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Managed Care Updates: Medicare and CGM, Omada Health Hires, Council for Diabetes Prevention Officers
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Managed Care Updates: Medicare and CGM, Omada Health Hires, Council for Diabetes Prevention Officers

AJMC Staff
A landmark reimbursement decision from Medicare, and news in diabetes prevention.
  When it formed in September 2016, council members voiced the need to work together to ensure the long-term viability of the DPP, which has more than 1400 providers with CDC recognition. At the time, Schmidt said it was clear that providers needed an entity through which they could share information and best practices. In the group’s first statement, Schmidt described the council as a “big-tent forum” that would allow members to stay current on government policy.2

  At the time, CMS was taking comments on the rules that will govern Medicare’s launch of the DPP. The agency has since set eligibility criteria, but is still working on rules for reimbursement, including how to work with digital providers like Canary Health and Omada Health.3 In the interview, Woodbury explained that, until recently, digital providers were barred from obtaining CDC recognition, which can take several years.

  As it stands, Medicare wants to require CDC recognition for reimbursement, but that could exclude digital providers who have not had time to achieve recognition. Without them, she said, “You’re going to have a lot of frustrated seniors—and, more importantly, seniors who should get the benefit.” 

  Said Woodbury, “It is going to be pivotal to have digital providers in the mix to scale this program.” The importance of scalability was explained by an Omada Health executive last spring in EBDM™.4

  A new challenge is ensuring that Medicare can still pay for the DPP, even if the ACA is repealed. HHS secretary Sylvia Mathews Burwell authorized reimbursement through a provision that allowed Medicare to fund programs after a successful pilot within the Center for Medicare & Medicaid Innovation. If that path to reimbursement goes away, Congress must allow a new one, Woodbury said.

  The National DPP is based on research funded by the National Institutes of Health; the initial study showed that participants with prediabetes reduced their risk of developing type 2 disease by 58%.5 A 10-year follow-up study published in The American Journal of Managed Care® found that long-term risk reduction among adherence participants was nearly 50%, and these individuals incurred fewer medical costs than those who took metformin to prevent diabetes.6

CGM and Medicare, References

1. Centers for Medicare & Medicaid Services. Regulations and guidance, ruling CMS-1682-R. CMS website. Published January 12, 2017. Accessed January 14, 2017.
2. JDRF encouraged by Medicare decision to take first step toward coverage of continuous glucose monitors for people with type 1 diabetes [press release]. New York, NY: JDRF; January 12, 2017. Accessed January 13, 2017.
3. Collins S. Medicare’s failure to cover CGM at odds with other health, research agencies. Am J Manag Care. 2015;21(SP11): SP378.
 4. Caffrey M. Dexcom’s evidence builds case for dosing ahead of key FDA meeting. The American Journal of Managed Care® website. Published June 16, 2016. Accessed January 14, 2017.
5. Caffrey M. FDA approves dosing for Dexcom G5, could pave way for Medicare coverage. The American Journal of Managed Care® website. Published December 20, 2016. Accessed January 14, 2017.
6. Centers for Medicare & Medicaid Services (CMS) classify therapeutic continuous glucose monitors (CGM) as “Durable Medical Equipment” under Medicare Part B [press release]. San Diego, CA: Dexcom; January 13, 2017. Accessed January 14, 2017.
7. Caffrey M. Dexcom committed to bringing CGM to Medicare population. The American Journal of Managed Care® website. Published July 22, 2016. Accessed January 14, 2017.
  8. Whitcomb v. Burrell, decided May 26, 2015. Accessed January 14, 2017.
  9. Quilliam BJ, Simeone JC, Ozbay AB, Kogut SJ. The incidence and costs of hypoglycemia in type 2 diabetes. Am J Manag Care. 2011;17(10):673-680.

Omada Health, References

1. Omada Health adds Dr. Paul Chew as chief medical officer, Tom Schoenherr as chief commercial officer [press release]. San Francisco, CA: Omada Health; January 6, 2017. dr.-paul-chew-as-chief-medical-officer-tom-schoenherr-as-chief-commercial-officer.
2. Staton T. Sanofi to slash 20% of diabetes sales force as struggling unit faces brand new biosimilar. Fierce Pharma website. new-biosim. Published December 12, 2016. Accessed January 14, 2017.
3. Fact Sheet. Medicare Diabetes Prevention Program (MDPP) expanded model. CMS website. Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02-2.html. Published November 2, 2016. Accessed November 3, 2016.
4. Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996-2013. JAMA. 2016;316(24):2627-2646. doi:10.1001/jama.2016.16885.

Council for Diabetes Prevention, References

1. Council for Diabetes Prevention announces new board of directors [press release]. Washington, DC: Council for Diabetes Prevention website, January 10, 2017. announces-new-board-of-directors/. Accessed January 10, 2017.
2.. Council for Diabetes Prevention launched to support delivery of CDC National Diabetes Prevention Program [press release]. Washington, DC: Marketwired; September 21, 2016. council-diabetes-prevention-launched-support-delivery-cdc-national-diabetes-2160355.htm. Accessed January 10, 2017.
3. Fact sheet. Medicare Diabetes Prevention Program (MDPP) expanded model. CMS website. https://www.cms. gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02-2.html. Published November 2, 2016. Accessed November 3, 2016.
4. Payne M. History lessons in innovation: digital behavioral medicine can address the diabetes “double epidemic” facing Medicare and America’s seniors. Am J Manag Care. 2016;22(SP7):SP275-276.
5. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
6. Herman WH, Edelstein SL, Ratner RE, et al; Diabetes Prevention Program Research Group. Effectiveness and cost-effectiveness of diabetes prevention among adherent participants. Am J Manag Care. 2013;19(3):194-202.

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