More than 3500 sites offer diabetes self-management education, and speakers at the annual meeting of the American Association of Diabetes Educators discussed how this system could be engaged to bring the Diabetes Prevention Program to all 50 states.
The existing system of more than 3500 sites that offer diabetes self-monitoring education (DSME) has the potential to bring the National Diabetes Prevention Program (DPP) to all 50 states, according to a leader from the American Association of Diabetes Educators (AADE) who spoke Sunday at the annual meeting in San Diego, California.
Director of Prevention Joanna Craver DiBenedetto, BS, MNM, said AADE’s experience with a network of 44 sites that offer the DPP through a CDC grant has produced a high-quality, cost-effective program that could scale up to reach millions in time for Medicare reimbursement, which is scheduled to start January 1, 2018.
The DPP is a yearlong lifestyle change program; groups of participants meet weekly for 4 months, then monthly during a maintenance period. Clinical trials have shown the program reduces the risk of developing diabetes 58%, and 77% in the Medicare population. Real-world results published in The American Journal of Managed Care showed the program remained cost effective over a 10-year period.
DiBenedetto and Linda M. Schoon, RD, CDE, who coordinates a grant-funded DPP site in Colorado, offered insights on how diabetes educators—who are trained to work with patients already diagnosed with the disease—could be leaders in the effort to bring DPP to the estimated 86 million Americans who have prediabetes. Those with this condition are 5 to 15 times more likely to develop type 2 diabetes (T2D), and face greater risk of heart disease and stroke.
Medicare’s decision to fund DPP, announced this spring, is widely seen as the first, crucial step in payers taking a proactive approach in halting T2D before it progresses. Diabetes accounts for $1 of every $3 that Medicare spends; the disease already costs the nation $245 billion each year, and that amount could soar if trends continue. At its current pace, diabetes could affect 1 in 3 adults by 2050.
The move to fund DPP came after a pilot showed Medicare could save $2650 over 15 months per person. Right now, CMS is taking comments on a plan to start certifying sites on January 1, 2017, with reimbursement starting a year later.
DPP’s strength comes from its impressive results despite low costs, with many programs offered in community settings. AADE sees that model continuing, with diabetes educators providing oversight to ensure quality, DiBenedetto said. “We are going to need a lot of coaches and boots on the ground,” she said.
AADE sees several advantages in tapping the existing system of DSME sites to deliver diabetes prevention, DiBenedetto said. These include:
· Educators are already billing Medicare and have a National Provider Identifier (NPI); the CMS proposal calls for DPP providers—called suppliers—to have an NPI.
· 80% of AADE members already take part in prevention activity, but only 0.4% are being reimbursed. “That’s a problem,” DiBenedetto said.
· DSME sites already make up nearly half of the sites—30 of 61—that have received full CDC “recognition,” a time-consuming process that requires sites to submit data that show participants lose 5% of body weight. “We’ve been collecting lessons and insights on how to get from pending to full status,” she said, which will be important for Medicare reimbursement.
· The 44 grant-funded sites have thus far seen an average weight loss of 5.2% at 6 months and 6% at 12 months.
· At AADE sites, 75% of the diagnoses of prediabetes are done with a blood test. CDC requires programs to confirm at least 50% of diagnoses this way, but many sites struggle to do this. A 9-part questionnaire is an alternate screening method.
· Patients who end up having undiagnosed T2D can be immediately placed in a DSME program. Every DPP program encounters this, and DiBenedetto said, “What better place to be than with your diabetes educator?”
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There will be challenges with the approach, she said. The AADE format is based on in-person training with some telehealth services, and there’s an awareness that an online component may be needed, DiBenedetto said. Digital behavioral health providers such as Omada Health are expected to be key in helping Medicare reach the millions with prediabetes.
Site coordinators are not accustomed to engaging payers, she said. “That’s been part of our grant-funded work—to understand the rate of return on investment.” DSME sites within a given state would have to start thinking of themselves as a network, as offering “a system of delivery.”
AADE will be submitting comments on the CMS proposal, and DiBenedetto encouraged individual members to comment as well. The organization is making sure its sites are ready for Medicare reimbursement, such as developing data collection and reporting tools.
Success in Colorado. Schoon said her program, located in Colorado, began offering classes in September 2015 and is already enrolling a new cohort of participant each month. So far, results have varied by site, but some are achieving more than 7% weight loss.
Schoon has forged key relationships with payers, including Anthem and Optum/UnitedHealthcare. And employers are coming up with their own ideas, such as financial incentives for workers who attend at least 75% of the classes. “It’s a great model to have a little skin in the game,” she said.
It’s essential to get the word out, especially personal testimonials. One newspaper column produced 50 phone calls, School said.
There are challenges, too. Things like contracts with third-party payers take time, and there’s quite a learning curve to billing. Some patients drop out, because they want a “quick fix” instead of a lifestyle change.
Right now, one of Schoon’s biggest problems is scheduling space. “Growing pains are a good problem to have,” she said.