Health vs. Money

It is often noted that diabetes is epidemic in the United States — affecting approximately 26 million people, or more than 8% of the population, according to the American Diabetes Association. Yet another figure supplied by that organization may be even more striking: An estimated 79 million Americans have prediabetes. To avoid a massive increase in the number of Americans with Type 2 diabetes, there will need to be serious prevention efforts aimed at those with prediabetes. What shape should those efforts take?

A recent study sheds some light on the topic. Presented last month at the 71st Scientific Sessions of the American Diabetes Association, results from the Diabetes Prevention Program — which enrolled over 3,000 adults at high risk for developing Type 2 diabetes — suggest that trying to prevent diabetes with either drugs or lifestyle intervention has both benefits and drawbacks. According to a HealthDay article on the study, participants were randomly assigned either to take metformin, to take a placebo (inactive pill), or to participate in a lifestyle intervention program. This phase lasted for three years and resulted in reduced rates of diabetes in the lifestyle and metformin groups, compared with the placebo group — by 58% and 31%, respectively.

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The researchers wanted, however, to measure the long-term effects of these interventions, so they followed participants for an additional 7 years without keeping track of continued behaviors or treatments. Ten years after the start of the study, having been assigned to lifestyle intervention was found to reduce the rate of diabetes by 34%, and having been assigned to metformin was found to reduce the rate by 18%, compared with the placebo group. Furthermore, these reduced diabetes rates resulted in an average savings of $2,600 in medical costs for each person in the lifestyle group and $1,500 for each in the metformin group. However, administering the lifestyle treatment during the three-year study period was also significantly more expensive than dispensing metformin during that time. Therefore, over ten years, metformin resulted in a net savings of $30 per person, while lifestyle intervention resulted in a net cost of $1,700 per person.

According to one of the study’s authors, these results mean that metformin should be “broadly appl[ied] without question” for prediabetes, since it both saves money and improves health. Even at the cost it rang up during the study, however, lifestyle intervention was “cost-effective” as a treatment because of its superior medical outcome. And there is reason to believe that effective lifestyle intervention treatments could be offered at a lower cost, using group treatments rather than one-on-one sessions, as the study used. An example of such a program is the YMCA’s Diabetes Prevention Program, available at many centers across the country (details vary based on location; read about the New York City program here).

But overall, how should insurance companies — or public insurance programs — decide what kinds of preventive treatments to cover? Should they focus only on overall cost savings, or also take improved health into account — even if a treatment costs more money in the end than it saves? Who should determine whether a treatment is likely to be cost-effective? Should this be a general or patient-by-patient determination? If a treatment is not found to be cost-effective — that is, it is expensive and not likely to provide a large medical benefit — who should pay for it? Leave a comment below!

  • David Spero RN

    It’s outrageous that insurers or any health leader should demand that “lifestyle interventions” must pay for themselves. Drugs and surgeries don’t have to be revenue-neutral. They just have to show some modest clinical benefit, and they’re approved without a second thought.

    But behavioral or social programs are supposed to pay for themselves. Why is that? I wrote about this in chapter 4 of my book Diabetes: Sugar-Coated Crisis. It’s all about who gets paid, not what’s best for the patients. We’ll pay drug companies or elite surgeons, but not health educators.

    However,it is certainly true that group programs are considerably cheaper and more effective than one-on-one programs. You don’t even need health professionals to lead them, trained amateurs can do just as well. A community-based group health approach like this is both clinically effective and cost-effective.