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Medicare's Diabetes Prevention Program Is Coming, but CMMI Has Work to Do

Mary Caffrey
No one questions the long-term savings that the Diabetes Prevention Program will bring to Medicare, but getting it off the ground will require several steps that have never been done before, including a new payment model.
Nina C. Brown-Ashford, MPH, CHES, remembers when the Center for Medicare and Medicaid Innovation (CMMI) received the first field reports from the pilot of the National Diabetes Prevention Program (DPP) with the Y-USA. The results were so positive that another agency veteran said, “I think there might be something here.”

That set in motion calls to CDC’s Ann Albright, PhD, RD, the director of the Division of Diabetes Translation, and a process that would lead CMS’ actuary to certify that pilot participants saved Medicare $2650 apiece over 15 months. Ultimately, 83% of the participants would take part in at least 4 sessions, and the average weight loss was 9 pounds.

Back in March 2016, it was official: DPP would go national in Medicare, come January 1, 2018.

“That felt really far away,” said Brown-Ashford, now the acting director of the Division of Health Care Delivery at CMMI. On Saturday, she described Medicare DPP as starting “on or after” that January 1, 2018, target date. While no one is arguing the benefits DPP will ultimately offer, starting a government program from scratch—with features no one has ever used before—is proving a daunting task.

Brown-Ashford led off a symposium at the 77th Scientific Sessions of the American Diabetes Association on success stories about the DPP, which has been shown in clinical trials to help those with prediabetes reduce their risk of progressing to type 2 diabetes by 58%. Recent evidence published in Diabetes Care from 4 years of experience with DPP found major progress and offer hints on improving the program.

Medicare DPP will involve many “firsts,” Brown-Ashford said: CMS must create a brand-new class of nonclinical suppliers in the community coaches. It will be fashioning an outcomes-based payment model on top of its fee-for-service reimbursement system. It must figure out how to pay groups that aren’t set up to bill Medicare (although an integrator, Solera Health, is positioned to take on this task).

For those fearful that an end to the Affordable Care Act might take the DPP down with it, Brown-Ashford offered good news: Medicare is scheduled to pay for DPP through the Part B trust fund. But Brown-Ashford could not give a publication date for the second round of rules, which would include critical guidelines for billing and participation for digital providers.

She did offer more specifics on how CMS plans to avoid fraud by requiring coaches to have National Provider Identifier (NPI) numbers, and she said that community programs can a preliminary status through CDC while they earn full recognition, so that there’s enough capacity to serve all the seniors who expect to take part.

Brown-Ashford is optimistic. With 25% of seniors developing T2D, the prospect of saving $2650 for a quarter of the Medicare population will drive the DPP forward. “We’re talking about a lot of money,” she said.

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