Evaluation of the Diabetes Health Plan to Improve Diabetes Care and Prevention

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O. Kenrik Duru, MD, MSHS; Carol M. Mangione, MD, MSPH; Charles Chan, MS; Abigail Keckhafer, MBA, MPH; Lindsay Kimbro, MPP; K. Anya Kirvan, RN, MS; Norman Turk, MS; Robert Luchs, MS; Jinnan Li, MPH; Susan Ettner, PhD

Suggested citation for this article: Duru OK, Mangione CM, Chan C, Keckhafer A, Kimbro L, Kirvan KA, et al. Evaluation of the Diabetes Health Plan to Improve Diabetes Care and Prevention. Prev Chronic Dis 2013;10:120150. DOI: http://dx.doi.org/10.5888/pcd10.120150

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Abstract

Investigators from the University of California, Los Angeles (UCLA), and members of the leadership and data analysis teams at UnitedHealthcare (UHC) are partnering to evaluate the Diabetes Health Plan (DHP), an innovative disease-specific insurance product designed by UHC specifically for patients with prediabetes or diabetes. The DHP provides improved access to care management, telephone coaching, and enhanced Internet-based communication with enrollees. The evaluation will use a quasi-experimental design, comparing patients from employer groups that offer the DHP with patients from groups that do not, to determine the effect of the DHP on incidence of diabetes, adherence to metformin, and costs of care among patients with prediabetes. Other factors studied will be cardiovascular risk factor control, adherence to preventive services, health care use, and costs of care among patients with existing diabetes.

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Introduction

Although diabetes incidence in the United States is rising for all ages, people aged 45 to 64 are most affected; diabetes incidence among people in this age group is 30% higher than among adults aged 65 or older (1). Many of these middle-aged patients are at risk of current and future disability from diabetes-related complications, and the combined direct and indirect costs of diabetes care for people in this group, including decreased productivity at work and increased absenteeism, are substantial (2). Public health stakeholders and employers share an interest in decreasing complications among patients with existing diabetes and in slowing disease progression among patients with prediabetes through early identification and increased adherence to preventive care and treatments. The Diabetes Health Plan (DHP), developed by UnitedHealthcare (UHC), is an innovative, multifaceted approach to prevent diabetes and improve diabetes management among working-age adults with the disease.
The DHP incorporates several enhancements to standard employer-based commercial benefit plans, including financial incentives of $150 to $500 per year for enrollees. These enhancements typically include reduced or eliminated copayments for office visits and for medications that reduce incidence of and complications from diabetes, access to diabetes-specific care management and individualized telephone coaching, enhanced Internet-based communication with beneficiaries via online data and adherence tracking, and improved access to diabetes education and information (3). Although participating employers are not required to offer each of these DHP components, more than 95% discount patient copayments for enrollees and most employers provide the other services. Results of some studies indicate that reducing copayments for evidence-based medications (ie, value-based insurance design) can modestly improve adherence to these medications (4,5), although these studies were not diabetes-specific and examined a single outcome (medication adherence) for follow-up periods of 12 months or less. The study we describe will be the first comprehensive, controlled, longitudinal evaluation to assess whether reduced cost-sharing for these services among people with prediabetes and diabetes improves multiple outcomes.
This real-time evaluation of the DHP is being conducted jointly by investigators at the University of California, Los Angeles (UCLA), together with employees of the Innovations Group at UHC, under the auspices of a cooperative agreement with the Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases. Our collaboration is grounded in the principles of community-based participatory research (6,7) and builds on a long-standing partnership between the UCLA research team and the leadership and data analysis teams at UHC, 1 of the largest providers of health insurance in the United States. Our experience evaluating system-level interventions, analyzing health plan data, and disseminating findings tells us that these evaluations must be conducted in close partnership. The health plan side of the partnership brings intricate knowledge of employer group-specific aspects of program implementation, detailed knowledge about their data, and perspective on the interpretation of the results. The academic side of the partnership contributes state-of-the-art analytic modeling, grounds the hypotheses in findings from peer-reviewed scientific literature, leads an objective evaluation, and provides the needed policy context.
The design of the DHP was influenced by findings from the Translating Research into Action for Diabetes (TRIAD) study, which examined the effectiveness of care management (8) and the deterrent effect of high copayments on use of needed services and medications for people with diabetes (9,10). This partnered evaluation of the DHP is a logical next step in an innovative model of translational research over more than a decade (11). This study will provide evidence to determine whether a benefit design that is tailored to the needs of people with a specific condition and provides low cost-sharing will reduce incidence of diabetes among people with prediabetes and improve cardiovascular risk factors, reduce complications, and lower costs for patients with diabetes.
This study is being conducted in a real-world setting, similar to the way many new health insurance products are implemented in employer groups. The quasi-experimental design fits well into the framework of the Natural Experiments in Translation for Diabetes (NEXT-D) study’s goals of evaluating natural experiments by using rigorous statistical methods. The findings from this study will provide useful information to employers, health plans, and public health stakeholders about the effectiveness of this type of multifaceted diabetes care and prevention approach.