Community Providers May Struggle With CMS Rule on the Diabetes Prevention Program

Brenda is the Founder & CEO of Solera Health, a technology-enabled managed services organization that supports accountable care communities through a national network of community-based and digital providers of evidence-based chronic disease prevention programs as an adjunct to primary care. Follow Brenda on twitter @solerahealth
The proposal from CMS may make it difficult for groups that have been providing the DPP to take part in Medicare reimbursement.
HHS Secretary Sylvia Burwell announced in March that the Diabetes Prevention Program (DPP) would be eligible for Medicare coverage, starting January 1, 2018. This new benefit was based on the documented savings and opportunity to prevent type 2 diabetes (T2D) among Medicare beneficiaries. CMS’ actuary certified that the Medicare DPP pilot program created an estimated $2650 return on investment per person over a 14-month time horizon. Based on the published program evidence, seniors who lose at least 5% of their body weight reduce their risk of developing T2D by 70%. It is especially significant that coverage for the National DPP marks that first time since the passage of the Affordable Care Act that Medicare coverage has been extended to a preventative health program.

The DPP is primarily delivered in group sessions in a community setting, facilitated by a non-clinical lifestyle coach trained to deliver the Centers for Disease Control and Prevention (CDC) standardized curriculum. The program can also be delivered virtually via text message, telephone, digital apps, video chat, and other modalities by more than 40 digital platforms currently recognized by the CDC.  

While it is good news that the CMS is extending Medicare coverage for the DPP, there are key issues that must be resolved. For example, the CMS’ concerns about program integrity means that they are delaying decisions on several important aspects of the rule, including whether to accept digital providers as DPP suppliers in Medicare. Currently, the eligibility of digital DPPs is still pending, as the CMS ruling states that they intend to “…continue gathering more information on the virtual delivery of DPP services.”  

To effectively scale the DPP to meet the needs of the estimated 20 million seniors who would qualify for the benefit, it is imperative that a variety of DPP providers are able to become Medicare suppliers to meet the needs for both scale and personalization. Behavior change is personal, and the highly diverse Medicare population requires a combination of hyper-local community organizations and digital providers delivering the DPP.

There is no road map for delivering a new Medicare benefit with non-clinical resources, and certainly not for a prevention program. CMS has designated Medicare DPP suppliers as a “high risk supplier type,” and this may result in too many burdensome program integrity/ compliance requirements. This could have the effect of deterring DPP suppliers from offering Medicare services or make being a supplier too financially risky. It appears that the CMS is also evaluating program costs relative to the "high risk" category for DPP providers, as this designation will add significant administrative burdens; these costs were not contemplated in the original pilot study, and, thus, were not factored into CMS’ actuarial analysis. CMS will propose a new fee schedule and reimbursement requirements in the 2018 Physician Fee Schedule. The “high risk” designation—similar to a home health agency—will create an even larger administrative burden on the local and community DPPs that may qualify as Medicare DPP suppliers, but in many instances are the least prepared to handle the burdensome regulatory and compliance requirements placed on DPP providers and their lifestyle coaches.  

Driven by this focus on program integrity, the CMS says that for now it will only reimburse programs that have received full recognition from the CDC. This means that fewer than 100 DPP providers (out of more than 1200 nationwide) will be eligible for Medicare reimbursement when it begins on January 1, 2018. This eliminates hundreds of qualified community-based DPP providers that don’t meet the Medicare DPP supplier eligibility requirements, although they are currently providing the DPP in their local communities. CMS is proposing additional quality and program integrity safeguards for organizations whose recognition is pending. Under the new category of “preliminary recognition” that the CMS has defined, DPP providers will have to meet even higher standards than the current full recognition requires.

As an integrator that connects different chronic disease prevention and management programs to payers and employers looking to offer them to their populations, we are concerned about these issues, and look forward to working with others to help the CMS modify its ruling before it is finalized in 2018. The key to scaling the DPP program to Medicare beneficiaries lies in broadening—not limiting—access to programs, whether they are national, community-based or digital. We believe that the CMS needs to recognize that patient choice and a range of DPP programs are critically important for reaching people who are qualified for the program as a covered benefit.
 
As we expect additional changes to the Medicare DPP rule, we remain optimistic that there will be changes to the 2018 fee schedule that will address the aforementioned issues. Key to these changes will be the designation of a technology-based integrator to successfully scale the CMS’ DPP initiative and achieve its vision of diabetes detection and prevention by connecting those at risk to the providers of choice among the hundreds of effective DPP options available. In the end, the most important goal is simply this: how can we take advantage of available resources to deliver effective DPPs and make it easier for people to participate and prevent diabetes?

For more information:
Council for Diabetes Prevention
www.NationalDPP.org
CMS’s MDPP Website:
https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/

Resources:
Final Rule Fact Sheet
Final Rule Press Release
 
 


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