Translating Knowledge into Action to Prevent Type 2 Diabetes: Medicare Expansion of the National Diabetes Prevention Program Lifestyle Intervention

Abstract

Policy Points.

• Although preventable chronic conditions such as type 2 diabetes carry a significant cost and health burden, few lifestyle interventions have been scaled at a national policy level.

• The translation of the National Diabetes Prevention Program lifestyle intervention from research to a Medicare‐covered service can serve as a model for national adoption of other interventions that have the potential to improve population health.

• The successful translation of the National Diabetes Prevention Program has depended on the collaboration of government agencies, academic researchers, community‐based healthcare providers, payers, and other parties.

Context

Many evidence‐based health interventions never achieve national implementation. This article analyzes factors that supported the translation and national implementation of a lifestyle change intervention to prevent or delay type 2 diabetes in individuals with prediabetes.

Methods

We used the Knowledge to Action framework, which was developed to map how science is translated into effective health programs, to examine how the evidence‐based intervention from the 2002 Diabetes Prevention Program trial was translated into the Centers for Disease Control and Prevention's large‐scale National Diabetes Prevention Program, eventually resulting in payment for the lifestyle intervention as a Medicare‐covered service.

Findings

Key findings of our analysis include the importance of a collaboration among researchers, policymakers, and payers to encourage early adopters; development of evidence‐based, national standards to support widespread adoption of the intervention; and use of public input from community organizations to scale the intervention to a national level.

Conclusions

This analysis offers timely lessons for other high‐value, scalable interventions attempting to move beyond the evidence‐gathering phase and into translation and institutionalization.

The increasing emphasis on value‐based payment in health care (ie, payment for the value of services rather than the volume of services)1 creates an imperative to more rapidly scale up evidence‐based interventions with proven value for patients and payers. However, the lag time between when an intervention is shown to be effective and when it is incorporated into routine care is notoriously long.2 Analysis of interventions that have been successfully institutionalized at a national level may shed light on the pathways to bring other evidence‐based interventions to scale. The Knowledge to Action (K2A) framework developed by the Centers for Disease Control and Prevention (CDC) is a useful tool for considering how evidence‐based interventions can be translated into effective programs, policies, and practices.3 This article uses the K2A framework to describe key milestones that led to the successful translation of an evidence‐based lifestyle intervention to prevent type 2 diabetes from research to payment as a Medicare‐covered service.

More than 30 million Americans have diabetes, and its prevalence is projected to double by 2050 if current trends continue.4 In addition, an estimated 84 million American adults have prediabetes, a condition in which blood glucose levels are elevated but are not high enough for a diagnosis of type 2 diabetes.4 Diabetes prevalence increases with age, affecting more than 25% of Americans aged 65 years and older.4 The Centers for Medicare and Medicaid Services (CMS) estimates that Medicare spent $42 billion more in 2016 on beneficiaries 65 years and older with diabetes than it would have spent if those beneficiaries did not have diabetes.5

The Diabetes Prevention Program (DPP), a landmark study published in 2002, showed that yearlong behavioral counseling, a modest weight loss of at least 5%, and increasing moderate physical activity could substantially lower the risk of type 2 diabetes for adults at high risk for the disease.6 Since that time, an expanding evidence base has demonstrated that this intervention effectively targets individuals with prediabetes, has the potential to improve quality of life for millions of Americans, and may help contain health care costs.7 In 2010, Congress authorized the CDC to establish the National DPP to develop an infrastructure for nationwide delivery of the National DPP lifestyle intervention, a community‐based, yearlong lifestyle change intervention. This intervention, modeled after the intervention in the DPP study, provides a structured program for people with prediabetes that focuses on healthy eating and physical activity (https://www.cdc.gov/diabetes/prevention/index.html).

By 2016, numerous employers, commercial health plans, and states were offering the National DPP lifestyle intervention as a covered health benefit. Nationwide Medicare coverage of the intervention began in 2018 as part of an expanded model test by the Center for Medicare and Medicaid Innovation (CMS Innovation Center).

The National DPP has achieved a level of adoption that is rare among prevention programs and clinical‐community partnerships. This article analyzes the three main phases in the K2A framework with respect to the National DPP's evolution: research (the DPP landmark study), translation (in which the evidence‐based program was translated into a community‐based intervention), and institutionalization (Medicare payment). Lessons learned from this analysis could be applied to future interventions with potential to improve population health outcomes, institutionalize public health practices, and lower health care costs.

Methods

We reviewed numerous frameworks related to the process of translating evidence into practice and policy and found that the K2A framework best captured key elements of the process of translation and institutionalization of the National DPP lifestyle intervention. We then reflected on our experiences as key team members from the CDC and CMS through the lens of the K2A framework to identify key milestones in the translation process establishing the National DPP intervention as a Medicare‐covered service.

Throughout this article, we use the terms “National DPP intervention” or “National DPP lifestyle intervention” to describe the intervention itself, “National DPP” to describe the infrastructure and partnerships to support nationwide delivery of the intervention, and “Medicare Diabetes Prevention Program” or “MDPP” to describe Medicare coverage of the intervention.

The Knowledge to Action Framework

Translating scientific knowledge into action to improve the public's health has long been a priority for the CDC. In 2011, the CDC's Work Group on Translation, a cross‐agency group of social and behavioral scientists, developed and published the K2A framework (Figure 1) to map how science is translated into effective health programs, policies, and practices.3 Evaluation underpins the entire process, and the framework is designed to be iterative, recognizing that experiments and practice in the field (real‐world settings) can also lead to further research and adjustments in program implementation.3, 8 The K2A framework further identifies (a) key decision points, such as when to translate and adopt an intervention; (b) the interactions involved in moving from one phase to the next, including the dissemination of information and materials to organizations that can use them to improve health and purposeful engagement of key stakeholders to mobilize resources and influence systems; and (c) the infrastructure needed to enhance an organization's ability to plan, implement, and evaluate sustainable programs, policies, and practices. The final stage of the K2A framework, and the goal for most evidence‐based interventions, is institutionalization, defined as “the maintenance of an intervention (program, policy, or practice) as an established activity or norm within an organization, community, or other social system.”8

Figure 1.

The Knowledge to Action Framework^a

^aThe Knowledge to Action framework was originally published by the Centers for Disease Control and Prevention Work Group on Translation.3 [Color figure can be viewed at http://wileyonlinelibrary.com]

Evidence Base for the Diabetes Prevention Program

In 2002, results from the DPP randomized controlled trial led by the National Institutes of Health (NIH) demonstrated the effectiveness of a structured lifestyle intervention in preventing or delaying the onset of type 2 diabetes in participants with prediabetes when delivered on a one‐on‐one basis.6 In this study, over 3,000 participants were placed in one of three groups to receive either a placebo, metformin, or a lifestyle intervention with the goals of losing 7% of body weight and getting 150 minutes of physical activity per week. During three‐year follow ups, participants in the lifestyle intervention group lost, on average, between 5% and 7% of body weight.6 Additionally, the incidence of type 2 diabetes was reduced by 58% in the lifestyle intervention group as compared to the control group; among participants aged 60 years and older, the lifestyle intervention was associated with a 71% reduced incidence rate.6 The incidence of type 2 diabetes in the metformin group was reduced to 31% as compared to the control group.6

Follow‐up studies to the DPP and other international studies showed that reduced type 2 diabetes incidence could be sustained for 15 or more years.9, 10 Other studies investigated a version of the yearlong DPP curriculum that had been modified slightly for delivery in a group setting by community‐based organizations. These studies found that the intervention helped program participants with prediabetes achieve the 5% to 7% weight loss needed to prevent or delay type 2 diabetes, and that such a program is cost effective and can help control health care costs.11, 12, 13, 14, 15

The Pathway to Medicare Coverage

Based on this strong body of evidence, the CDC developed the National DPP, a partnership of public and private organizations working collectively to develop a sustainable infrastructure for nationwide delivery of the intervention. The CDC's Division of Diabetes Translation originated the National DPP and has led the program from its inception. Through the National DPP, the CDC and partners focus on increasing (a) the supply of quality program delivery organizations; (b) awareness and demand for the intervention among people at risk; (c) identification and referral of people with prediabetes through the health care sector; and (d) coverage for the intervention among public and private payers. The CMS Innovation Center conducted a model test of the National DPP intervention among Medicare beneficiaries and subsequently expanded the model to provide coverage and payment nationally after it was determined that the model test would meet certain statutory criteria.

Figure 2 applies the K2A framework to depict key activities in the progression from the foundational research on the DPP to institutionalization of the National DPP. Three pivotal features supported this process. The first was the strong evidence base described previously (the research phase of the K2A framework). The second involved translation of the DPP research study into a national infrastructure for type 2 diabetes prevention (the National DPP) through a collective impact approach.16 This approach aligned stakeholders across sectors—health plans, community‐based organizations, businesses, health care organizations, state and federal agencies, and numerous others—behind a common goal of realizing the intervention nationally (see the Appendix for a breakdown of the roles of stakeholders in different sectors involved in this process). The third pivotal feature in the institutionalization process was the CMS Innovation Center's ability to expand innovative payment and service delivery models that improve or maintain quality and reduce costs for CMS programs, which resulted in national Medicare coverage of the lifestyle intervention.

Figure 2.

The Knowledge to Action Framework for the National Diabetes Prevention Program^a

Abbreviations: CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare and Medicaid Services; DPP, Diabetes Prevention Program; DPRP, Diabetes Prevention Recognition Program; Y‐USA, YMCA of the USA.

^aSee the Appendix for a detailed timeline and relevant references for the activities summarized in this diagram. [Color figure can be viewed at http://wileyonlinelibrary.com]

A National Agenda for Type 2 Diabetes Prevention Through Lifestyle Intervention

The process of establishing the National DPP demonstrates the translation of knowledge obtained from the DPP research study and subsequent effectiveness studies into a set of products and services through a collective impact framework. Collective impact provides a framework for cross‐sector collaboration to address complex problems that cannot be resolved by one organization alone and brings stakeholders together to achieve social change.16 In the case of the National DPP, stakeholders with a shared call‐to‐action to prevent type 2 diabetes collaborated to establish a set of common measures and a system for continuous monitoring of outcomes. The National DPP provided a common agenda, allowing all stakeholders to focus on implementation of the intervention and achieving nationwide scale.

In 2008‐2009, recognizing the potential of the DPP research study's lifestyle intervention as an effective tool to stem the rising rate of type 2 diabetes, the CDC convened a group of academics, government agencies, community‐based organizations, and payers to solicit feedback and commitment to nationwide implementation of the lifestyle intervention. This convening yielded two critical short‐term results: the emergence of early adopters and a supporting structure for additional translation and innovation diffusion.17 Following this meeting, the CDC, the YMCA of the USA (Y‐USA), and UnitedHealth Group formed a partnership to establish, bring to scale, and secure coverage for the program. The CDC also supported the Y‐USA in offering a community‐translated version of the DPP intervention in Louisville, Kentucky, building on earlier NIH‐funded work in Indiana, and later expanding to communities across the country as part of a staged roll‐out plan.12, 13 In 2010, Congress authorized the CDC to establish the National DPP as part of the Public Health Service Act,18 enabling the CDC to create an infrastructure to support this translation work.

As early adopters of the National DPP, the Y‐USA and UnitedHealth Group assumed an important role in influencing other organizations. Their early successes in operationalizing the program and demonstrating cost‐effectiveness catalyzed investments across a growing number of payers and were instrumental in increasing adoption of the intervention by other organizations and in additional areas of the country. For example, by 2016, 11 states were offering the National DPP lifestyle intervention as a covered health benefit for eligible public employees and two states offered Medicaid coverage for the intervention.

This expansion was supported by multiple elements in the National DPP infrastructure, most notably the CDC's Diabetes Prevention Recognition Program (DPRP).19 The DPRP was established in the National DPP's authorizing legislation to evaluate and monitor organizations’ effectiveness in delivering the lifestyle intervention and was launched to the public in 2012.19, 20 The DPRP Standards and Operating Procedures (DPRP Standards) serve as a common, national set of measures used to evaluate and recognize those program delivery organizations that achieve the outcomes proven to prevent or delay onset of type 2 diabetes.21

The DPRP Standards reflect the elements shown to be effective in preventing type 2 diabetes, including intervention intensity and duration, participant eligibility requirements, weight loss (at least 5% of body weight), physical activity (with a goal of 150 minutes per week), and attendance throughout the entire 12‐month intervention. The DPRP Standards draw upon published research, data analyzed by the DPRP, and lessons learned from CDC‐recognized organizations. They are modified every three years to allow for flexibility and responsiveness to the practice‐based evidence acquired through various methods of implementation across the country—a key element for successful diffusion of practice innovations.17

Establishing Nationwide Medicare Coverage of Type 2 Diabetes Prevention Services

By the end of 2016, 94,144 individuals had participated in the National DPP intervention through 1,217 CDC‐recognized organizations, and many private payers covered the intervention.22 However, the nation's largest payer, Medicare, had not yet covered it, posing a challenge to achieving true institutionalization. For example, referrals to the National DPP lifestyle intervention were not yet a part of routine care for most providers, despite private payer coverage.

In 2012, the CMS Innovation Center funded the DPP model test, as part of the Health Care Innovation Awards. This test funded 17 Y‐USA sites to deliver the intervention to almost 7,000 Medicare beneficiaries. Independent evaluation of the test demonstrated significant cost savings (spending reductions of $278 per person per quarter across three years).23 Additionally, 45% of beneficiaries achieved 5% weight loss, and there was a significant reduction in hospitalizations, providing key indicators of improved quality of care.24

The CMS Innovation Center authority under the Social Security Act enables innovative payment and service delivery model tests to be expanded nationally if they meet certain criteria. Specifically, models may be expanded if the secretary of Health and Human Services determines that the model will reduce spending without sacrificing quality of care or improve quality of care without increasing spending. Model expansion must be supported by a certification from the CMS chief actuary, and it cannot limit the coverage or provision of existing benefits. In March 2016, using the results of the model test evaluation, published studies, and data from CDC's DPRP, the Secretary of Health and Human Services determined that payment and coverage of the National DPP lifestyle intervention would be expanded nationwide by 2018.25

This announcement marked a turning point in the translation process, the start of a two‐year policymaking process involving formal stakeholder engagement through rulemaking. CMS faced a number of policy decisions in expanding a model originally tested at 17 locations across the United States into an expanded nationwide model, which was established as the MDPP. Three factors were critical in this process. The first was extensive input from mobilized stakeholders, who submitted thousands of comments across two rulemaking cycles to inform final details of the expanded model. The second was the existing infrastructure created by the National DPP. CMS largely relies on the CDC for program quality assurance under the MDPP. For example, delivery organizations are required to meet CDC recognition criteria and use CDC‐approved curricula, and the DPRP Standards define key program delivery and coverage policies. To facilitate this interdependence, a strong alignment was established between CMS and the CDC through both formal agreements and structured partnership at all levels.

The third factor critical to scaling the DPP within Medicare was the use of checks and balances. The rulemaking process requires CMS to respond to public comments and either make policy changes or describe why certain policies could not be modified. Although certain policies had little room for modification, such as the use of weight loss as the primary performance outcome, other policies were established in response to public comments. For example, policies were established to allow organizations to use incentives, such as free gym memberships, to keep beneficiaries engaged in the program. This process allowed public input into the program (checks) while maintaining the fidelity to the smaller model test and preserving potential savings for the Medicare program (balances).

This translational process ultimately yielded the creation of a new Medicare supplier type and MDPP supplier standards. These standards allow community‐based, CDC‐recognized organizations to enroll in Medicare as MDPP suppliers and receive payments for furnishing MDPP services. More broadly, the supplier type and accompanying supplier standards accomplish three objectives:

• They establish a framework to formally institutionalize the MDPP expanded model within Medicare, creating a structure against which CMS can continuously monitor and make improvements as necessary.

• They set the stage for diffusion of the innovation into a variety of settings, including community settings.

• They allow flexibility to adapt the MDPP expanded model to the context of the health care or community setting where it is delivered.

Finally, the resulting payments to MDPP suppliers are largely performance‐based, meaning larger payments are made if participating beneficiaries achieve at least 5% weight loss. This aligns with CMS's goal to shift from volume‐based payments to value‐based payments and reflects broader trends in the health care system.1

Discussion

This analysis using the K2A framework sheds light on factors that led to national implementation of the DPP intervention at a level that most other evidence‐based, cost‐effective interventions have not achieved. At least three factors were critical: (a) the translation of a strong evidence base demonstrating the long‐term effectiveness and cost‐effectiveness of the intervention across a variety of settings; (b) cross‐sector engagement led by the CDC, resulting in the development and implementation of a national infrastructure for type 2 diabetes prevention and a clear set of quality standards for dissemination; and (c) a mechanism for evaluating promising approaches and expanding interventions that meet statutory criteria for a nationwide model in the Medicare program through the CMS Innovation Center.

The Future of Translation and Institutionalization in Type 2 Diabetes Prevention

The analysis presented here describes the translation of DPP research and institutionalization of the National DPP lifestyle change intervention to date; however, it is critical that this process continue to truly institutionalize the intervention as a norm within the health care system. Medicare coverage of the intervention broadens the scope of prevention from clinic‐centered approaches to clinical‐community partnerships, establishing a role for community‐based organizations in health care service delivery. This presents both an opportunity and a challenge. The opportunity is that community organizations offering the National DPP intervention can establish themselves as critical partners in value‐based care delivery. The challenge is that these organizations are not traditionally accustomed to medical recordkeeping, submission of claims, and rules protecting beneficiary health information to assimilate and succeed in this system.

Similar to the steps involved in scaling the National DPP intervention, achieving national availability of the intervention for Medicare beneficiaries may require early adopters to showcase their successes to pave the way for others. The first successful MDPP suppliers will spread awareness of the MDPP expanded model, creating momentum for more suppliers and the development of other infrastructure such as referral pathways and multipayer reimbursement. This could lead to system‐level institutionalization in the regions where the MDPP suppliers are located. Monitoring and evaluation of the National DPP, as well as input from these early adopters of MDPP, will drive additional iterations of the K2A process to further institutionalize the DPP intervention within the health care system, and across other payers.

To ensure success, it is also critical for Medicare and other payers to reach communities at highest risk for type 2 diabetes and to achieve the results observed in the initial DPP model test across a diverse set of suppliers nationwide. One challenge may be that many CDC‐recognized program delivery organizations offer virtual or online versions of the National DPP lifestyle intervention, which the MDPP only allows when providing make‐up sessions.

Another challenge is ensuring racial and socioeconomic equity in service delivery. The original Medicare model test studied a population in which 82% of participants were non‐Hispanic whites.26 However, the burden of type 2 diabetes is highest in racial and ethnic minority groups.

To meet these challenges, the CDC has funded ten national organizations to increase the National DPP footprint in underserved geographic areas and reach populations that are currently underenrolled in the program relative to their type 2 diabetes risk. CMS will closely monitor the extent to which suppliers are reaching people in high‐risk groups and will attempt to examine MDPP's impact on population subgroups. The CDC will continue to provide technical assistance, information, and resources through the DPRP and the newly established National DPP Customer Service Center. The CDC will also work with stakeholders to increase the number of CDC‐recognized organizations, particularly those reaching underserved populations.

Implications for Future Evidence‐Based Interventions

Increasingly, researchers and practitioners understand that evidence is necessary but not sufficient to generate change and diffuse innovation. The K2A framework emphasizes that supporting structures and the translation of knowledge into products are critical to transition from small‐scale interventions to nationwide programs. The application of the K2A framework to the National DPP highlights the pivotal role that supporting infrastructure (eg, national standards, trained workforce, supply of quality program delivery organizations, and public/private payer coverage) and stakeholders aligned behind a common approach can play in translating research into practice. For researchers and practitioners seeking to scale up promising innovations and evidence‐based interventions, this article demonstrates that the K2A framework may provide a useful tool for mapping out a translation pathway.

This analysis also illustrates the power of combining the K2A framework with a collective impact approach for complex, multisector work. In the case of the National DPP, early adopters of the evidence‐based intervention created necessary momentum for diffusion of the innovation. This occurred while different types of organizations—from community‐based organizations to large, multistate health systems and health plans—gained CDC recognition, and as employers and health plans made the program available as a covered benefit. These early adopters further catalyzed institutionalization among large payers such as CMS, which will likely accelerate later‐stage adoption by other parties.27, 28 The evidence and the infrastructure provided by the National DPP allowed CMS to conduct a Medicare‐specific model test at a relatively large scale (17 sites and nearly 7,000 beneficiaries), and the findings from that model test and other early adopters supported national expansion of the model test.

The CMS Innovation Center played a critical role in institutionalizing the National DPP lifestyle intervention through the MDPP expanded model. Other interventions may not require a regulatory approach to coverage and payment to achieve institutionalization within the health care system. For example, research that provides evidence for clinical guidelines or quality measures can also shift norms, thereby translating evidence into sustainable, routine care—a form of institutionalization even in the absence of insurance coverage.

Regardless of the pathway to institutionalization, foundational research and supportive infrastructure of public and private stakeholders is critical to nationwide implementation of programs such as the National DPP. Equally critical is the importance of incorporating evaluation feedback loops to build a persuasive case for payers and policymakers. In the case of the MDPP, the evidence of the intervention's effectiveness on quality and expenditures, the supportive infrastructure established by CDC through the National DPP, and coverage of the intervention by private payers supported implementation and testing of the model nationwide.

This analysis has emphasized the importance of coalition building, translation supporting structures, and evaluation feedback loops as critical elements that helped the National DPP intervention achieve scale. It is also important to acknowledge the role of systems‐level context and enabling factors that contributed to the effectiveness of this translation effort. An aligned group of stakeholders was able to achieve Congressional action to support the creation of the National DPP, and evidence of the National DPP intervention accumulated at a time of significant changes in health care payment models, as payers emphasizing value‐based payments were seeking cost‐effective interventions and opportunities to leverage community‐based partners in disease prevention efforts. These contextual factors created a more supportive environment in which to translate evidence into practice and policy.

Conclusion

The National DPP's successful progression from a clinical trial to a nationally recognized program adopted by public and private payers demonstrates how the K2A framework can be used as a roadmap for other high‐value, scalable interventions. Based on our analysis, we predict that future interventions that achieve meaningful impact at scale will (a) arise from early and continuous engagement among public and private stakeholders, (b) build from a strong evidence base to develop shared measures and standards, and (c) be adaptable to a dynamic, value‐based health care system that includes new entities such as community‐based organizations. These timely lessons can be applied to health care innovations with potential to improve population health outcomes and control health care costs.

Milestones in DPP Research

 

Date	Milestones
2002	Findings are published from a landmark DPP trial in which participants with prediabetes were assigned to (a) placebo; (b) metformin; or (c) a structured lifestyle change intervention. The investigators conclude that the lifestyle intervention reduced development of type 2 diabetes by 58% when compared with placebo and by 33% when compared with metformin. Compared with placebo, the lifestyle intervention reduced the development of diabetes by 71% in participants age 60 years or older.6
2007‐2012	Studies demonstrate effectiveness of a translated version of the DPP lifestyle intervention delivered by trained health care professionals and paraprofessionals in community settings.12, 13, 14, 29
2009; 2015	Follow‐up studies demonstrate in the 10 years since the landmark DPP trial, diabetes incidence was reduced by 34% in the lifestyle intervention group and 18% in the metformin group compared with placebo. 9, 30
2012	Published evidence demonstrates the cost‐effectiveness of the DPP research intervention and suggests that translated versions have potential for cost savings.31
2016	Evaluation of the CMS diabetes prevention program model test shows cost savings among participants in the community‐translated version of the DPP lifestyle intervention delivered through the Y‐USA.24

Abbreviations: CMS, Centers for Medicare and Medicaid Services; DPP, Diabetes Prevention Program; Y‐USA, YMCA of the USA.

Milestones in DPP Translation

Knowledge into Products

 

Date	Milestones
2008‐2009	CDC develops a framework for the National DPP and convenes stakeholders (University of Indiana, Y‐USA, insurers, state health departments, CMS, AHRQ) to seek input to inform nationwide implementation. CDC, Y‐USA, and UnitedHealth Group begin initial work to establish, scale, and secure coverage for the program.
2010	Congress authorizes CDC to establish the National DPP.18
2010‐2011	The first CDC curriculum is developed and made publicly available. It translates the scientific evidence from the DPP research study into a nonresearch, community‐based, yearlong intervention.32
2011	The first set of national quality standards are developed for organizations delivering the National DPP lifestyle change intervention; CDC's DPRP is established. The first lifestyle coach training program is launched by Emory University with CDC support.
2015	CDC DPRP allows virtual program delivery.
2016	The second CDC curriculum (Prevent T2) is developed for use by CDC‐recognized organizations delivering the National DPP lifestyle intervention.32 HHS secretary determines that the DPP model test has met the criteria to be expanded nationally as a Medicare‐covered service.25
2018	CDC DPRP national quality standards are revised to align with MDPP expansion.21

Abbreviations: AHRQ, Agency for Healthcare Research and Quality; CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare and Medicaid Services; DPP, Diabetes Prevention Program; DPRP, Diabetes Prevention Recognition Program; HHS, US Department of Health and Human Services; MDPP, Medicare Diabetes Prevention Program; Y‐USA, YMCA of the USA.

Dissemination/Engagement

 

Date	Milestones
2009‐2012	CDC funds a Y‐USA initiative to offer the community‐translated version of the DPP lifestyle intervention in a community setting in Louisville, Kentucky, and to expand to communities across the country as part of a staged roll‐out plan. By 2012, Y‐USA DPP sites are operating in 28 states and Washington, DC.11
2012	The first set of national organizations receives CDC funding to establish and sustain CDC‐recognized organizations delivering the National DPP lifestyle intervention across multiple states.
2013‐present	CDC and the AMA form a national partnership to increase awareness of prediabetes and the National DPP in the health care community, and expand prediabetes screening, testing, and patient referrals to CDC‐recognized organizations; in 2014, CDC and AMA release a call to action to “Prevent diabetes STAT” (screen, test, act, today).33
2016	The first multi‐year national prediabetes awareness campaign (Do I Have Prediabetes.org) is launched by CDC, AMA, ADA, and the Ad Council. CMS begins rulemaking to establish MDPP expansion.

Abbreviations: ADA, American Diabetes Association; AMA, American Medical Association; CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare and Medicaid Services; DPP, Diabetes Prevention Program; MDPP, Medicare Diabetes Prevention Program; Y‐USA, YMCA of the USA.

Practice

 

Date	Milestones
2012	CDC DPRP is launched as the quality assurance arm of the National DPP to ensure adherence to national standards by organizations delivering the National DPP lifestyle change program. CMS funds Y‐USA to conduct a DPP model test among Medicare beneficiaries.
2017	CDC State Diabetes Burden Toolkit, Diabetes Prevention Impact Toolkit, and National DPP Coverage Toolkit are released for use by states, employers, and insurers to calculate diabetes burden, estimate health and economic effects of the National DPP lifestyle change program, and implement coverage for the National DPP.
2018	CDC launches National DPP Customer Service Center to support CDC‐recognized organizations and all National DPP stakeholders.

Abbreviations: CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare and Medicaid Services; DPP, Diabetes Prevention Program; MDPP, Medicare Diabetes Prevention Program; Y‐USA, YMCA of the USA.

Milestones in DPP Institutionalization

Program/Policy

 

Date	Milestones
2010	Following an early collaboration with CDC, Y‐USA, and other partners, UnitedHealth Group becomes the first commercial plan to cover the National DPP lifestyle intervention with no out‐of‐pocket charges for eligible participants enrolled in employer‐sponsored benefit plans, paving the way for future coverage by other carriers.
2014	Community Preventive Services Task Force recommends combined diet and physical activity programs for people at increased risk for type 2 diabetes.34 USPSTF recommends intensive behavioral counseling interventions for adults who are overweight or obese and have additional cardiovascular disease risk factors.35
2015	USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40–70 years who are overweight or obese, and encourages clinicians to offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity (Grade B preventive service).36 CDC funds a demonstration project in Maryland and Oregon—through the National Association of Chronic Disease Directors—to test the feasibility and effectiveness of different models to obtain Medicaid coverage for the National DPP lifestyle intervention.
2017‐2023	CMS launches support for MDPP suppliers and implements monitoring and evaluation activities for the MDPP expanded model.
2018	National DPP lifestyle intervention is included as a covered health benefit for state/public employees in 19 states. Nine states have full or partial Medicaid coverage through Medicaid authorities, demonstrations, or pilots. CDC‐recognized organizations begin to enroll as MDPP suppliers. The MDPP expanded model launches for all eligible beneficiaries under Medicare Parts B and C.

Abbreviations: CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare and Medicaid Services; DPP, Diabetes Prevention Program; MDPP, Medicare Diabetes Prevention Program; USPSTF, US Preventive Services Task Force; Y‐USA, YMCA of the USA.

Roles of Public and Private Sector Stakeholders in Institutionalization of the National DPP Intervention^a

 

Role	Public Sector (Government) Entities	Private/Nonprofit Sector Entities
Research: Fund and conduct research to determine whether lifestyle intervention or pharmacological therapy (metformin) would prevent or delay onset of type 2 diabetes in individuals with impaired glucose tolerance.	NIH CDC IHS and tribal clinics	Academic institutions
National‐level program administration; Coordinate activity among partners; establish national quality standards; administer DPRP.	CDC	Program delivery organizations, national associations, and others provide input and feedback on the national standards
Payer: Provide payments to CDC‐recognized program delivery organizations furnishing the National DPP intervention. Establish and enforce program and payment policies.	Medicare (including Medicare Advantage) Medicaid	Commercial payers (eg, UnitedHealth Group) Employers
Provider (known as MDPP supplier in Medicare): Provide the National DPP intervention to individuals with prediabetes.	Local governments (eg, local departments of health)	Community organizations (eg, Y‐USA, Black Women's Health Imperative) Hospitals Clinics Universities
National partners: Support national implementation through development of guidelines, education, and awareness‐raising campaigns, etc.	N/A	National associations (eg, AMA, AADE) Ad Council

Abbreviations: AADE, American Association of Diabetes Educators; AMA, American Medical Association; CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare and Medicaid Services; DPP, Diabetes Prevention Program; DPRP, Diabetes Prevention Recognition Program; MDPP, Medicare Diabetes Prevention Program; N/A, not applicable; NIH, National Institutes of Health.

^aThis table is for illustrative purposes and does not include an exhaustive list of stakeholders involved in the National DPP or MDPP.