What the proposed rules say about ensuring access to all Medicare beneficiaries who need to avoid diabetes.
In July, CMS issued its annual Physician Fee Schedule, which included a “Proposed Expansion of the Diabetes Prevention Program (DPP) Model.” This is the first step toward providing the DPP to millions of our nation’s seniors with prediabetes, and the beginning of a new era in chronic disease prevention for America.
For years, the medical community has struggled with questions about the effectiveness of the DPP, an interventional approach based on National Institutes of Health (NIH) research delivered primarily by non-clinical, non-credentialed community organizations and digital DPP providers. The DPP was authorized by Congress, and propelled forward by a public-private partnership with the CDC, community-based non-profits, and the private sector. Today, with ample evidence that DPP programs help prevent or delay the onset of full-blown diabetes in people at risk, and by doing so, save money, the answer is unquestionably yes—it works. Now, the question facing policymakers and all those who want the DPP to succeed is: how do we make sure that all Americans, including our seniors, have access to the program?
The new CMS proposed ruling represents a good start in answering that question. Some of the key tenets of the proposed DPP ruling include:
Referrals: The CMS proposes to allow beneficiaries to participate by “self-referral, community-referral, and healthcare practitioner-referral.”
Curriculum: The CMS proposes using a 12-month CDC-approved DPP curriculum, with 16 core sessions over 16-26 weeks, with the option for monthly core maintenance sessions after 6 months. CMS furthermore proposes that those who successfully complete the yearlong program and maintain the minimum weight loss, be eligible for additional monthly maintenance sessions.
Reimbursement: The CMS proposes a reimbursement table using a pay-for-performance model, linking payment with number of sessions attended and achievement of weight loss goals, as attested and documented by DPP providers. Documentation should be detailed and kept for 7 years, including status, sessions attended, coaches, date and place, and weight, and comply with HIPAA and all privacy laws. CMS requests feedback on the payment structure and guidance on the technical infrastructure to meet these requirements and other regulatory obligations.
Choice of DPP Provider: The CMS recognizes the importance of patient choice to select the DPP provider that best meets each individual’s unique needs and preferences. CMS requests guidance on quality metrics for public reporting that benchmark DPP performance to support member choice.
There are certainly other issues that need to be further vetted and modified before this ruling is finalized. One large concern is that many of the DPP providers recognized by the CDC are non-clinical and non-credentialed and could not meet the CMS compliance and regulatory requirements to provide DPP services to Medicare members. The fact is, one of the most compelling aspects of the DPP program is that it is delivered by hyper-local community organizations with lower-cost trained lifestyle coaches, so we need to find a way to ensure that these non-traditional programs can be available to the Medicare population. To improve the maximum number of lives and save the maximum amount of precious healthcare dollars, we need to work together to scale this program across the country by leveraging these community organizations and digital DPP providers recognized by the CDC. The challenge is that the majority of these organizations lack the technology and infrastructure necessary to meet the rigorous Medicare documentation, compliance and reporting requirements to prevent and detect fraud, waste and abuse and protect patient privacy.
Another concern is whether the proposed administrative burden would have an adverse impact on access. Complying with “high risk” supplier regulations and statutes, requiring all coaches get NPI numbers and enroll in Medicare, complying with HIPAA and patchwork of privacy laws, auditing and reporting requirements, and other new mandates on top of the already paperwork-heavy DPP, may be too much. Alternative quality metrics and oversight must be considered in order to create an environment that is conducive to sustainability and nationwide scalability.
One solution is to use centralized DPP integrators that can network the diverse ecosystem of DPP providers nationwide to support member choice and ease of referral for all healthcare providers, and can also manage the compliance and data privacy and security requirements proposed by the CMS. These DPP integrators would help bridge the gap between Medicare patients who qualify for the DPP, health plans that want to offer it, and the thousands of community and digital DPP providers currently offering the program. This model would empower people who qualify for DPP with a choice of programs, either in their community or online, ensuring that they find one that best fits their lifestyle and needs.
America needs to be ready to meet the challenge presented by its 86 million people with prediabetes. Access, quality, and choice will be critical to the future success of the program. How this DPP Medicare benefit is implemented sets an important precedent for leveraging community organizations and digital providers in our healthcare system as an adjunct to primary care, and we need to walk this path together to get it right before 2018.