How Employers Can Tackle Prediabetes To Reduce Healthcare Costs

Intervening to minimize disease progression is the place to start

The American Diabetes Association (the Association) recently released a new economic report that details the fiscal impact of diabetes in the United States – and the results should alarm employers, benefit managers, and HR executives.

 

According to the Association, about 30.3 million people in the U.S. are living with diabetes. In 2017, the total estimated costs associated with diagnosed diabetes were a staggering $327 billion, an increase of 26 percent compared to 2012. About one-third of this cost -- $109 billion -- is due to medical costs to care for patients with diabetes. Another $30 billion is due to indirect costs in the employed population, including increased absenteeism and reduced productivity.
 
These high prevalence and cost statistics for type-2 diabetes are concerning by themselves, but they fail to fully reflect the true burden that diabetes will place on the healthcare system – and employers – in the years ahead. When looking to plan for the future, one must consider the prevalence of prediabetes.
 
More than 84 million Americans have prediabetes – but about 90 percent are unaware they have it. Prediabetes is not a medical disease, but rather, an indicator of insulin resistance which, over time, may progress to type-2 diabetes. As many as 25 percent of individuals with prediabetes will develop type-2 diabetes within five years.[i]
 
Prediabetes may, in some cases, be a blessing in disguise. With behavior modifications that include losing weight and increased physical activity, an individual may prevent or delay a type-2 diabetes diagnosis.
 
Employers can play a pivotal role in helping individuals identify prediabetes and take actions to reduce progression to type-2 diabetes. Many individuals in the United States do not have a regular physician, and their only meaningful contact to health services is through an employee wellness program.
 
Employers have a significant reason for concern about prediabetes. New diabetes therapies are on the rise and with them, costs. According to Truven Health data, between 2006 and 2016, the list prices of Humalog and Novolog, two popular rapid-acting insulins, increased by 290 percent.

Moreover, diabetes is often associated with several other health conditions, including heart disease and chronic kidney disease, a leading cause of kidney transplantation. Addressing prediabetes to reduce the risk of progression to type-2 diabetes may prevent many other adverse health outcomes, as well.

Many employers who utilize Blueprint for Wellness rely on a non-fasting, or fasting glucose blood test to aid screening for prediabetes and type-2 diabetes. The non-fasting glucose test really provides no relative value due to not knowing so many factors that affect that test. Given as a fingerstick or venipuncture, these tests provide a snapshot of current glucose levels and lack the ability to provide more of a long-term look at diabetes risk.
 
Hemoglobin A1c, performed only by venipuncture (or via a dried blood spot collection card), evaluates these levels over time and is less likely to be subject to dietary and other factors. While fasting glucose is a helpful marker of prediabetes, research shows that some individuals with normal fasting glucose results are at higher risk for diabetes, and a glycated hemoglobin (HbA1c) test may help identify this risk more reliably.^[ii]
 
As a part of our wellness program, we decided to employ both fasting glucose and hemoglobin A1c tests to aid in the detection of prediabetes. We also created a program to provide a personalized, confidential report to any participant whose test results marked prediabetes or type-2 diabetes. Along with the report is an offer to speak with a board-certified physician about the results, free of charge.

Screening is a crucial first step, but alone, it may not be enough to prompt an individual to take action.
 
Diabetes Prevention Programs (DPPs) are an outgrowth of public health efforts to address the diabetes crisis. In 2009, the U.S. Health and Human Services (HHS), with the Centers for Disease Control and Prevention (CDC), established a national DPP targeted at persons with a high risk for type-2 diabetes. Through this initiative, public and private organizations employ these evidence-based lifestyle change programs, recognized by the CDC, to help prevent or delay type-2 diabetes.
 
In order to achieve full CDC recognition, DPP providers must meet rigorous standards. These include approval of an organization’s curriculum; a minimum percentage of participants entering the program with a qualifying blood test; a minimum level of participant engagement; and the achievement of average participant weight loss in accordance with CDC standards.
CDC-endorsed national DPPs are well-recognized within the medical community as an effective tool for intervening in prediabetes and minimizing risk of type-2 diabetes. People with prediabetes who participate can reduce their risk of developing type-2 diabetes by up to 58 percent.[iii]
 
Individuals identified with prediabetes may participate free of charge. During the 16-week program, they can access education, coaching, and lifestyle modification services, all available through personal laptops, cell phones, or desktop computers.
 
Results to date are encouraging. In research unveiled at the 2018 American Diabetes Association Scientific Sessions, we reported that about one-third of individuals (32%) with prediabetes no longer had glucose or hemoglobin A1c levels in the prediabetes range after participating in the program. About 28 percent lost five percent or more of body weight, a risk factor for diabetes.
 
Diabetes is only one of the conditions that contribute to rising healthcare costs. We have found that the same “identify early, then act” model Quest employed for prediabetes can also apply to other health concerns, such as chronic kidney disease, heart disease, and tobacco use.
 
And, we have hard data to back up our results. Through a combination of smarter benefits design, vendor management, and wellness initiatives, we’ve been able to lower healthcare costs annually for our company and employees for the first time in ten years. After years of annual medical cost increases of about 6 percent, we achieved a negative annual medical cost rate of -1 percent in 2017 and a zero inflation rate in 2018. Now, we’re helping other employers implement wellness services this way, with the aim to replicate our success.
 
If an employer’s cost curve is rising, then focusing on preventing type-2 diabetes and other chronic conditions is critical. Measuring risk, and intervening to minimize disease progression is the place to start.
 
Notes

[i] https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html
[ii] Shiffman D, et al "Elevated hemoglobin A1C is associated with incident diabetes within 4 years among normoglycemic, working-age individuals in an employee wellness program" Diabetes Care 2018; DOI:10.2337/dc17-2500.
[iii] https://www.cdc.gov/diabetes/prevention/prediabetes-type2/preventing.html