Abstract
The National Diabetes Prevention Program (NDPP) is an evidence-based lifestyle intervention that reduces the risk of type 2 diabetes. The NDPP is overseen by the Centers for Disease Control and Prevention but with local delivery by organizations across the United States. Since its launch in 2012, the program has achieved widespread adoption by over 3000 organizations.1,2 However, over half of organizations have since discontinued their NDPP, often due to challenges with financial sustainability.3-5 In contrast, organizations that have maintained NDPP delivery can offer important insights into financial sustainability strategies that could be adopted by other programs.
Methods
We interviewed program coordinators from 21 organizations that had successfully sustained their NDPP, which we defined as delivering the NDPP for 5 or more years and with plans to continue delivering the program into the foreseeable future. Organizations were sampled to ensure representation across all US regions and organization types and a balance between organizations that did or did not also offer the Medicare Diabetes Prevention Program (MDPP). The MDPP closely mirrors the NDPP but includes additional delivery requirements established by the Centers for Medicare & Medicaid Services. Here, we conducted a thematic analysis of sustainability practices.
Results
Among the 21 sustaining organizations, 15 were nonprofits, and 6 were governmental entities. They represented a range of settings: 9 were community-based organizations, 8 were health care organizations, 2 were local health departments, and 2 were university settings. They had delivered the NDPP for 8.5 years on average. Their strategies for financial sustainability clustered into 6 strategies for program financing and 5 for cost control.
Program Financing
Medicare and Other Third-Party Payers
Eleven coordinators (52%) who delivered the MDPP described Medicare billing as an important component of their overall financial sustainability. Health care organizations were well positioned to leverage existing billing infrastructure. As one coordinator noted, “Fortunately, with us being a hospital-based clinic, it wasn’t that cumbersome for us because we already bill people for their other visits” (nonprofit health care organization).
Another health care organization described how their billing team successfully received reimbursement from Medicare Advantage plans despite encountering initial difficulties: “We had to retell stories a whole bunch of times . . . why this is a federal thing and you [Medicare Advantage plans] have to do it. . . . A very persistent medical biller brought the right players in and got people stirred up. . . . They’re paying now.” (Nonprofit academic medical center)
Three organizations (14%) reported funding from Medicaid, which has provided NDPP coverage on a state-by-state basis. Three organizations (14%) also described support from employer groups.
Participant Self-Pay
Six organizations (29%) described offering self-pay options but often with financial assistance available. As one coordinator explained, “We have an out-of-pocket fee for the program—very minimum. It’s $50 a month, and if they say, ‘We can’t pay that’ . . . they can come for as little as $10 a month” (nonprofit community-based organization).
Another program coordinator noted, “We’re able to subsidize the cost . . . [the self-pay fee] ranges from $25 out of pocket up to $429 if they don’t qualify for a subsidy” (nonprofit community-based organization).
Grant Funding
Grant funding played a central role in sustaining NDPP delivery for 18 organizations (86%). Grant size and scope varied widely, ranging from small awards that offset a portion of delivery costs to large grants that fully covered program expenses. As one interviewee explained, “At the end of the day, I write a lot of grants because Medicare would never cover all the costs of what we do” (nonprofit community-based organization).
Grant funding was also viewed as essential for removing financial barriers to program access, with one organization stating, “We have this big pot of people that are like, ‘Well, my diagnosis is prediabetes,’ and it’s like, yeah, but your insurance doesn’t cover it, so I’m always writing grants to offset costs for those people” (nonprofit community-based organization).
Leveraging Nonprofit Status
Three organizations (14%) characterized the uncompensated costs of NDPP delivery as part of their community benefit obligations tied to their nonprofit status. As one interviewee explained,
“Our CFO doesn’t really agree with the time we spend on this program and the reimbursement, but it’s a community service . . . [and] we are a nonprofit organization” (nonprofit health system).
Similarly, another coordinator noted, “Management told me that it’s not a good [insurance] reimbursement rate for the services we’re providing, but that it’s worthy to keep it going. . . . They put it in categories of volunteer and outreach in community. . . . So, they have good reasons why they’re kind of self-funding it a bit.” (Nonprofit health system)
The third organization described absorbing the costs that exceeded their grant funding: “We just write it off . . . I enter in all my nonbillable community things [into our accounting system]” (nonprofit academic medical center).
Leveraging Resources as a Governmental Agency
Five organizations (24%) described how some essential personnel time for delivering the NDPP was funded through their existing public sector budgets. As one coordinator explained, “We’re a state entity . . . [my] salary is covered by the state because I’m a state employee . . . [and] my directors are supportive of me spending my time on the program” (public university).
Another coordinator noted, “Some of our staff, you know, their salaries are already covered by the city” (government-run senior center).
Charitable Donations
Two organizations (10%) raised funds through charitable donations. One organization asked former participants to sponsor new enrollees: “I’ll do letters to all past participants asking them if they would sponsor someone through the program at the $720 cost” (nonprofit community-based organization).
The other coordinator described an annual fundraising drive to support their program: “We have a huge fundraising event . . . last year we raised over $100 000” (nonprofit community-based organization).
Reducing Costs
Low-Cost Recruitment Channels
Sixteen organizations (76%) relied on provider referrals, including community-based organizations that successfully partnered with local providers. As one coordinator stated, “We have a partnership with a hospital affiliate in our area that refers patients” (nonprofit community-based organization).
Three organizations (14%) also noted the efficiency of patient portal messaging, with one coordinator stating: “[The provider I partner with] sent a mass MyChart message . . . out of probably 300 people, maybe 50 people said yes . . . and then half of them enrolled. It took a couple hours to fill two cohorts of DPP” (nonprofit community-based organization).
One organization also had notable success using social media: “We did a survey through Facebook that would ask people, are you at risk? [with] a drawing where they could win a cash prize [of up to $75 for completing the survey] . . . and our first year we got 521 people to fill it out . . . this year we did it again and got 810 people.” (Nonprofit community-based organization)
Minimum Group Size
To lower costs per participant, 13 coordinators (62%) had a minimum group size, with an average of 8 participants to justify launching a yearlong cohort. For example, one coordinator explained, “There’s a lot of prep work . . . is it worth it with 6 people? [No, so] we try not to run a class with less than 8” (nonprofit community-based organization).
Another coordinator similarly described needing a minimum number of participants to contract with an employer group: “We almost have to have 15 from [an] employer to make a go of it, ’cause my time out there and doing the legwork” (nonprofit health system).
Virtual Delivery
Twelve coordinators (57%) indicated that virtual delivery of group classes was important for financial sustainability, including to reduce staff time spent on recruitment and travel. As one organization explained, “I guarantee we wouldn’t do the program at all anymore if it was only in person. . . . Virtual [delivery] has allowed us to fill classes way faster because you can have referrals from all over the place” (nonprofit community-based organization).
Another coordinator noted: “The only option is virtual . . . we have a 24-county service area . . . [and with] transportation . . . that would be your entire 8-hour day to run one [in-person] class” (nonprofit health care organization).
Reducing Group Facilitation Costs
Organizations described a variety of efforts to reduce the costs of facilitating group classes. Three organizations (14%) trained student volunteers, with one coordinator explaining, “Our director is a master trainer. . . . This year we had 52 nursing students who were trained. . . . Three, sometimes four, nursing students made up [a coaching] team” (government-run senior center).
Another organization benefited from having former participants serve as volunteers: “I have individuals that have gone through the program and become volunteer lifestyle coaches because they want to give back . . . it’s an extra probably $300 bucks that we don’t have to spend on the lifestyle coach per person” (nonprofit academic medical center).
Five organizations (24%) noted that they relied on part-time or contract positions, which saved on costs for fringe benefits. The NDPP was designed to use a relatively low-cost staffing model, and two organizations (10%) reported paying wages consistent with lay health roles even when employing health care professionals, such as diabetes care and education specialists or registered dietitians, in order to remain financially viable. As one coordinator explained, “We pay [our coaches] less ’cause we have to. . . . We start them out at $18 an hour. . . . If they pick up their three cohorts, then we bump ’em up to $20. . . . I just brought on a certified diabetes educator that I worked with in the past.” (Nonprofit community-based organization)
Reducing Administrative Overhead
Ten organizations (48%) reduced their administrative overhead by partnering with more efficient external service providers. One coordinator noted, “I don’t recommend anyone doing the paper [claims] submissions. . . . Not the way to go. [Now] we work with [a billing vendor and] I’m really happy” (nonprofit community-based organization).
Two organizations (10%) specifically worked under an umbrella hub arrangement, partnering with another delivery organization that provided a centralized administrative infrastructure. As one coordinator explained, “We [originally] worked with the hub for more of a billing purpose, and then data reporting, ’cause I did all the data reporting before, and it was doable, [but] it took a lot of time. . . . We joined that hub to alleviate some of the burden.” (Nonprofit academic medical center).
Discussion
Among organizations that have maintained NDPP delivery, financial sustainability was supported by a range of strategies related to billing, fundraising, operations, staffing, and partnerships. There was no single model for financial sustainability, and organizations adopted multiple approaches that aligned with their local context. A limitation is that we did not sample organizations that were fully sustainable through revenue generation, if such organizations exist. Despite expanding payer coverage, grant funding remained a critical component of sustainability for nearly all programs, highlighting the continued gap between reimbursement rates and the costs of NDPP delivery.
At present, there does not appear to be a viable business case for delivering the NDPP as a revenue-generating service. We have previously described how this challenge stems in part from the way Medicare reimbursement rates were established based on incomplete estimates for delivering NDPP services. 4 Nonetheless, organizations can take initiative to negotiate contracts with more viable payment rates when possible. For example, a prior case study showed how a delivery organization used their established diabetes self-management education and support reimbursement rates to value NDPP delivery and negotiated to receive $45 to $63 per participant per session, or up to $1086 to $1520 for 24 sessions (all amounts adjusted to 2025 USD). 6 Organizations may strengthen the case for more favorable coverage models by emphasizing the NDPP’s benefits to payers, which include potential cost savings from reduced health care utilization and reduced absenteeism, as outlined in The Diabetes Prevention Impact Tool Kit. 7 In the near term, the sustainability strategies identified in this study may help organizations bridge the gap while reimbursement models continue to evolve. ■
Practice Pearls for Sustaining National Diabetes Prevention Program Delivery
Footnotes
Author Contributions
Declaration of Conflicting Interests
The authors have no conflicts of interest to declare.
Funding
This work was supported by the National Institutes of Health (No. R15HL163736) and the Kaiser Permanente Center for Health Research.
Guarantor Statement
Natalie Ritchie is the guarantor of this work and takes responsibility for the integrity of the data and the accuracy of the analyses.
