Programmes to prevent patients progressing from pre-diabetes to diabetes, and to improve management of patients with diabetes: UnitedHealth Group, US

In a randomised trial in 2002, the original Diabetes Prevention Program showed that in patients with pre-diabetes, lifestyle changes could reduce conversion to diabetes by 58%.That pilot programme was very expensive, however – it involved 16 sessions of one-on-one counselling – and was not rolled out.

Together with the Centers for Disease Control, UnitedHealth Group has now created a scalable, affordable version of the programme, which produces savings within one year by reducing health costs. People at high risk of pre-diabetes are identified via analysis of claims and other data.

They are then contacted and urged to attend a free test to see if they meet the criteria for prediabetes. If they do, they are urged to join a free 16-week group programme, run by the YMCA, that helps them lose weight, eat a healthier diet, and adopt a healthier lifestyle. Most people in the US live within easy reach of a YMCA, and the programme is paid for by UnitedHealth, other insurers, or employers. United is constantly experimenting with ways to incentivise people to go for testing, to stay in the programme, and to maintain weight loss and healthy lifestyles.

The group programme achieved much the same results as the earlier, individual programme had done, but at about a sixth of the cost per participant. So if the group programme is
combined with the Diabetes Control Program, see below, the savings can be very considerable due to reduced health costs, and over three years the return on investment is approximately three to one.

Prevention programmes have also been tested in China, Finland, and India. In many patients with type 2 diabetes, the disease is poorly controlled. But control of blood glucose, blood pressure, and serum lipids can reduce the complications of diabetes very substantially.

Every percentage-point drop in HbA1c reduces the risk of complications by 40%, and every 10 mm Hg drop in systolic blood pressure reduces complications by 12%, Improved control of blood lipids can reduce cardiovascular complications by up to 50%. In the Diabetes Control Program, patients with poorly controlled diabetes are again identified by analysis of claims and other data.

The patients are then contacted, and with the consent of their physician they are urged to visit the local Walgreens pharmacy. There, specially trained pharmacists help the patients to monitor their diabetes, and discuss with them their medication and lifestyle. The pharmacies are typically located close to the patients and are trusted. The regular monitoring and support from the pharmacists reduce complication rates as compared with those of usual care, as shown in clinical trials.21,22 As with the group prevention programme, there is no cost to the patient, since the pharmacists are paid by United, other insurers, or employers.