April 1 Brings Day One of the Medicare Diabetes Prevention Program, and Challenges for Health Plans


Some Medicare Advantage plans may not be fully ready for the requirements of this history-making preventive service.

Sixteen years after a National Institutes of Health study showed it worked, and 2 years after the CMS actuary said it could save millions of dollars, the Medicare Diabetes Prevention Program (DPP) launches today, making history in the way CMS fights a disease that accounts for $1 in every $3 spent in Medicare.

Medicare DPP achieves 2 key milestones:

  • First, an evidence-based preventive service will be expanded to all beneficiaries at no cost, which means every Medicare Advantage plan must have a way to offer it to members under CMS’ rules.
  • Second, community groups with nonclinical providers, such as the Y-USA, can be paid to offer the plan through medical claims instead of grants.

The American Journal of Managed Care® spoke on Friday with Brenda Schmidt, founder and CEO of Solera Health, a company that serves as an integrator—the only one of its kind—to provide technology, regulatory, and support services that will allow community programs, health systems, and Medicare Advantage plans meet CMS requirements. At the same time, Solera touches the consumer, connecting those interested in the DPP with a program best suited to their needs. The company adds Medicare DPP to its network after years of working with commercial plans, community groups, digital providers, and other network participants.

It’s been a busy time leading up to April 1. “We’ve been doing a lot of testing,” Schmidt said. “There are so many new administrative requirements, and new CPT [Current Procedural Terminology] codes.”

And there were still Medicare Advantage plans calling over the past week, unsure if their steps to meet CMS requirements would meet demand. “A lot of Medicare Advantage plans thought the launch would be delayed,” Schmidt said. Unique features of the program—such as those to accommodate seniors with 2 residences—are catching some health plans off guard, she said.

This morning, Solera launched, which directs users to a short questionnaire to help gauge eligibility; those who meet baseline criteria are instructed how to learn more.

Preventing diabetes in up to 22 million seniors is both an opportunity and a daunting task. CMS imposed strict requirements on prospective Medicare DPP suppliers, and it decided not to include digital providers for now. Thus, there is concern there may not be adequate capacity to meet demand from seniors in the early going, especially in some rural areas.

DPP takes place over 12 months; in its original, in-person format, participants meet for weekly sessions for the first 16 weeks, known as the “core sessions.” After that, participants met monthly for maintenance sessions. Findings show the program reduces the risk progression to diabetes by 58%, and by 71% for those age 65 and older. The CMS actuary encouraged Medicare to move forward after finding it saved $2650 per beneficiary over 15 months.

But CMS rules require blood testing to diagnose every participant, fingerprinting for every health coach, and a fee schedule that many warned would not sustain smaller programs. Groups including the American Association of Diabetes Educators warned that CMS was moving away from the low-cost, community-based nature of the DPP.

Schmidt said CMS was in for a surprise when many longtime community DPP providers declined to become Medicare DPP suppliers. “Those [community] organizations looked at the requirements,” she said, including legal and financial liability, “and they realized they didn’t have the operational administrative infrastructure.”

Instead, Schmidt said, “We’re seeing a shift in the market, with other organizations stepping in, from grocery store chains to independent pharmacies.”

From the start of the National DPP in 2010, CDC has been the agency that regulated the DPP curriculum and determined whether a provider had met preliminary or full recognition; the latter step took 2 years.

For the launch, CMS rules permit an “interim” recognition status that may roll back to April 1 for some DPP suppliers, Schmidt said. It will be interesting to see in the coming months how many proposed Medicare DPP suppliers achieve adequate CDC recognition status; however, she said believes by the end of 2018, market capacity will be much improved.

Solera, meanwhile, is contracted with 37 Medicare Advantage plans and will be able to reach out to 600,000 beneficiaries already known to be eligible for Medicare DPP. “We are proactively reaching out to members through a variety of community channels,” Schmidt said. “We are doing outreach in a very deliberate manner,” with an eye toward not overwhelming a given area’s DPP infrastructure.

User experience data will be shared with CMS, she said.

What Health Plans Need to Know

Schmidt said some Medicare Advantage plans are still surprised to learn that Medicare DPP is a one-time benefit that must be portable. If a senior starts the 16-week program at her winter home in Florida, it’s up to the health plan to find a replacement program when she moves back to her summer home in Connecticut, for example. Because CMS is only allowing a limited number of virtual classes as make-up sessions, health plans will have to arrange for a separate in-person program for the beneficiary to complete the process, Schmidt said.

When plans hear about this they are taken aback. “A national network of nonmedical providers is not what a health plan does,” she said. Solera has created a model of “interoperability” by giving each beneficiary a unique ID that can be used to not only switch to a program in a new location, but also track the attendance and milestones that are key to CMS’ complex value-based payment structure.

“We’ve already enrolled 16,000 people in 2018, so we’ve figured out how to enroll people at scale,” Schmidt said. “I’m hoping the industry can look to us, to see how we can make a difference in people’s lives based on this mechanism.”

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