it's like jumpstart
your physical activity--
we hold it there at
the wellness center.
And first I thought, you know,
it's more than a gimmick,
it's really a lot of people
are intimidated by going
into a wellness center
or gym on their own.
We heard that when we held
the first session there.
I wouldn't have come
unless I was
with a group and group support.
Now I see it's approachable
and I'll continue to attend.
And that was great and that
relationship is fantastic
and even when we leave
and that program ends,
those 2 organizations
are still there.
So, that's our ultimate goal
is to really show individuals
who might not be familiar
with those resources
that they're truly
available for them
to use throughout
their lifetime.
And absolutely we
want to make sure
that the programs are
culturally appropriate.
On the west side of the state
in our Grand Rapids office,
they do a fabulous job
of working with Latino
and Hispanic communities
and they have some very
passionate coaches there
that not only make sure the
food models are appropriate
but the trackers are
appropriate and that the way
that we dialogue with
individuals in those locations,
they can-- is appropriate
and we're there
and it's a safe environment
in which they can come.
It's just amazing what that
group is doing these days.
So, I mentioned just really
briefly engaging participants,
but participants
are at the crux.
We could have all those
6 factors on paper,
it looks great, we got started,
we have 12 to 15 participants
at a minimum starting
the workshop,
but we need to engage
participants from the beginning.
We need to engage them at
the information session.
We have them take
a readiness test.
If they're not ready
at the info session,
they might not be a
candidate at least this time
around to continue that program.
And we actually ask them--
the coach thoroughly
engages them throughout,
not only during the sessions,
but we take checkpoints
and we do a baseline survey,
we do an 8-week survey,
we do a 16-week, and we do
a 9-month, because we want
to take checkpoints to make
sure are we missing anything.
Are the individuals engaged?
Is there a good relationship
and strong with their coach?
It's really important
that we do it throughout.
Once you get them in the doors,
it's not done, it's
just beginning.
What you see here on this slide
are some really sound bites
of individuals and some of--
I mentioned the 4
surveys that we provide.
What amazing things
did they learn
and how would you
change the program?
We take a lot of their feedback
on how would you
change the program
and incorporate it
into our workshops.
One good example
is healthy recipes.
We do a recipe rehab in one
of the sessions and it's great
because participants
bring in their own recipes
and they're more
engaged other than--
aside from us giving
a script, you know,
here's what you must take.
It's like, no, here's
what I go home and cook,
how can we make it healthier.
Because they're likely to
continue in that situation
than if we didn't do that.
So, how do we sustain
the momentum?
We've been successful to date.
We've had CDC full
recognition for 4 years,
we hope to have it much longer.
It's been challenging.
It's exciting.
What's made us successful
to date are our high engagement
rates, the support that we have
in the communities, our
different funding partners.
Even though those are
some of the same factors
that will help us be
successful down the road,
the environment's
totally changed.
Different funding
sources are there.
We're looking at doing a blended
model with online and in person
to account for what
you heard David
and others talk about,
the virtual DPP.
There's more competition.
More organizations are
getting into the marketplace.
And there's growing pains
and we have to get coaches
to keep continually being
engaged in the program as well.
It's not easy.
It's ongoing.
We're hoping that we can
stop and take checkpoints
and continue to sustain
the momentum that we built
for much longer down the road.
So, the key takeaways.
We need to engage participants.
We need to collaborate
with partners.
We need to address challenges.
And even when we do all
that, we need to keep--
we need to keep the main purpose
in mind and the main purpose
to me is, for individuals
that participate,
we need to make sure that we
can help them create sustainable
healthy lifestyles.
If we forget that, then we
won't have a program at all.
So, thank you for your time
and I'm going to turn it
over to Ann for Q and A.
[ Applause ]
>> I'd like to turn it
over to Susan to see
if we have any questions
coming in online.
>> Thank you, Dr. Albright.
We do. I first want to
remind our online viewers
to submit your questions
to grandrounds@cdc.gov
or via Facebook.
Our first question from
Samantha on Facebook.
She talks about her last
pregnancy being diagnosed
with gestational diabetes
being a real eye-opener.
Is there anything
we can do to see
that restaurants can provide
reasonably-priced options
for people with diabetes?
>> Well, I'll start
that conversation.
There are efforts going
on throughout the public
health community working
with restaurants and other
foodservice organizations.
So, there are efforts.
They really start with the
consumers in the community.
If people demand things or
are interested and they speak
to these restaurants
and these locations,
then they are often
interested and willing
and listening to
their customers.
So, it should be the customers
who put that out there.
One strategy that people can
often use too is when you go
into a restaurant order your
meal and take half of it home.
Put it immediately in a
to-go container, half of it,
and take the rest of it home.
So, you can also
ask the restaurant,
but you can also do
some things yourself.
>> OK. We'll go with another
question from online viewers
from Sensig.
Can you talk briefly-- this
is for the whole panel--
about the-- they're calling
it metabolic surgery,
I believe they're talking
about gastric bypass--
and the impact on
diabetes overall?
>> I'll start or I'll answer.
There are a few tools in our
armamentarium for preventing
or delaying type 2 diabetes.
You've heard about primarily
today the evidence-based
lifestyle change program
that is really critical.
You also mentioned briefly
the medication metformin
and there are a couple of others
that are also potential
candidates.
There is the opportunity
and another third tool
would be bariatric
or our various versions
of bariatric surgery.
Again, a tool in
our armamentarium.
This is a conversation
that people should have
with their clinician
to determine
which of the tools is
most appropriate for them.
I would underscore, however,
that lifestyle is common
to every single one.
Regardless of whether you
have surgery or you're
on a medication, lifestyle
always wins the day.
So, it's imperative that
you engage in lifestyle
and whatever other additional
therapies your clinician thinks
are most appropriate for you,
but definitely talk
to your clinician.
Any-- let me just pause
for a moment and see
if there are any questions
in the room before we
continue with any online.
And I know sometimes it
takes-- oh, good job, Steve.
[ Laughter ]
>> So, this is Steve Redd.
I have a question
about the challenges
in scaling the program.
The number of people
with prediabetes is pretty large
compared to the number of people
that you've been able to enroll.
And I know that you're
working hard
to make the program available
to more people, but I wonder
where the-- where are the points
where you especially
need to make progress?
>> Yeah, there's probably
a lot to say, but I'll try
to be as succinct as I can.
Yes, there are an estimated 84
million people with prediabetes.
Part of the issue
we have faced is
that people have been
completely unaware
of this condition, for starters.
So, we really do have
to generate increased
public awareness.
We must have a national
conversation about this,
just as we are about opioids
and we have about HIV/AIDS.
We must have that
conversation as a nation.
So, that's first and foremost.
People have to be aware.
They have to know.
And then it really is
about engaging people
in the interventions that
have been proven to prevent
or delay type 2 diabetes.
There's a lot of
noise out there.
There are a lot of things--
people trying various programs,
people trying all
sorts of array of diets
that they go on and off.
This is definitely an area
that is crowded with things
that people are attempting
to do.
So, I think part of it
then is also focusing
on the evidence-based
interventions.
Third, I would say that also as
a nation we have to get serious
about scaling lifestyle.
We can distribute
medications well,
people can get surgical
procedures,
they know about them,
they know how to get them.
We have not treated
lifestyle in the same way.
So, I would say that
those things are critical.
We have to talk more about this.
People have to know
where they stand.
We have to treat lifestyle
seriously in the country
and be very committed.
Look at anything in history,
whether it was sending somebody
to the moon, whether it was the
Wright brothers launching the
first plane, whether it's
been any of our conflicts.
If people give up, then we will
never get where we need to go.
So, you cannot be
faint of heart.
We must press on.
So, having said that,
around really getting
lifestyle implemented
and for the first time in our
history taking it seriously
and not growing faint of
heart, we also, as I mentioned
in my remarks, must also
change the environment
in which we live, work,
play, and worship.
These are not mutually
exclusive.
In fact, they are--
must be done together.
So, it requires both that
we are full throttle going
after this intervention
and getting it scaled
and we are changing the
environment and looking
at all those potential
options and looking
at the evidence behind
those as well.
So, it's a dual approach and
they are really complementary
and must be done together
and taken seriously together.
>> From the Medicare
perspective,
I would agree wholeheartedly
with everything Ann just said.
I think it's pretty
simple though,
as I shared in my remarks,
beneficiaries need to know
that they're at risk,
so they need to know
that they're prediabetic, so
screening by their physician,
primary care provider, even
a health fair, you know,
start the conversation there.
We need suppliers that
can deliver this service
to beneficiaries.
So, folks that are
already CDC-recognized,
having them enroll, get
the necessary support
and services they need to be
able to do that, but then folks
who could be enrolled in
Medicare but aren't yet,
you know, CDC-recognized,
getting them started
on that process because we
know it takes about a year
to get preliminary recognition,
and then to refer your
Medicare beneficiaries
to suppliers near them.
>> I'll add just one more thing
because sustainability won't
happen without funding and I'm,
you know, I'm glad that
Medicare is going to fund
for Medicare beneficiaries,
but the rate
at which we fund is going to
be challenging for individuals,
whether you're online or in
person, to sustain the program.
So, let's not forget
about the funding.
>> Well, I know we're at
the top of the hour and any
of the questions
that we did not get
to from online we
will actually--
we will absolutely answer all
of those questions for you,
so no worries, and if any of you
in the audience have questions
that we did not get to,
the speakers will be here
for a bit longer and you can
also give us your question
and we'll be sure to
get an answer to you.
Thank you so much
for your interest
and participation in
this Grand Rounds.
[ Applause ]
>> We'll see you next month.
Public Health Grand Rounds.
