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Case for Coverage for Commercial Plans and Employers
Making the Case for Coverage for Commercial Plans and Employers
This section explains how to make the case to cover the National Diabetes Prevention Program (National DPP) lifestyle change program for commercial plans and employers, and is broken down into five stages. Click on a link below to go directly to that stage.
- Stage 1: Assessing Readiness- Where is the Organization in the Process?
- Stage 2: Preparing the Case for Coverage
- Stage 3: Planning the Benefit
- Stage 4: Assessing Success and Scalability
- Stage 5: Post-Program Launch
Why Making the Case for Coverage is Important
The National DPP lifestyle change program’s ability to improve health in participants and reduce health costs for payers is supported by a significant amount of evidence. Unfortunately, this evidence is not widely known. For employers and commercial plans to secure leadership support and funding for the National DPP lifestyle change program, they need to understand this evidence, as well as key decision points needed to plan a successful delivery. Many individuals could compile this information for an employer or a commercial plan, including a stakeholder within the organization, a broker, a benefit consultant, or another interested party, such as a public health department, a business group on health, or a CDC-recognized organization.
The Unique Positioning of Employers with a Self-Funded Health Plan
The case for coverage may be particularly well received by employers with a self-funded health plan. When employers use a self-funded health plan, the employer is responsible for managing the financial risk of providing benefits to its employees and their eligible family members. This means that the employer is on the front line for managing health plan expenses and containing cost increases. Therefore, these employers are highly motivated to implement changes that will contain health care costs and are likely to be more receptive to offering the National DPP lifestyle change program.
Employers with a fully-insured health plan do not have these same financial motivations as employers with a self-funded plan, since those in a fully-insured plan have shifted the financial risk associated with the management of the plan, including care management and wellness programs, to the fully-insured health plan vendor. Employers’ interest in the National DPP lifestyle change program will also vary based on the size, demographics, disease burden, stability, and dispersion of the workforce, as well as whether the company continues to have financial obligations to employees after retirement.
In addition to the cost of health care, there are other financial incentives that increase the likelihood that employers with a self-funded plan would be interested in the National DPP lifestyle change program. First, employers are aware that improving health can decrease work absenteeism and increase productivity. Second, employers are starting to see the value of creating a healthy workforce in increasing overall employee satisfaction. When employees are healthy and believe that their employer cares about their (and their family’s) health, it can reduce employee turnover and impact the way employees interact with customers, improving customer satisfaction.
Employers also have advantages when implementing the National DPP lifestyle change program. Most employers have systems in place to collect employee feedback regarding health care, such as regular in-person meetings, surveys, and responding to issues that have been escalated to human resources. These vehicles make it likely that employers would quickly learn from employees what is and isn’t working, leading to improved program implementation and increased adherence.
The case for coverage can be shared with employers one-on-one, or to multiple employers at once such as through business groups on health, other collaboratives on health, industry specific trade groups, brokers, HR associations, and health care publications targeted to employers.
Self-funded health plan administrators
In addition to sharing the case for coverage of the National DPP lifestyle change program with employers directly, it can also be shared with self-funded health plan administrators. These entities provide administrative support for multiple employers with self-funded health plans, yet do not assume the risk for the cost of health care. While a self-funded health plan administrator does not have the same financial incentives or program flexibility as an employer, they do have access to large numbers of employers in different industries, geographies, and demographics.
The role of the administrator can also extend beyond establishing coverage. Once the program is implemented, the self-funded health plan administrator may be able to pull together detailed claims data and outcomes reporting for the enrolled participants, providing deeper insight into the impact of the National DPP lifestyle change program on the members’ health and the total cost of care. The self-funded health plan administrator may also be able to reward participating and engaged members with incentives through their own wellness platform.
Stage 1: Assessing Readiness
Is the Organization Ready to Cover the National DPP Lifestyle Change Program?
Thoughtful planning will lead to a more successful implementation of the National DPP lifestyle change program. The Readiness Assessment documents above can help commercial plans and employers think critically about where they are in their preparations for coverage and help identify next steps.
Stage 2: Preparing the Case for Coverage
Step-by-Step Guide to Using the Coverage Toolkit for Commercial Payers
A helpful way to start gathering information for the case for coverage is to use the Step-by-Step Guide to Using the Coverage Toolkit for Commercial Payers. This document walks the user through where information can be found in the Coverage Toolkit and is a useful way to become aware of the resources that are available.
Identify the Decision Makers and Potential Advocates
A key step to preparing the case for coverage is identifying the decision makers or potential advocates within an organization who may have leverage or interest in pursuing coverage of the National DPP lifestyle change program. For employers, the individual responsible for benefits and/or wellness typically plays a critical role in making or evaluating the case for coverage. This individual’s title may be the Director of Benefits, Director of Wellness, Wellness Program Manager, Chief Medical Officer, Corporate Director of Human Resources, or an equivalent title.
State Health Departments can also be strong advocates for the National DPP lifestyle change program. Each state is funded by the CDC’s Division of Diabetes Translation to scale the National DPP by increasing awareness of prediabetes and increasing referrals to, availability of, and coverage for the National DPP lifestyle change program. Most states have dedicated staff who focus on these efforts. The State Health Department should be considered a resource for payers in regard to the National DPP as they are highly informed in health policy, able to navigate rules and regulations, and bring far-reaching experience and relationships among various government and private sector services, programs, and people. More information about how businesses and public health agencies can partner together can be found here.
Making the case for coverage for the National DPP lifestyle change program can be a challenging task, so it is important to understand what motivates employers and commercial plans to cover the National DPP lifestyle change program or other wellness programs.
For example, a study conducted by the National Business Group on Health and Optum (a health services innovation company) looked to answer whether employers were offering health and wellness programs for reasons beyond health care cost savings. The study included 275 survey responses from employers, 90% of which had 3,000 or more employees. The findings showed that 91% of the employers reported offering health and wellness programs for reasons beyond medical cost savings, with the three primary reasons being: reduction of employee health risks, reduction of overall health care costs, and improvement of employee productivity. The top additional reasons for providing these health and wellness programs included the following (listed in order of importance):
- Manage/reduce disability claims
- Improve employee job satisfaction
- Impact business performance metrics and profitability
- Improve employee daily health decisions at work
- Attract or retain talented employees
- Reduce the number of sick days
- Reduce presenteeism
- Improve employee morale
Consider the Timing
Employers and other commercial payers may be more receptive to considering coverage of the National DPP lifestyle change program at certain times of the year. For example, the graphic below shows the typical benefit decision-making timeline for employers that operate on a calendar year. While employers may make decisions outside of this timeline, they are more likely to be amenable to learning about the National DPP lifestyle change program during the 1st quarter (January-March) or the 2nd quarter (April-June) of the year. Employers that operate on a fiscal year rather than a calendar year, such as many public sector employers, typically have open enrollment during the 2nd quarter (April-June), and therefore may be more receptive to new benefit information during the 3rd quarter (July-September) and the 4th quarter (October-December) of the year.
Address Questions about the National DPP Lifestyle Change Program
When discussing the program with decision makers and potential advocates, it may be necessary to address questions about the National DPP lifestyle change program such as, “Why can’t this be a ‘one size fits all’ program for all my members and/or employees,” and “A year is a long time; can we shorten the program?” The Barriers to Coverage FAQ document above seeks to address frequently asked questions about coverage of the National DPP and provide answers and links to information on the National DPP Coverage Toolkit.Case studies and short videos can also be a helpful way to convey the potential impact of the National DPP lifestyle change program to decision makers and generate interest in the program. For example, this video shares the experience of Costco employees who participated in the National DPP lifestyle change program online. Additional case studies of employers who have offered the National DPP lifestyle change program can be found on the Coverage in Practice page of the Coverage Toolkit, in the “Examples of Employers Covering the National DPP Lifestyle Change Program” section.
Gather Data and Create a Budget Projection
The purpose of creating a case for coverage is to convince a decision maker that it is advantageous to cover the National DPP lifestyle change program. A key piece of that argument is demonstrating that the program can improve employee or member health and reduce health care costs. Commercial plans and employers with a self-insured health plan are responsible for managing the financial risk of providing benefits to plan members. This means that these organizations are highly motivated to implement changes that will contain health care costs and will likely respond favorably to data demonstrating how the National DPP lifestyle change program can contribute to cost savings.
The following resources contain data in support of covering the National DPP lifestyle change program:
Cost & Value
The Cost & Value page of this toolkit compiles several resources describing the effectiveness and cost implications of the National DPP lifestyle change program. The Evidence page of the toolkit also contains additional resources.
Presentation Template & Outline
The Case for Coverage Template and the Case for Coverage Presentation Outline can be helpful resources when preparing a presentation to stakeholders and leadership to explain how the National DPP lifestyle change program works and how it can solve problems specific to the organization. Leveraging existing resources, such as this presentation and outline, can decrease the time required to compile a case for coverage.
An example of a presentation was designed by the AMA to make the case to health care organizations to offer the National DPP lifestyle change program to their employees can be found here. However, many of the arguments in this presentation could apply to a broader audience.
Case studies can also be effective tools to communicate the impact the National DPP lifestyle change program could have on an organization, especially when challenges and lessons learned are included.
- This document tells the stories of five employers offering the National DPP lifestyle change program as a covered health or wellness benefit.
- Click here to see case studies of how three organizations (Dow Chemical Latham and Watkins and the University of Michigan) made the decision to cover the National DPP program and the different approaches they took to offer the program to their employees. For more information, or to request the full employer toolkit, please contact the AMA directly at email@example.com.
- This document contains case studies of six organizations’ experiences in the New York Metropolitan and Greater Philadelphia regions offering the National DPP lifestyle change program as a covered health or wellness benefit.
The American Medical Association (AMA) created an Eight Step Implementation Guide for employers that contains helpful information on the potential costs and benefits of covering the National DPP lifestyle change program, as well as the subsequent implementation steps. For more information, or to request the full employer toolkit, please contact the AMA directly at firstname.lastname@example.org.
Commercial plans and employers are likely to be most responsive to data that is reflective of their member or employee population. For example, data that matches the demographics (age, gender, socioeconomic status, etc.), industry, or geographic location of the member or employee population is more persuasive. Where such data is unavailable, national statistics can still contribute to the case for coverage.
Budget and Impact Tools
The tools listed below are available to help assess potential costs and savings related to the National DPP lifestyle change program. Additional information describing the value of the National DPP lifestyle change program can be found on the Cost and Value page.
Information & Instructions
This Commercial Budget Projection Template (click the icon to open) explains the process and can help guide you in the development of state-specific estimates.
Budget Projection Workbook
This Budget Projection Workbook (click the icon to download) allows you to run calculations to test your estimates.
This video walks you through how to use the Budget Projection Template and Workbook:
The CDC Diabetes Prevention Impact Toolkit is a user-friendly, interactive website that allows commercial plans and employers to assess the likely cost-effectiveness or cost-savings of covering the National DPP lifestyle change program. The default values in the Impact Toolkit are based on the best available data from relevant research, program implementations, state and industry averages, and expert judgment. Users of the Impact Toolkit can adjust those values based on the population served, expected adherence levels, program cost, and more.
Cost Savings Calculator
The American Medical Association (AMA) developed a Cost Savings Calculator to help employers, insurers, health care systems, and public health entities calculate potential medical cost savings from providing the National DPP lifestyle change program as a covered benefit. This tool assesses potential cost savings based on organization type, cost of the program, prevalence of prediabetes, anticipated enrollment, and anticipated completion.
Other Financial Benefits to Covering the National DPP Lifestyle Change Program
There are also other financial benefits to covering the National DPP lifestyle change program beyond the direct effect on health care costs that would be of interest to a commercial plan or employer. The graphic below helps illustrate some of these benefits.
Stage 3: Planning the Benefit
There are many decisions to be made about how to implement the National DPP lifestyle change program. These decisions are outlined in the Pathway to Coverage document. This document expands on the steps listed in the Readiness Assessment from Stage 1 and provides additional ideas for each phase to help the user create the appropriate coverage model for their organization.
Who Will Deliver the Program?
The National DPP lifestyle change program must be delivered through a CDC-recognized organization. CDC-recognized organizations are those that have demonstrated the ability to effectively deliver the evidence-based lifestyle change program with quality and fidelity as described in CDC’s Diabetes Prevention Recognition Program (DPRP) Standards.
Contracting with CDC-Recognized Organizations
Commercial plans and employers have the option to contract with CDC-recognized organizations to deliver the National DPP lifestyle change program. If this option is chosen, contracts between commercial plans and CDC-recognized organizations should outline expectations between the parties and include the National DPP lifestyle change program requirements. For more information on common elements included in a contract with a CDC-recognized organization, see the Contracting with CDC-Recognized Organizations page and the Prospective Contract Components Between a Commercial Payer and a CDC-Recognized Organization document.
Commercial plans and employers can see CDC-recognized organizations listed by state here.
Alternatives to Contracting with CDC-Recognized Organizations
Instead of contracting with a CDC-recognized organization, commercial plans and employers can choose to seek CDC recognition and provide the program themselves. Alternatively, they can also contract with a third-party organization to create a network of CDC-recognized organizations that provide the National DPP lifestyle change program. There are specific requirements that need to be met if an organization elects to take this approach, and resources about this process can be found on the CDC and DPRP websites, as well as through the National Diabetes Prevention Program Customer Service Center.
How Will the Program Be Delivered?
There are many considerations for how to deliver the National DPP lifestyle change program, which can be found on the Delivery page of the Coverage Toolkit.
Which Billing Model Will Be Used?
There are two billing models that payers can use when covering the National DPP lifestyle change program:
- Invoicing: Commercial plans and employers can contract with CDC-recognized organizations and establish an invoicing method for billing. In this scenario, the CDC-recognized organizations invoice the payer based on the terms defined in the contract.
- Medical Claims: CDC-recognized organizations can submit claims either directly to the payer or to the applicable third-party organization that handles billing and/or network management. To cover the National DPP lifestyle change program in a claims-based system, commercial plans will need to update their systems to accept claims with a specified combination of CPT codes with modifiers and ICD-10 diagnosis codes.
Whether a claims process is used, or an invoice is sent, CDC-recognized organizations would be required to comply with all HIPAA regulations to ensure participant privacy.
For more information on selecting a billing model, see the Coding and Billing page.
One of the final steps to planning the benefit is deciding a start date for the program and making an engagement and outreach plan for members or employees. The Pathways to Coverage document describes this process in detail, and additional information can be found on the Screening and Identification; Recruitment and Referral; and Enrollment, Incentives and Retention pages of the Coverage Toolkit.
How the benefit is rolled out can have a substantial effect on the overall success of the program. One option is to take a “phased approach” to implementation. For example, a large employer may choose to offer a program only to a portion of its employees at the beginning. This will allow the employer to evaluate the effectiveness of the program and to work through any challenges before a large-scale implementation. Smaller organizations may find that they do not have enough eligible participants in the program to make a phased implementation tenable.
State and local public health agencies may distribute new and compelling case studies of successful programs that improve community health. Consider sharing the organization’s involvement with the National DPP lifestyle program through public health channels for increased enrollment, increased program recognition, and/or an enhanced corporate image. Feel free to let us know of your work or contact us if you need additional help or information.
Stage 4: Assessing Success and Scalability
Planning to evaluate the impact of the National DPP lifestyle change program is an important part of the coverage discussion. There are several reasons why an employer or commercial payer would benefit from evaluating the program:
- Obtaining feedback to improve the delivery of the National DPP lifestyle change program
- Gathering data that demonstrates the value and effectiveness of the program
- Measuring changes over time against a baseline
- Securing continued funding for the program
- Establishing accountability for the use of resources
- Comparing the efficacy of the National DPP lifestyle change program to different interventions
More information regarding each of these advantages can be found here, along with solutions to common reasons individuals may feel reluctant to make an evaluation plan.
What to Measure
The CDC has some required measurements for the program including attendance and weight loss. Payers may consider tracking additional items in order to look at a larger impact and additional value components of coverage of the National DPP lifestyle change program, such as:
- Biometrics- A1C’s, lowering/decreasing medications, other biometric measurements (blood pressure, lipids, etc.)
- Satisfaction – Were employees positive about the programming and did they believe they benefited?
- Efficiency – Did the program operate within the specified budget and timelines?
- Knowledge – What did participants learn about diabetes prevention?
- Outcomes – Have participants changed their behavior and are health indicators improving? How has this affected productivity, absenteeism, and/or customer satisfaction?
- Claims— How have medical claims been affected (lower hospital admittance/ incidences)?
The Program Measurement & Evaluation Guide: Core Metrics for Employee Health Management from the Health Enhancement Research Organization and Population Health Alliance describes metrics that can be applied to any program intended to improve the health of a population, including the National DPP lifestyle change program. It includes metrics for financial outcomes, health impact, participation, satisfaction, organizational support, productivity and performance, and value on investment, and suggestions for how to select specific metrics within each category.
How to Gather the Data
Commercial plans likely already have robust evaluation strategies. However, many employers may be less experienced with building an evaluation plan.
There are many approaches that can be used to gather the necessary data. The evaluation approach does not have to be high cost or labor intensive. Some sources of information could include:
- Surveys such as participant satisfactions surveys, self-reported behavior surveys, and productivity questionnaires
- Focus groups or interviews
- Medical and pharmaceutical claims
- Time tracking mechanisms
- National DPP lifestyle change program registration documents
- Health Risk Assessment (HRA) results
- Biometric testing
The Midwest Business Group on Health has a Diabetes Management in the Workplace Toolkit that includes additional suggestions for evaluation and measurement of the National DPP lifestyle change program.
Organizations may already be collecting data that could be used to evaluate the National DPP lifestyle change program, and they may also choose to start collecting new metrics as part of the implementation of the program.
For employers, there will likely be employee confidentiality considerations when gathering data. Employers should collect individual-level data anonymously and report it in the aggregate, and may choose to do so through a third-party organization.
Scaling or Expanding the Program
Collecting and evaluating information about the National DPP lifestyle change program puts commercial plans and employers in the position to scale up or expand the program in an effective and data-driven manner. Understanding rates of uptake among members or employees, success rates, and other outcomes can be beneficial in helping make decisions on program scalability.
Scaling up the program may have additional benefits. For example, there are often efficiency gains when programs are scaled to larger groups, allowing the expanded group to be covered by the program with little to no additional overhead or administrative costs. However, scaling up may have hidden costs as well, which is why the decision should be data-driven.
Data collection needs for scaling the program will likely revolve around the business decisions that need to be made. Business-related data elements may include:
- Cost per program participant
- Program enrollment and retention rates
- Benefits directly resulting from the program, such as:
- Reduced health care costs
- Reduced employee absenteeism
- Improved productivity
- Improved member/employee satisfaction
- Improved customer satisfaction
- Future costs, based on expansion
- Return on investment models, based on expansion
- New logistical needs, based on expansion, such as:
- Larger meeting places or more frequent use of meeting places to allow for multiple classes
- Potential need for additional staff
- Expanded delivery options, such as including an online option if not previously offered
These data aren’t all inclusive but may help drive thinking around what should be considered when scaling the program. For more information on general business decisions associated with the National DPP lifestyle change program, please see the Cost and Value page.
Stage 5: Post-Program Launch
After implementation of the National DPP lifestyle change program has begun, there are a number of ways a commercial plan or employer can ensure the program has enough traction to support ongoing coverage of the program.
Continue to Engage the Network
Potential National DPP lifestyle change program participants may come from a variety of referral sources. While the initial launch may be limited to select members or employees, many payers have found that without continually working to engage the network, referrals lag and the success of the program can be limited. Continuous engagement with the referring provider network, the CDC-recognized organization(s), and other key partners can help to strengthen the program and make the case for continued coverage of the National DPP lifestyle change program.
Commercial plans and employers may consider outreaching to local providers’ offices to encourage referrals of eligible members to the National DPP lifestyle change program. Many entities have found that individuals are more likely to enroll in the program when referred by their health care provider. The CDC-recognized organization can also take the lead on outreaching to health care providers. Additional information about provider referrals can be found on the Recruitment and Referrals page of the Coverage Toolkit.
Using Health Care or Claims Data for Referrals
Commercial plans and employers can bolster referrals by working with the health plan administrator and/or network providers to generate eligibility reports (in a HIPAA compliant manner). The contact information of individuals who are potentially eligible for the program can be transmitted to the CDC-recognized organization or the health care provider for outreach. Also, as more health care providers are engaged for referrals, the query fields could be shared with them to expedite the initial screening for eligible participants among their patient population.
Continue to Engage Eligible Individuals and Participants
Making individuals aware of their eligibility for the National DPP lifestyle change program is a helpful step toward enrollment, but simple awareness is often not enough to translate into referrals into program participants. Also, participants may engage in the program initially, but lose interest over time. Supplementary engagement and encouragement provided at key times may help motivate individuals start and continue the program.
Just like with the initial outreach, targeted efforts can help support continued participation or additional enrollment into the program. As an employer, wellness events can be organized, internal emails can be sent, or announcements made at company-wide meetings. Incentives may also be offered for participating in a screening for the National DPP lifestyle change program, enrolling in the program, reaching program milestones, or completing the program. Commercial plans can send mailers to members or make phone calls to individuals who have not yet accepted the offer to participate. Health care providers can also be leveraged to provide encouragement to program participants who have stopped attending.
Additional information on how commercial plans and employers can increase the retention of program participants can be found on the Enrollment, Incentives, and Retention page of the Coverage Toolkit.
These efforts to continue to engage and expand the referral network, as well as engaging the participants themselves, can be refined through analyzing the data that is generated by program participation, as outlined in Stage 4.
Resources to Help Make the Case for Coverage
Coverage Toolkit Resources
- CDC’s Diabetes Prevention Impact Toolkit
- List of CDC Recognized Organizations
- Resources related to delivery of the program:
- AMA Cost Savings Calculator
- AMA Eight Step Implementation Guide (For more information, or to request the full employer toolkit, please contact the AMA directly at email@example.com).
- Employer Case Studies
Content last updated: March 30, 2020