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Medicare Proposal Aims to Prevent Diabetes (NYT)

WASHINGTON — The Obama administration plans on Wednesday to propose expanding Medicare to cover programs to prevent diabetes among millions of people at high risk of developing the disease, marking the sixth anniversary of the Affordable Care Act with the prospect of a new benefit, federal officials said.

Sylvia Mathews Burwell, the secretary of health and human services, is scheduled to announce the proposal at a Y.M.C.A. here. Under the plan, Medicare would pay for certain “lifestyle change programs” in which trained counselors would coach consumers on healthier eating habits and increased physical activity as ways to prevent Type 2 diabetes, formerly called adult onset diabetes. Such programs have been found effective in people with a condition known as prediabetes, meaning that they have blood sugar levels that are higher than normal but not high enough to be considered diabetes.


Sylvia Mathews Burwell, the secretary of health and human services, in Flint, Mich., last month. Credit Bill Pugliano/Getty Images

That expansion was made possible by provisions of the Affordable Care Act, which President Obama signed six years ago Wednesday.

The Centers for Disease Control and Prevention estimates that 86 million adults, including at least 22 million people 65 or older, are prediabetic, increasing their risk of heart disease, stroke and diabetes itself.

In 2012, the National Council of Y.M.C.A.s, also known as Y.M.C.A. of the U.S.A., received a federal grant of nearly $12 million to test the value of a diabetes prevention program in eight states. The curriculum for the program was approved by the C.D.C.

After a formal evaluation, Ms. Burwell said, “this program has been shown to reduce health care costs and help prevent diabetes.”

Federal officials said that Medicare saved $2,650 for each person enrolled in the prevention program over 15 months, compared with similar beneficiaries not in the program. That was more than enough to cover the costs. In addition, officials said, Medicare beneficiaries in the program lost about 5 percent of their body weight, which was enough to reduce substantially the risk of future diabetes.

Under the 2010 law, the health secretary can, by regulation, expand such demonstration projects nationwide if she finds that they would reduce Medicare spending without reducing the quality of care, and if the Medicare actuary agrees. That is a major change from the situation before the health care law, when an act of Congress was generally required to make even minor changes in Medicare benefits.

The proposal must go through a public comment period, but without the need for congressional approval, there is little doubt it will go into force before Mr. Obama leaves office.

Ms. Burwell said the counseling for people with prediabetes was the first preventive service to become eligible for expansion into the Medicare program under the Affordable Care Act.

Dr. Matt Longjohn, the chief health officer at the national Y.M.C.A. organization, said the results of the demonstration project vindicated the role of “lay health workers” in preventing chronic disease. These workers, he said, delivered preventive services at a much lower cost than doctors, nurses and other health professionals, and the services were “just as effective in terms of weight loss.”

Private insurers have also begun to cover diabetes prevention services like those provided by Medicare and the Y.M.C.A.s.

“The program helped me a lot, and I hope it helps other folks,” said Timothy L. Enfinger, a 45-year-old nuclear licensing engineer in Wilmington, N.C., who received the service through UnitedHealthcare and his employer, General Electric.

He said in an interview that he had lost 35 pounds, lowering his weight to 240 pounds. And he told the government: “I was pretty much your standard couch potato before the program. Now my wife and I go walking every day, sometimes as much as two and a half miles. I feel a lot better.”

Services covered by the proposed diabetes prevention benefit could be provided in person or online. Omada Health, a San Francisco company founded in 2011 with venture capital, says it has provided diabetes-prevention services online to more than 45,000 people, most of whom had employer-sponsored insurance.

“With Medicare coverage, our work with seniors is likely to grow dramatically,” said Mike Payne, the head of medical affairs at Omada.

Prediabetes is treatable, federal officials said, but only about 10 percent of people with the condition are aware they have it. Left untreated, up to one-third of people with prediabetes will develop diabetes within five years, the government says.People can use a test devised by the C.D.C. to assess their risk of prediabetes.

The government has not said how it would pay for diabetes prevention services. Medicare could reimburse providers directly or could pay for their services as part of a package that also includes the services of doctors who monitor the progress of patients.

Omada executives said that health insurers and employers paid the company $650 to $800 in the first year for each person who successfully completed its program and lost weight, reducing the risk of diabetes. But Medicare could use a different approach. Medicare officials will set forth details of payment in a proposed regulation that will be open to public comment.

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