Story:
Defusing the Diabetes Time Bomb: Tackling a National Epidemic through Innovations in Care Delivery and Community-Based Partnerships

The Challenge

Among the greatest health challenges the U.S. faces today are the related, and largely preventable, epidemics of obesity, prediabetes and diabetes. According to the Centers for Disease Control and Prevention (CDC), nearly 26 million American adults have diabetes and another 79 million people, or about a third of the adult population, have prediabetes, putting them at grave risk of developing the condition. According to “The Global Burden of Disease Study 2010,” published in December 2012 in The Lancet, obesity has increased  82 percent globally in the past two decades.  It is now a larger health crisis than hunger and the leading cause of disabilities around the world.

Left unchecked, more than half of all Americans will likely have diabetes or prediabetes by 2020 (at an annual cost of $512 billion) according to research by the UnitedHealth Center for Health Reform & Modernization. Moreover, about 25 percent of people with diabetes and 90 percent with prediabetes are unaware of their condition, complicating efforts to drive behavior changes that, if adopted, could lead to better health.

Fortunately, with lifestyle and behavior changes, and increased access to care, a person’s risk for developing diabetes can be significantly reduced and the impact of the disease mitigated. In fact, studies conducted by the National Institutes of Health (NIH), the CDC, and Indiana University found that a person with prediabetes can prevent or delay the onset of diabetes by 58 percent with lifestyle changes and a modest five percent weight reduction.

The Opportunity: Targeting a National Problem through Practical Innovation

Diabetes, prediabetes and obesity for children and adults are big problems that no one company or organization can solve alone. Many of the strategies currently used to combat this multi-faceted public health crisis have fallen short, leaving millions living with (or at risk for) the disease without the proper knowledge and resources to take better control of their health.

To effectively address these devastating conditions, evidence-based approaches must be made more widely available on a national scale, yet delivered in imaginative ways to effectively meet the needs of the individuals and local communities the programs are designed to serve. Through one of its innovation centers, UnitedHealth Group has focused resources on developing creative, yet practical solutions that address earlier diagnosis, new consumer engagement solutions, and new delivery models that offer much broader dissemination opportunities to address this growing problem..

Our journey began with a single pilot, but the lessons learned from that and each subsequent experiment have generated new opportunities and ultimately spawned a multi-dimensional platform of complementary approaches to the health issues of obesity, prediabetes and diabetes.  The variation in program elements across the platform reflect different ways to engage diverse groups of people in their health; strategies to address both the supply of, and demand for, care resources; and opportunities to leverage new emerging technology.

• ·         We began with an employer-offered Diabetes Health Plan that uses a combination of incentives, wellness coaching and rewards to encourage plan participants to reach certain health goals.
• ·         Recognizing the need for a delivery solution that was independent of a particular health plan, we added the Diabetes Prevention and Control Alliance (DPCA) – also an initiative paid for by employers, but delivered by a network of nonprofit and corporate partners through coaches and pharmacists based in local communities.
• ·         The success of these two initial programs lead to a focus down the clinical chain on a community-based childhood obesity intervention (JOIN for ME^SM).  JOIN for ME creates a safe haven for children and a parent to adopt new strategies for nutrition and exercise. 
• ·         Most recently, in an effort to reach cohorts of people we found were not well served by the original Diabetes Prevention Program model, we created a virtual version of it called  Project NOT ME™ to support wider dissemination of this critical intervention.

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Each innovation posed unique challenges, but also helped the company deepen our understanding of the challenge and helped us identify best practices to inform the creation of additional programs.

A Closer Look at UnitedHealth Group’s Diabetes and Obesity Portfolio: Care Built on Innovation

UnitedHealth Group’s innovation platform spurred the development of the following programs, which comprise our integrated diabetes and obesity portfolio. We developed these programs and services over the past six years, combining integrated approaches to consumer outreach, diagnosis, data management, technology, and reimbursement with creative thinking to engage partners across the health system to reverse this public health crisis.

• ·         Diabetes Health Plan: About 79 million adults in the U.S. have prediabetes. Prediabetes, when left untreated, often graduates to full-blown type 2 diabetes, which can be both physically and financially devastating for the patient as well as exceedingly costly for employers. Type 2 diabetes is a highly treatable condition. Millions of Americans who are diagnosed with prediabetes and type 2 diabetes every year can learn how to care for their condition with the help of their doctors and by making healthy choices about lifestyle and health behaviors.

That’s why in 2008, we began the clinical development of a new kind of benefit offering, the Diabetes Health Plan (DHP). This first-of-its-kind health plan, launched commercially in 2009, uses financial incentives to reward individuals with diabetes and prediabetes who participate in wellness coaching and routinely follow independent steps medically proven to help manage their condition. The plan also incorporates a unique actuarial model that uses historical claims data to identify potential undiagnosed pre-diabetic and diabetic patients to address the need for earlier identification in this clinical chain.

Unlike traditional health plans, the DHP incents people with diabetes and prediabetes to adopt healthier behaviors and manage their conditions pro-actively, because it offers those who follow key treatment and testing requirements the prospect of lower annual out-of-pocket costs. At an estimated savings of up to $500 a year, these benefits include some diabetes supplies and diabetes-related prescription drugs at no charge, as well as lower co-payments for related doctor visits.

After a successful pilot, UnitedHealthcare began offering the program to customers. As of early  2013, 40 employers have signed up for the plan, with about 85,000 individuals enrolled from within their broader base of employees and family members. The City of New Orleans and the American Postal Workers Union Health Plan are among the employers that currently offer the program. The DHP is proving to have a positive impact on compliance with critical steps that help people with diabetes take control of their health and reduce their risk of developing dangerous complications.

• ·         The Diabetes Prevention and Control Alliance (DPCA): Obesity, prediabetes and diabetes are hardly new health challenges, but combating them through an approach that utilizes community organizations and is based onevidence-based clinical guidelines is novel. The approach is now changing the way consumers experience health care and is helping to raise critical public awareness about the prevalence of and risks for diabetes.

In March 2010, Congress passed legislation under the Patient Protection and Affordable Care Act authorizing the CDC to establish and manage the National Diabetes Prevention Program – a network of evidence-based lifestyle intervention programs that demonstrated promising results when tested through controlled trials and pilot projects with NIH, the CDC, the YMCA, Indiana University, clinical centers, employers and retail pharmacies. The legislation also empowered the CDC to provide grants supporting community-based diabetes prevention services based on the NIH-led research.

Despite the legislative backing, the National Diabetes Prevention Program was not reaching critical mass due to issues of cost, access and a lack of process to bring the approach to scale.

UnitedHealth Group recognized the opportunity and immediately set to work to create an infrastructure that would eventually enable expansion of the program nationwide. To do this effectively, we needed to develop a new care delivery model that met people where they live and work, rather than following the traditional model that required more formal, one-on-one doctor’s visits. Through the process, we discovered that using community-based health coaches and allied health professionals would help us translate the groundbreaking research and successful pilot projects into an affordable, sustainable model that would ultimately reach more people and help them make the lasting lifestyle changes necessary to achieve greater results.

Following this strategy, we launched the Diabetes Prevention and Control Alliance in April 2010 in partnership with the YMCA of the USA (the Y) and retail pharmacies. The DPCA is an employer- and community-based initiative aimed at tipping the scales against the epidemic of diabetes, prediabetes and obesity that is anchored by two innovative and integrated programs:

• o   The Diabetes Prevention Program is a lifestyle coaching program conducted in a group setting. Originally developed through the YMCA, the program  helps people with prediabetes and those who are at high risk for developing type 2 diabetes prevent or delay the onset of the disease through healthy eating, increased physical activity and other lifestyle changes. It is a year-long program with 16 weekly sessions, and then, monthly follow-up. The program is part of the National Diabetes Prevention Program supported by the CDC, but was only available through a handful of local Y facilities. UnitedHealth Group partnered with the Y to:  build out data mining that identifies people with prediabetes, and generate invitations to them to participate in the program; create financial incentives for both the participant and the Y related to program completion and achievement of critical goals; and introduce capital, technology and process that allows expansion of the program to Ys across the country ; and

• o   The Diabetes Control Program, which is targeted for those who have already developed the condition, helping them manage the disease and avoid complications. This program offers private, one-on-one consultation for the participant with a local pharmacist, who provides education and support for self-care such as compliance with medication and seeking necessary health screenings (ie annual retinal eye exams, regular measurement of blood glucose levels, etc.).

In addition to the YMCA,  the DPCA has expanded to include several partners, including Albertson's, Cub Pharmacy, Kroger, Novo Nordisk, Rite Aid, Safeway, Shop 'n Save and Winn-Dixie. In collaboration with these organizations – both non-profit and commercial – we have expanded the resources available to people outside of their doctor’s office as they work to improve their health.

It is worth noting that this approach not only introduces new industry services, but is also a new business model. The program can be made available to people enrolled in any health plan (not just those enrolled in a UnitedHealthcare plan), including government-sponsored health programs, creating new revenue streams for UnitedHealth Group. Since there are no out-of-pocket costs for the participant associated with the programs, the health and financial incentives are greater for a broader population.

• ·         JOIN for ME^SM: One of the greatest risk factors for developing type 2 diabetes is obesity and the clinical chain to diabetes reaches even further back – to childhood. Childhood obesity is robbing millions of Americans of their chance to lead healthy and productive lives. According to the CDC, approximately one-third of all American children are obese or overweight, leading to increased health risks, higher health care costs, and decreased parental productivity at work. Obesity now affects 17 percent of all children and adolescents in the U.S. – nearly triple the rate from just 30 years ago. As the Diabetes Health Plan and DPCA programs were developed, it became apparent to us that there needed to be a corollary approach specifically designed to address child health. As a result, we created an experiment called JOIN for ME^SM, a community-based lifestyle-intervention program for obese or overweight children.

UnitedHealth Group developed JOIN for ME^SM in the summer of 2010 in partnership with a scientific advisory board, led by Gary Foster, Ph.D., Professor of Medicine and Public Health and Director of the Center for Obesity Research and Education at Temple University. The program, initially piloted with the Y of the USA and the YMCA of Greater Providence, is a community-based pediatric obesity lifestyle intervention program that helps overweight or obese children ages six to 17 reduce excess weight and lower the risk of related health problems. The program combines whole-family lifestyle and behavior modifications delivered to families in 16 weekly sessions, followed by eight monthly maintenance sessions over a year.

Similar to the company’s efforts to provide access to the evidence-based Diabetes Prevention Program through the DPCA, JOIN for ME^SM was designed to provide affordable and accessible care in local communities, but focused specifically on the needs of families with at-risk children This initiative served as a “next-step” that continued to build on the progress of the DHP and DPCA.

JOIN for ME^SM began as a proof of concept study, but has demonstrated that the combination of whole-family engagement and peer support helps participants achieve clinically significant reductions in excess weight and improvements in quality of life. Preliminary results were published in the October 2012 edition of Pediatrics.

Subsequently, UnitedHealth Group expanded the JOIN for ME^SM construct in a pilot study currently being conducted with Microsoft, adding a gaming component to the program. Participants have access to controller-free gaming devices that involve physical participation, such as Microsoft Kinect for Xbox360, to evaluate the effectiveness of gaming devices in promoting physical activity and improving weight outcomes among overweight or obese children. Preliminary results are promising and the study will be submitted for publication early this year.

• ·         NOT ME™ video-on-demand programing: One of the things we learned from the Diabetes Prevention Program was that, while some people are highly motivated by in-person group settings, others are not, and thus are less likely to participate and reap the benefits.  As part of our broader efforts to make evidence-based programs more widely available in more convenient, cost-effective ways, UnitedHealth Group in January 2012 announced a partnership with Comcast Corporation to evaluate the effectiveness of using video-on-demand (VOD) to deliver the Diabetes Prevention Program to people in the convenience of their own homes. The 16-episode NOT ME™ video-on-demand programming leverages popular culture and uses a reality TV format that follows six adults who are at high risk for developing type 2 diabetes (with prediabetes) as they go through the Diabetes Prevention Program. Delivering the DPP at local Y branches reduced program costs to roughly one-eighth the amount of the traditional DPP intervention, while achieving striking results. Bringing the program into people’s homes through video-on-demand holds the promise to make this clinically proven prevention program even more accessible and cost-effective.

A pilot study was designed by Ron Ackermann, M.D., MPH, Northwestern University Feinberg School of Medicine, who conducted the original Diabetes Prevention Program translational pilot and is considered a national expert in the prevention and control of common chronic illnesses. Preliminary results from the pilot with 300 participants show great promise and the companies are considering expanding access to the DPP on-demand model. The results will be submitted for publication early this year.

The innovation process driving the development and launch of these programs built on the lessons we learned in bringing first the DHP and then the DPCA to market. For example, we learned through the DPCA that while the prevention and control programs were successful with the people who enrolled, many people were not comfortable with – or were unable to – venture out to a community center like the Y to participate. Also, with childhood obesity on the rise, many young people needed access to diabetes and prediabetes programming, but the information and delivery needed to be tailored to their specific needs. JOIN for ME^SM and NOT ME™ grew directly out of these key learnings gleaned through the process of implementing the DHP and DPCA.

It is worth noting that while UnitedHealth Group’s innovation center designed and tested each of these diabetes and obesity offerings, on-going management of the programs is transferred to the most appropriate business segment once the offerings are operating as a functional level. This keeps the innovation platform free to create new offerings, and also ensures a better vantage point to gather lessons learned from each trial.