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Medical Guidelines Embrace Prevention, Screening, and Treatment: Time for Medicare to Follow

Back in June, we wrote about the growing recognition – by both the US Government and the private sector - that preventive medicine was the next big frontier in health care. At that time, we were finally seeing signs that the biggest players in the health care industry were prepared to transition a sick care system into a true health care system. At a Congressional hearing in May, the leader of the Medicare Innovation Center Dr. Patrick Conway made this explicit, testifying “To improve care delivery…we are focused on improving the health of our communities – with a priority on prevention and wellness to prevent chronic disease in the future.”


As of this week, the policy momentum around prevention continues to grow.


The June 2015 announcements by HHS Secretary Burwell and the Bipartisan Policy Center built on August 2014 guidance from a key medical guidelines body – the US Preventive Services Task Force (USPSTF) – that recommended “intensive behavioral counseling” (shown to be the most effective defense for those at risk for obesity related diseases like diabetes and heart disease) for adults who are obese or overweight with at least one additional risk factor for cardiovascular disease. The guidance specified that these counseling services must provide frequent patient contact, intensive counseling on diet and exercise, a basis in behavioral science, leadership by health professionals – and will often be delivered outside of the the primary care setting in either in-person settings or virtual settings like Omada’sPrevent program. In highlighting the value of intensive behavioral counseling, the USPSTF specifically cited the success of the Diabetes Prevention Program.


Since the USPSTF is empowered by the ACA to deliver binding guidance (at Grade A or B levels) requirements for coverage in commercial health plans (including those purchased by self-insured employers), beginning in 2016, every commercial health plan offered by employers or on the health care plan exchanges will be required to make these types of programs available to enrollees at risk for cardiovascular disease (including individuals with prediabetes who are also at risk for type 2 diabetes).


The problem is, that in order for behavioral counseling to be effective, at-risk patients must be enrolled in them, which in turn requires those patients to know that they are at risk – and the plain fact of the matter is that tens of millions of at-risk American adults don’t know it. Nearly one in three people with type 2 diabetes aren’t aware of their condition, while nearly nine in ten individuals with prediabetes don’t know it. Part of the reason for this gap is that until this week, USPSTF guidance was notoriously soft on screening requirements (the previous guidance, released in 2008, specified that only adults with high blood pressure should be screened for abnormal glucose levels).


All of that changed earlier this week, when USPSTF released new guidance that greatly increases the number of US adults who should be screened for abnormal blood glucose and diabetes (Omada had the privilege to submit comments on the final draft of that guidance). Beginning next year – and including all plans offered on the exchanges starting next week – commercial plans will require providers to screen overweight or obese adults 40 and older for abnormal blood glucose levels. If patients have abnormal blood glucose levels – in plain language, if they have prediabetes or diabetes– providers will need to refer those individuals to intensive behavioral counseling programs to promote healthy lifestyles.


It is worth noting that the guidance was not as extensive as we wished (and in fact not as extensive as the original draft guidance from USPSTF) – specifically, it ignores underdiagnoses among younger adults 18-40. As noted in the American Diabetes Association’s press release on this topic, adults aged 20-44 have rates of undiagnosed diabetes nearly 60 percent higher than the adult population as a whole. In its response to the news, the Diabetes Advocacy Alliance (of which Omada Health is a member) also noted that diabetes is not only a risk factor for heart disease and stroke, but that undiagnosed or uncontrolled diabetes can also lead to blindness, kidney disease, and amputations – factors the USPSTF final guidance did not cite.


While we are disappointed that the USPSTF guidance was not broader, it is a step in the right direction. Perhaps most importantly, it represents recognition of a principle long espoused by public health experts – in order for effective prevention to occur, it ‘takes two to tango’ – both effective screening and effective preventive treatment must be in place and covered by insurance. The combination of USPSTF guidance from August and this week finally provides the necessary two-part mandate to insurers that is required for meaningful inroads to be made into reducing the diabetes epidemic in the US.


It is worth talking about the ‘mandate’ for commercial coverage of USPSTF Grade A and B recommendations. For the past year, there has been some ambiguity about whether health plans would have to cover this type of behavioral counseling, or simply have to refer patients to it. Just last week, that ambiguity was removed, as theLabor Department issued additional guidance making it clear that plans had to cover the cost of the benefit, not simply the referral. This Labor Department guidance is the first of its kind, and it gives us hope that in the wake of the new USPSTF screening guidance, commercial plans will more proactively cover and encourage both screening as well as rigorous, evidence-based intensive behavioral counseling programs like Omada’s Prevent.


It is also worth noting that the ACA mandate for coverage of USPSTF-recommended interventions only applies to commercial health plans. It is ironic that the rule-maker in this case – the US Government – left the largest health plan in the country, Medicare, off the hook.


Right now, CMS is not mandated to follow USPSTF recommendations. We would strongly encourage HHS to take this opportunity to end this dissonance by adopting a preventive approach to treatment of individuals at risk for diabetes and heart disease. Right now, Medicare will screen individuals for type 2 diabetes, and reimburse for expensive treatment, but does not reimburse for the proven, effective Diabetes Prevention Program (DPP) intervention (Omada’s Prevent is recognized by the CDC as a DPP that meets the CDC’s evidence-based standards in this area). This this leaves a serious void; more than two-thirds of Medicare beneficiaries have at least two or more chronic conditions, and the program spends nearly $200 billion every year treating diabetes. If a Medicare beneficiary has prediabetes, his or her provider has no incentive to offer treatment that could prevent the disease – and thousands of dollars of spending – down the road.


We are very glad that USPSTF has recognized and recommended the synergistic combination of glucose screening and intensive behavioral counseling, and we are hopeful that commercial health plans will follow their guidance with rigor. We also hope that CMS decides that it’s time to lead, rather than lag the commercial market, by making the decision to cover DPP for all Medicare beneficiaries.