Educate Don’t Amputate: Hospital Profits Versus Diabetes Prevention Study

Newswise — Diabetes is the most singularly expensive disease. Nationally, it consumes $176 billion a year in health care dollars. In New York State diabetes costs $8.7 billion a year including $1.3 billion in annual Medicaid costs.¹

This study provides insights and projections for both the medical savings and avoided burden of diabetes cases that would result from using a fraction of New York Metropolitan area “nonprofit” hospital profits to deliver the NDPP. With profits for the 25 largest Metropolitan area hospitals reported to be $1.43 billion, even 25% of those profits could fund evidence-based diabetes prevention for 357,000 pre-diabetics, thereby preventing 207,060 new diabetes cases!

The cost to patients in ongoing illness and terrible complications is devastating. Diabetes is the nation’s major cause of lower-limb amputations and dialysis and blindness; 19% of diabetes patients age 20 and over already have vision problems. Depression rates of people with diabetes range from 30% to 50% and growing studies show that diabetes increases the risk of Alzheimer’s by 40 to 70%.^2,3

Yet, in an unprecedented failure of concern and response, the overall medical and public health systems have watched diabetes relentlessly explode for years without any serious effort at prevention; this explosion has proceeded unabated even though it is fully recognized in medicine that diabetes is largely preventable.

The National Diabetes Prevention Program (NDPP), a multi-session lifestyle course, is backed by 15 years of massive and undisputed federal research showing that it helps pre-diabetics reduce by 58% their risk of developing diabetes. Indeed, it is not only the best researched diabetes prevention program in the United States, but similar programs are recognized and backed by research in several other nations. In the U.S., it has been shown to obtain the same results for women and men and a range of ethnic and racial groups. The focus of the program is to help participants achieve two goals---to lose 5 to 7% of their body weight and start exercising, even walking, for ½ hour a day 5 days a week. The program is provided in a supportive group setting where participants learn basic nutrition, portion control, exercise strategies and other “lifestyle” tips and support each other to steadily achieve their goals through step-by-step, manageable changes.⁴

The NDPP, which provides group participants 22 sessions over the period of a year, costs about $800 to $1,000 to deliver. Meanwhile, lifetime costs for a diabetes patient have now reached $150,000 to $200,000. Returns on the NDPP can be documented within months of patient participation.  The most recent large federal demonstration, for example, provided the NDPP to pre-diabetic Medicare patients—the age group at most risk for developing diabetes. Average health care savings for these 5,696 NDPP enrollees was $2,650 per enrollee in 15 months.⁵

With the huge numbers of pre-diabetics----84 million----who have been allowed to simply build up in the U.S., it is obvious that prevention is now an emergency ---indeed a crisis--- that requires the proper funding of any other crisis. About 5% of pre-diabetics “convert” to diabetes every year; without intervention and prevention, the U.S. will have another 21 million diagnosed diabetics within five years! Given the massive savings targeted diabetes prevention will reap for the medical system, it is fair and logical to propose that that system itself to lead in investing in prevention.

In recent years, nonprofit hospitals have widely reaped unprecedented profit levels. Politico has reported that the nation’s top teaching hospitals have increased their income by literal billions since the advent of the Affordable Care Act---while out rightly slashing their charity care.⁶

In New York, Crain’s has reported that the 25 largest New York Metropolitan area nonprofit hospitals had an overall profit of $1.43 billion in 2016.⁷

Study Purpose

The purpose of this study is to provide insight and projections for both the medical savings and avoided burden of diabetes cases that would result from using a fraction of such New York Metropolitan area “nonprofit” hospital profits to deliver the NDPP.

The “25 largest list” used here is recognizably not a complete inventory of New York State or New York City hospitals; and even within that 25, profits can vary by many millions.

Nonetheless, in the face of the current diabetes crisis, it is crucial to examine every possible means of preventing further agony to communities already overwhelmed by the epidemic.

Our focus is also to assure the NDPP becomes really available and accessible. This means using funds to enable community groups in the highest need neighborhoods to provide the NDPP. While it is important for hospitals to offer the NDPP to any pre-diabetic patients who want to participate, most people aren’t eager to travel to hospitals for health education. Funding from any source must shift to communities so that accessible classes are available where people live and where they will engage with local organizations they know.

After projecting savings in costs and prevented diabetes cases, we suggest basic strategies to assure funds are used to bring the NDPP to the highest risk communities.

Methods and Projections

New York City now has a projected 1.3 million pre-diabetics.⁸ Without intervention, a projected 25% will proceed to develop diagnosed diabetes within five years, adding 325,000 cases to New York City’s current caseload of 700,000 diabetics.

New York State already has 1.6 million people with diabetes and 5.4 million pre-diabetics.⁸ Without prevention, the state will add another 1.35 million diabetics onto its caseload.

Chart 1: Current and Projected Diabetes Cases within Five Years for New York State and City

To project diabetes cases that could be avoided within five years, we use a cost of $1,000 per pre-diabetic participant in the NDPP. While there are not comprehensive studies of delivering the NDPP through community groups, we have projected this cost based on the experiences of Health People, which only provides a peer educator-facilitated NDPP and has so far entirely delivered its NDPP at community sites in the South Bronx. The cost is meant to include outreach to enroll people who don’t ordinarily participate in health education.

Just 25% of the $1.43 billion profits of the 25 largest New York area hospitals amounts to $357 million. At $1,000 per participant, that would fund NDPP courses for 357,000 pre-diabetics; in turn, with an overall 58% risk reduction, these courses would prevent 207,060 new cases of diabetes. To put in perspective the caseload prevented, 207,060, is 64% of the new diabetes cases New York City will have within five years if nothing is done to address pre-diabetes---and 15% of the new cases expected for the state overall if nothing is done!

Chart 2: Cases Prevented Using $357 Million, from Large Hospital Profits to Fund the NDPP

Health Cost Savings

With the lifetime cost of a single case of diabetes having reached $150,000 to $200,000, preventing 207,000 diabetes cases would, over time, realize health savings of $30 billion.

The savings in agony for communities already overwhelmed by diabetes and its horrific complications are incalculable. Diabetes has already, for example, struck 15% of adults in the Bronx and 14% in Brooklyn; but even several upstate counties now have diabetes rates approaching 10% of adults. Diabetes is the major cause of lower-limb amputations, vision problems, blindness and dialysis; it raises the risk for Alzheimer’s by 40 to 70%.^2,3

Comment

The NDPP, while not the only route to diabetes prevention, is recognized across the globe as an amazingly reliable and cost effective preventive strategy. The British National Health Service, in fact, is gearing up to provide its similar group prevention course to all pre-diabetics who wish to enroll.

In the U.S., most insurers still won’t pay for the NDPP. Most disappointing, despite the extraordinary results from the federal Medicare demonstration project, the “payments” for the NDPP which Medicare has said it will finally start in 2018 are so low that, in reality, few clinical providers or community groups will be able to implement the program. (If participants don’t lose 5 to 7% of their body weight, even though clinics and groups faithfully provide the standard 22 NDPP sessions over a year, providers will only receive $195 in reimbursement per participant!)⁹

In the U.S., moreover, it is clearly necessary to support community groups who can reach the high risk people concentrated in low-income neighborhoods to deliver the NDPP. The Medicare demonstration largely took place at YMCAs across the nation. Even though the Y did an impressive job of enrolling thousands of participants, it was unable to reach minority participants. For those whose racial/ethnic group was recorded, only 7.6% of participants in the Y-USA NDPP Medicare demonstration were black; and only 1.8% were Hispanic.¹⁰

In New York City, where the majority of pre-diabetics are black and Hispanic, giving them an equal chance to avoid diabetes means enabling groups right in their neighborhoods to provide the NDPP.

Study Limitations

This study only projects potential savings from using a fraction of the profits of the New York Metropolitan area’s 25 largest hospitals to fund a real initiative in evidence-based diabetes prevention. It does not look at the entire New York City or New York State hospital universe. Profits vary enormously from hospital to hospital and some hospitals, of course, lose money. How community groups from low-income areas could participate in such an initiative in a fair and transparent way, and become NDPP providers is a question that needs further examination. Projected participant costs for community groups to deliver the NDPP are necessarily based on limited experience.

Conclusion

Diabetes in New York City and State is beyond an emergency: it is a crisis. The spectacle of basically an entire medical system, with millions and millions of “extra” dollars at hand, watching while hundreds of thousands of people are overtaken by a crippling, but preventable epidemic is unprecedented. This spectacle is the more striking in view of the low cost of the NDPP compared with the large health savings it produces. Even a fraction of the profits of “nonprofit” hospitals can finally launch the major diabetes prevention initiative which should have started years ago.

Reference List

1. Mathis A, Legendre Y, Montalvo W, Zahn D. Diabetes: A Hidden Health Care Cost Driver in New York. NYS Health Foundation. https://nyshealthfoundation.org/uploads/resources/hidden-health-care-cost-driver-analysis-october-2010.pdf. Published October 2010.

2. Chatterjee S, Peters SA, Woodward M, et al. Type 2 Diabetes as a Risk Factor for Dementia in Women Compared With Men: A Pooled Analysis of 2.3 Million People Comprising More Than 100,000 Cases of Dementia.Diabetes Care. 2016;39(2):300-307. doi:10.2337/dc15-1588.

3. Inacio PDP. Alzheimer's Risk Higher Among Middle-Age Diabetics, Smokers and Those with High Blood Pressure. Alzheimer's News Today. https://alzheimersnewstoday.com/2017/03/02/heart-risks-in-middle-age-boost-dementia-risk-later-in-life/. Published March 2, 2017.

4. Centers for Disease Control and Prevention. National Diabetes Prevention Program: Research-Based Prevention Program. https://www.cdc.gov/diabetes/prevention/ prediabetes-type2/preventing.html. Published January 14, 2016.

5. Centers for Medicare & Medicaid Services. Diabetes Prevention Program Independent Evaluation Report Summary. https://www.cms.gov/Newsroom/MediaReleaseDatabase/ Fact-sheets/2016-Fact-sheets-items/2016-03-23.html. Published March 23, 2016

6. Diamond D. How hospitals got richer off Obamacare. Politico. https://www.politico.com/ interactives/2017/obamacare-non-profit-hospital-taxes/. Published July 17, 2017.

7. Schifman G. New York-area hospitals resuscitate profits. Crain’s New York Business. http://www.crainsnewyork.com/article/20170602/HEALTH_CARE/170609985/new-york-area-hospitals-resuscitate-profits. Published June2, 2017.

8. New York, New York. American Diabetes Association. http://www.diabetes.org/in-my-community/local-offices/new-york-new-york/.

9. Fact Sheet: Final Policies for the Medicare Diabetes Prevention Program Expanded Model in the Calendar Year 2018 Physician Fee Schedule Final Rule. https://innovation.cms.gov/Files/fact-sheet/mdpp-cy2018fr-fs.pdf. Published Nov. 2, 2017.

10. Hinnant L, Razi S, Lewis R. et al. RTI International Evaluation of the health care innovation awards: community resource planning, prevention, and monitoring, annual report 2015; awardee-level findings: YMCA of the USA. https://innovation.cms.gov/Files/reports/hcia-ymcadpp-evalrpt.pdf. Published March 2016.