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CMS Must Add Virtual Providers, Revamp Payment for Diabetes Prevention Program

Mary Caffrey
A group that represents both community-based and virtual providers finds many issues with CMS' proposal for Medicare's Diabetes Prevention Program.
CMS must let virtual providers offer the Medicare Diabetes Prevention Program (DPP) when it launches next spring, a stakeholder group argued in comments submitted to CMS.
Excluding virtual providers isn’t CMS’ only problem, according to the Council for Diabetes Prevention, which responded to a July 13, 2017, proposal. The Council, representing 75 community-based and virtual DPP providers and health systems, said the proposed payment structure won’t cover costs and creates too many headaches for the grassroots groups that have made the DPP a success.
In March 2016, then-HHS Secretary Sylvia Mathews Burwell called for Medicare funding of DPP, a landmark shift to paying for a preventive service. The move recognized the growing burden of diabetes in the United States—it is estimated that 1 out of every 3 adults could have the disease by 2050, and already the disease accounts for $1 of every $3 Medicare spends. An estimated 84 million Americans have prediabetes, so stopping the progression of diabetes is considered key to slowing Medicare spending. Burwell’s announcement came after a DPP pilot with the YMCA found the program saved $2650 per Medicare beneficiary.
But the Council’s comments noted that CMS’ proposal strayed from the science and spirit of the original DPP, to the point that successful community groups that planned to serve Medicare clients may decide it’s not worth it. Providers who wish to become Medicare suppliers can do on January 1, 2018, with the program set to launch April 1, 2018.
The DPP is a 12-month, evidence-based lifestyle program with a CDC-approved curriculum; it features 16 weekly core sessions, followed by a maintenance period of monthly sessions. Evidence shows the program stops prediabetes from progressing as participants make modest changes and lose at least 5% of body weight. In a landmark study published in 2002, the program showed a 58% reduction in participants progressing to diabetes.

A copy of the Council’s comment was provided to The American Journal of Managed Care®. Among the issues it cited:
  • Reimbursement is inadequate to support program costs, in part because Medicare wants to require every coach to have National Provider Identification (NPI). Making the cost structure work could require class sizes much larger than successful programs recommend. Rather than inflate program costs with NPI requirements for each coach, the Council recommends beefing up requirements for program coordinators.
  • Besides the low payment rates, CMS ties reimbursement to an additional maintenance period of 2 years, well beyond the time frame tested in clinical trials. Council members were not opposed to a maintenance period after the initial 12-month program ends, but thought it should not be tied to reimbursement—and should, perhaps, be paid for by beneficiaries themselves. “The overwhelming perspective is that the additional 2 years of ongoing maintenance required to be provided by a Medicare DPP supplier in the proposed rule was unrealistic and excessive, creating a major burden that will be next to impossible for many organizations to realistically achieve," the Council wrote in comments.
  • The once-per-lifetime limit will be hard to enforce and is at odds with the realities of making lifestyle change, the Council argued. No guidance is offered for what happens if a senior must interrupt the program for a medical or personal reason, or how in-person suppliers deal with “snowbirds” or other life-related events. Requiring a break between attempts is reasonable, the comment stated; tobacco cessation and obesity counseling programs offer good models.

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