Anthem Covers Diabetes Prevention in California

In July 2016, Anthem Blue Cross of California, one of the largest health plans in the state, began 100% coverage of the National Diabetes Prevention Program (National DPP) lifestyle change intervention for commercial members. Anthem executive leadership championed the program and rallied support for inclusion of the National DPP lifestyle change program as a preventive benefit as a result of the U.S. Preventive Services Task Force (USPFTF) making a grade B recommendation for referrals to intensive behavioral counseling to address abnormal blood glucose and type 2 diabetes. The Affordable Care Act requires many health plans to include services with a grade A or B USPSTF recommendation. The National Diabetes Prevention Program met the requirements for intensive behavioral counseling and its strong demonstration of success convinced Anthem that the program was the perfect fit.

Under the direction of Anthem Medical Director, David Pryor, M.D., Chris Tompkins, an Anthem health promotion manager, assists California clients with implementation of evidence-based health promotion and wellness interventions. Tompkins also uses Anthem Blue Cross programs and resources to help  clients address a variety of lifestyle conditions of their employees/members. He weighs the scientific evidence for effectiveness against the implementation cost and potential cost benefits as well as the practical implementation of the intervention.

“Providing the National DPP lifestyle change program as a covered benefit was a good business decision for Anthem and a great solution to address prediabetes and underlying risk factors associated with it for Anthem clients and members,” said Tompkins. “The evidence is strong for achieving weight loss, which not only can prevent or delay type 2 diabetes, but other lifestyle conditions as well. Avoiding a lifetime of expensive treatment for many high-risk members at risk for developing type 2 diabetes ultimately will result in a cost savings for Anthem clients” he said. 

Tompkins recommends that state health departments who are looking to build a relationship with a health plan, start with the health plan’s office of the medical director as it is likely the place where interventions such as the National DPP are reviewed for consideration. Other health plans may have staff with similar responsibilities to Tompkins and titles such as Community Wellness Coordinator or Health Promotion Coordinator.

Working with a Network Partner

To engage members in California who are at risk for prediabetes, Anthem partners with a third-party administrator, or what they call a “network partner.” This network partner works with the Anthem account teams and the clients to identify members at risk and match them with National DPP providers that offer lifestyle change classes that adhere to the requirements and meet the strict quality standards of CDC’s Diabetes Prevention Recognition Program (DPRP). Anthem supports only CDC-recognized programs and those with pending recognition, as it is in their best interest to ensure quality delivery and strong administrative support to reduce the risk of fraudulent claims. Anthem currently supports in-person and virtual programs delivered in English and Spanish. Another advantage of working with a network partner is that they can oversee all aspects of program delivery, including marketing and direct outreach to members, contracts with vendor providers, and billing of claims. “Our network partner has set up a simple, online 1-minute screening tool where people can learn if they have prediabetes and qualify for enrollment in the National DPP lifestyle change program as a covered benefit. Qualified individuals can enroll right then and there,” Tompkins said. Anthem learned early on that educating the account teams, customer service, clients, and members on the difference between prediabetes and diabetes is critical in order to recruit the right people for the right intervention. In fact, they added the following question to the online screening test: Have you ever been told that you have diabetes? If the answer is yes, the member is redirected to an Anthem diabetes management program, if eligible. Anthem’s clients may not be familiar with the term prediabetes and may think that the National DPP lifestyle change program is for those who already have diabetes making it important to raise awareness about prediabetes and diabetes, as well as the National DPP.

Working with Employers

Depending on client need, Anthem assembles a team of experts that may include the Anthem Account Team,  a health promotion manager, a broker, and the network partner to help them present the high-quality interventions they promote to the client. They want to maximize their time with the client and help them make good business decisions for their employee/member benefit packages. When promoting the National DPP Tompkins goes prepared to share evidence-based research for the client. He makes sure to tell them that a member with diabetes costs them two to three times more than someone without diabetes. He estimates how many of the employees are likely to develop type 2 diabetes without an intervention and the associated costs for treatment. He also stresses the fact that nine out of 10 individuals that have prediabetes are not aware of it. The role of the network partner is to develop a strategic plan for communicating the National DPP to the client’s employees/members while considering the organization’s culture and communication methods to have the greatest success in engaging at-risk employees/members in the program.

Value Based Payment

Anthem sets four milestones for members to achieve, thus establishing four opportunities for claims to be generated and paid to the network partner, who, in turn, pays the National DPP provider. The milestones are 1) enrollment and starting the program, 2) completion of four weeks in the program, 3) completion of nine weeks in the program, and 4) achievement of 5% weight loss or more.

“Simply put, our network partner does not get paid unless the milestones are met,” said Tompkins. This value-based payment structure forces the use of quality vendors that have the ability to succeed.

All Anthem-supported National DPP programs adhere to the regulations set forth by the CDC’s Diabetes Prevention Recognition Program for the collection of data. In addition, Anthem’s network partner reports on milestones met by participants, participant preferences for in-person vs. virtual programs, and on outreach and promotion. Continuous review and analysis of the data supports decision-making and improvements to the process.

California Marketshare

Anthem is leading the market in California as one of the few health plans including National DPP as a covered benefit. In 2015, Anthem Blue Cross had 17% of the private insurance market in California and was California’s largest health insurance carrier of self-insured organizations with 38% of the market. At that time, individual, small group and large group enrollment was 2,385,082 and self-insured enrollment was 2,539,730, according to the California Healthcare Foundation. As more insurers cover the National DPP, it becomes less challenging for California employees to participate.

National DPP Coverage Decisions Benefitting Californians

January 2017

CalPERS, the agency that manages health benefits for California public employees, their families and retirees began coverage of the National DPP for about 1.5 million people

April 1, 2018 (revised proposed date)

Medicare Diabetes Prevention Program (MDPP) services available to eligible beneficiaries.

July 2018

Medi-Cal, the California Medicaid program begins coverage with an annual $5 million allocation from the California state general fund.

As consumer demand grows, Tompkins anticipates that more health plans will begin to cover the National DPP.

“At this point, it is critical for state health departments to continue building awareness and making a clear distinction between diabetes and prediabetes as well as providing information about quality interventions and their value. Without a good understanding of what is at stake and the quality interventions that exist, consumers, health plans, employers, health professionals/providers, and health systems will miss out, and the diabetes epidemic will continue to explode,” said Tompkins.

Careers at NACDD

You are exiting NACDD’s website to enter a third-party site