Challenges With Implementing the Diabetes Prevention Program for Medicare Beneficiaries in an Integrated Health System

ABSTRACT

Objectives: In April 2018, CMS began reimbursing both clinical and community settings for providing the CDC-recognized Diabetes Prevention Program (DPP) to eligible Medicare beneficiaries. To better understand the process of offering the program to Medicare beneficiaries, we interviewed relevant stakeholders in a large, integrated health care delivery system.

Study Design: Qualitative interview study.

Methods: We conducted semistructured interviews with 12 delivery system stakeholders. Data were analyzed following a thematic analysis approach.

Results: Stakeholders described systemic challenges to the implementation of Medicare DPP (MDPP), including inadequate reimbursement for the health care system, low awareness of MDPP among patients and providers, and challenges with utilizing third-party vendors to connect patients to CDC-recognized MDPPs.

Conclusions: Although the reimbursement of DPP for Medicare beneficiaries was a landmark decision, the current structure and requirements make it difficult for health systems and community-based providers to implement and promote this benefit. This study highlights the challenges that even integrated health systems are facing to implement MDPP, as well as potential strategies to overcome these barriers and expand the reach of the program. Medicare should seek ways to increase the financial incentives and decrease the barriers associated with implementing MDPP.

Am J Manag Care. 2021;27(11):e400-e403. https://doi.org/10.37765/ajmc.2021.88784

Takeaway Points

The significant findings of this study include the following:

• Stakeholders in an integrated health care delivery system described systematic challenges to the implementation of the CDC-approved Diabetes Prevention Program for Medicare beneficiaries.
• Challenges included inadequate reimbursement for the health care system and low awareness of the program among patients and providers.
• New strategies are needed to expand the program’s reach and effectiveness for Medicare beneficiaries.

Among the 88 million adults in the United States with prediabetes, 5% to 10% will develop type 2 diabetes each year.¹ Preventing the development of type 2 diabetes is critical for mitigating risks including heart disease and stroke, as well as the economic costs of diabetes care—currently $327 billion annually.² In the landmark Diabetes Prevention Program (DPP) clinical trial, the behavioral lifestyle intervention that focuses on healthy eating and physical activity was shown to be efficacious in decreasing the incidence of diabetes compared with placebo and metformin.^3,4 Since then, there have been many efforts to expand the reach of the program.^5-7 In April 2018, CMS began reimbursing both clinical and community settings for providing a CDC-recognized DPP to eligible Medicare beneficiaries and mandated Medicare-approved organizations that offer Medicare Advantage plans to offer the program.^8-10

The mandate to cover an effective behavioral lifestyle program was unprecedented and much needed. However, some scholars expressed concern that the reach of DPP for Medicare beneficiaries may be limited, citing poor infrastructure development, low reimbursement rates, and high standards for CDC recognition.^11-15 As of 2019, access to Medicare DPP (MDPP) was suboptimal, with 75% of states offering no CDC-recognized MDPP sites, less than 1 site per 100,000 Medicare beneficiaries, or availability limited to single municipalities.¹⁶

As part of a larger study to evaluate the implementation of DPP in a large, integrated health care system (R01DK115237), we interviewed delivery system stakeholders to understand the implementation process of the program for Medicare beneficiaries.

METHODS

This study was conducted with delivery system stakeholders at Kaiser Permanente Northwest (KPNW), 1 of 8 KP regions across the country. KPNW provides care to approximately 610,000 members in Oregon and southwest Washington. We invited stakeholders to participate in 30- to 45-minute semistructured phone interviews that were recorded with permission of the participants. Stakeholders were selected based on their roles, insights, and experience with implementing the DPP at KPNW. They were the health coach lead of the Health Engagement and Wellnesses Services (HEWS) department, a HEWS project manager, and 2 HEWS health coaches; 5 primary care physicians (PCPs), including the clinical lead for the prediabetes workgroup; 1 Medicare product consultant responsible for rolling out programs to beneficiaries; 1 senior consultant who oversaw DPP implementation across all KP regions; and the KPNW vice president of quality, patient safety, and population health. Together, these stakeholders represented unique perspectives and insights into broad aspects of the MDPP implementation and included most KPNW roles that were involved in decision-making or distribution of the program. We created an interview guide that contained questions for all stakeholders, as well as additional questions for specific stakeholder roles. Participants were not offered any incentives for participation. In total, we conducted semistructured interviews with 12 delivery system stakeholders.

All recordings were transcribed professionally and analyzed by 3 researchers (I.G., A.F., D.P.-T.) following a saliency analysis approach.¹⁷ The goal of the analysis was to identify key challenges of high importance rather than common views among stakeholders. I.G. developed a coding dictionary based on preliminary review of all transcripts. Each researcher then was assigned 2 random transcripts and applied the coding dictionary to each of the transcripts. During a discussion among these researchers, codes were added, refined, and redefined. The final coding dictionary was applied to all transcripts.

RESULTS

The saliency analysis revealed several key challenges to implementing MDPP identified by stakeholders. Most Medicare patients within KPNW are Medicare Advantage plan beneficiaries. This plan has a capitated payment structure; Medicare did not offer any increase in the capitated rate for implementing MDPP. Unlike in the fee-for-service setting, this creates a short-term financial disincentive to wide implementation of the program for comprehensive medical systems, even if in the long term costs are decreased. For example, developing and maintaining an in-house MDPP would have required substantial investment in staff without offering short-term financial incentives: “[…W]e discovered that KPNW is capitated in our Medicare reimbursement, so even if we were a [CDC-]recognized program and could get reimbursed to supply MDPP to Medicare members as part of their benefit, we weren’t going to get any more money for it,” the HEWS project manager said. It should be noted that there was a concerted effort by researchers to demonstrate the long-term return on investment to KPNW leadership; however, the need to achieve a balanced budget each year outweighed the long-term benefits. Although stakeholders did not describe the outreach effort by researchers, they also pointed out the tension between long-term cost savings through participation in programs such as MDPP vs the importance of short-term costs of widespread implementation of the program as a major challenge for implementation.

Stakeholders also expressed concerns about the ability to meet CDC program recognition requirements based on session attendance and achieving 5% or more weight loss.¹⁸ To ensure that all KP health system regions were able to meet the CMS mandate, the KP national Program Office contracted with a broker to identify and refer patients to existing CDC-recognized DPPs in the geographical vicinity. However, uptake of MDPP among eligible patients remained low at KPNW (enrollment was fewer than 10 members at the time of this study).

Stakeholders were not aware of any promotional efforts by KPNW to publicize MDPP to Medicare beneficiaries. Thus, they stated that the low enrollment in the program was likely due at least in part to a lack of awareness among PCPs and eligible patients about the availability of the benefit and, as a result, low referral rates to the program. When hearing about the benefit in an interview, a PCP commented, “I [had] no idea any of this existed and I think that’s the problem; we have so many things coming at us I can’t keep half of it straight in my head.” No interviewees were aware of any patients requesting enrollment in MDPP.

KPNW also had existing weight loss and diabetes prevention programs in place that patients, including Medicare beneficiaries, participated in after being referred by their provider. In fact, PCPs stated that they were more familiar with these existing health system–based programs and regularly referred those to patients with increased risk for diabetes or cardiovascular disease. In the eyes of stakeholders, the existing programs offered an alternative of equal or greater value than the MDPP benefit. Thus, the decision to contract with new programs instead of adapting existing offerings appears to have limited awareness and utilization of the program.

Those familiar with the MDPP referral infrastructure commented on the challenges posed by working with a broker, including difficulty learning about the quality of the programs and member satisfaction with the offerings: “Are we going to get the feedback about how effective these programs are? Are we going to get formal feedback about how members have done, about the numbers? I want to know that it is working, that the solution that was found is a positive one, that it’s a positive experience for [patients]; whether we want it or not, because they’re getting it through [the health system] it’s a reflection of us,” the HEWS project manager said.

DISCUSSION

This is one of the first qualitative studies to present insights into offering MDPP in a real-life health care delivery setting. We found that stakeholders described systemic challenges to the implementation of MDPP, including inadequate reimbursement for the health care system, lack of awareness of MDPP among patients and PCPs, and challenges in working with a third-party vendor to connect beneficiaries to a CDC-recognized program. Improving the feasibility of implementing MDPP is crucial for ultimately increasing the reach of the program.

Our findings suggest that health systems such as KPNW, whose Medicare beneficiaries are mostly Medicare Advantage plan members, have no financial incentive to develop and offer a CDC-recognized DPP to meet the CMS mandate. The cost-effectiveness of implementing DPP over the lifetime of an individual at risk for type 2 diabetes has been demonstrated.¹⁹ However, for the short-term implementation of MDPP, a gap exists between costs for service delivery and reimbursement, as has been pointed out in earlier research.^11,13,20 Revising existing reimbursement models and rates may be one tool for improving feasibility of implementing MDPP in clinical and community-based settings. In the context of its Advantage program, Medicare could increase the monthly stipend for patients who have prediabetes if the care provider offers MDPP.

Referral rates to MDPP at KPNW were low (fewer than 10 members). These numbers mirror low referral rates nationwide; only 4.2% of adults from a representative sample of eligible patients were referred to a DPP.²¹ For MDPP, the referral rates are limited by the lack of sites offering the program.¹⁶ To increase enrollment in MDPP, CMS and health care systems need to enhance awareness about the benefit among providers and patients. A survey study among PCPs found that only 38% of participants knew about the National DPP and only 23% referred patients to the program,²² which resonates with our findings. Providers will refer to programs that they know and trust, and patients often rely on the advice of their providers. Adding MDPP as a referral option in the electronic health record (EHR) could be one way of increasing visibility of the program. In previous research, PCPs who were using the EHR were more likely to refer patients to the National DPP.²² An EHR-based referral option would also need to be accompanied by informational content (eg, letters, brochures, emails, websites) tailored to providers and patients to further increase awareness.

Other strategies to ease implementation and boost enrollment could include developing ways to simplify the MDPP recognition process by CMS, in particular the requirement for a minimum weight loss. Expansion of health coverage for DPP, including now being covered by Medicaid in certain states,²³ also enhances the feasibility of implementing the program and increases access for patients younger than 65 years. In addition to the challenging criteria for becoming a CDC-recognized program, CMS currently covers only MDPP delivered as in-person group classes, which further limits access. In the wake of the COVID-19 pandemic, there are calls for CMS to extend coverage for virtual and digital DPP.²⁴ A digital DPP option might be more palatable to health systems with limited capacity to offer an in-person program and more convenient for patients.

Although contracting with a broker could help facilitate clinic-community partnerships to increase uptake of MDPP, limited availability of MDPP sites in the community is still a barrier to program success.^16,25 At present, there are 18 CDC-recognized DPP sites across the state of Oregon, an insufficient number to address the needs of the approximately 1 million Oregonians who have prediabetes.²⁶

Several health systems, including some KP regions (Georgia, Southern California, Colorado), have successfully implemented and offer a CDC-recognized DPP to all eligible patients. Additional studies are needed to understand facilitators of program implementation among health systems that have successfully developed and received CDC recognition for a health system–based DPP and the extent of the reach for these programs.

Limitations

There are limitations to our research. Our findings are based on a small number of interviews. However, the selected stakeholders represented a wide variety of professional perspectives and provided in-depth insights into the implementation of MDPP at KPNW. We were unable to interview the broker that KPNW selected to connect patients with MDPP sites. This interview could have furthered our understanding of the referral process. As an integrated health care delivery system, the challenges described here may not apply to all other health care delivery settings. However, existing research supports the findings of this case study.^11,25,27

CONCLUSIONS

The low uptake of the MDPP benefit mirrors the lack of success of earlier Medicare policies to address obesity²⁸ and suggests a need for better alignment between CMS requirements and existing incentives and infrastructures within health systems. Although the reimbursement of DPP for Medicare beneficiaries was a landmark decision, the current structure and requirements for MDPP make it difficult for health systems and community-based providers to implement and promote this benefit. This study highlights the challenges that even integrated health systems are facing to implement MDPP, as well as potential strategies to overcome these barriers and expand the reach of the program. Medicare should seek ways to increase the financial incentives and decrease the barriers associated with MDPP.

Author Affiliations: Center for Health Research, Kaiser Permanente Northwest (IG, AF, DP-T, SLF), Portland, OR.

Source of Funding: This study was supported by the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (award No. 1R01DK115237). The views presented here are solely the responsibility of the authors.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AF, SLF); acquisition of data (AF); analysis and interpretation of data (IG, AF, DP-T); drafting of the manuscript (IG, DP-T, SLF); critical revision of the manuscript for important intellectual content (IG, AF, DP-T, SLF); obtaining funding (SLF); and administrative, technical, or logistic support (DP-T).

Address Correspondence to: Inga Gruß, PhD, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Ave, Portland, OR 97227. Email: inga.gruss@kpchr.org.

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