CMS Must Add Virtual Providers, Revamp Payment for Diabetes Prevention Program

A group that represents both community-based and virtual providers finds many issues with CMS' proposal for Medicare's Diabetes Prevention Program.

CMS must let virtual providers offer the Medicare Diabetes Prevention Program (DPP) when it launches next spring, a stakeholder group argued in comments submitted to CMS.

Excluding virtual providers isn’t CMS’ only problem, according to the Council for Diabetes Prevention, which responded to a July 13, 2017, proposal. The Council, representing 75 community-based and virtual DPP providers and health systems, said the proposed payment structure won’t cover costs and creates too many headaches for the grassroots groups that have made the DPP a success.

In March 2016, then-HHS Secretary Sylvia Mathews Burwell called for Medicare funding of DPP, a landmark shift to paying for a preventive service. The move recognized the growing burden of diabetes in the United States—it is estimated that 1 out of every 3 adults could have the disease by 2050, and already the disease accounts for $1 of every $3 Medicare spends. An estimated 84 million Americans have prediabetes, so stopping the progression of diabetes is considered key to slowing Medicare spending. Burwell’s announcement came after a DPP pilot with the YMCA found the program saved $2650 per Medicare beneficiary.

But the Council’s comments noted that CMS’ proposal strayed from the science and spirit of the original DPP, to the point that successful community groups that planned to serve Medicare clients may decide it’s not worth it. Providers who wish to become Medicare suppliers can do on January 1, 2018, with the program set to launch April 1, 2018.

The DPP is a 12-month, evidence-based lifestyle program with a CDC-approved curriculum; it features 16 weekly core sessions, followed by a maintenance period of monthly sessions. Evidence shows the program stops prediabetes from progressing as participants make modest changes and lose at least 5% of body weight. In a landmark study published in 2002, the program showed a 58% reduction in participants progressing to diabetes.

A copy of the Council’s comment was provided to The American Journal of Managed Care®. Among the issues it cited:

  • Reimbursement is inadequate to support program costs, in part because Medicare wants to require every coach to have National Provider Identification (NPI). Making the cost structure work could require class sizes much larger than successful programs recommend. Rather than inflate program costs with NPI requirements for each coach, the Council recommends beefing up requirements for program coordinators.
  • Besides the low payment rates, CMS ties reimbursement to an additional maintenance period of 2 years, well beyond the time frame tested in clinical trials. Council members were not opposed to a maintenance period after the initial 12-month program ends, but thought it should not be tied to reimbursement—and should, perhaps, be paid for by beneficiaries themselves. “The overwhelming perspective is that the additional 2 years of ongoing maintenance required to be provided by a Medicare DPP supplier in the proposed rule was unrealistic and excessive, creating a major burden that will be next to impossible for many organizations to realistically achieve," the Council wrote in comments.
  • The once-per-lifetime limit will be hard to enforce and is at odds with the realities of making lifestyle change, the Council argued. No guidance is offered for what happens if a senior must interrupt the program for a medical or personal reason, or how in-person suppliers deal with “snowbirds” or other life-related events. Requiring a break between attempts is reasonable, the comment stated; tobacco cessation and obesity counseling programs offer good models.

Leaving Out Virtual Providers

The Council “takes great exception” to CMS’ decision to exclude virtual providers, including several that have achieved recognition from CDC. First, the comment asked CMS to make a distinction between digital providers who offer online coaching and support and a broader group of providers who may offer help over the phone or through video conferencing. But the comment doesn’t hide the shock this group experienced when CMS’ proposal limited their participation to 4 make-up sessions:

“Assuming CMS’ stated rationale that it lacks the requisite authority, this should have been made abundantly clear in 2016 and allayed any false hopes or anticipation of inclusion,” the comment read. “If indeed authority was lacking, CMS could have initiated a virtual model expansion last year to allow for more timely guidance for virtual providers.”

In fact, the Council isn’t buying the argument that CMS lacks the power to bring in virtual providers on the first day. It argued that CDC has 2 years’ worth of data on hand, that many providers have gone through CDC’s recognition process, and they are ready to scale the program to parts of the country where no in-person programs exist. At a minimum, the Council wrote, CMS should allow virtual providers to serve beneficiaries who live too far from in-person programs, similar to the rules for telehealth.

To prevent fraud, programs can use Bluetooth or wireless scales, or beneficiaries can confirm weight loss with a primary care physician.

Sean Duffy, CEO of Omada Health, cited the original goal of saving Medicare money in his company's individual response.

"By excluding virtual DPP suppliers from the expanded model, CMS will likely fall short of its (Medicare) DPP savings goals. In the proposed rule, HHS assumed that as many as 110,000 eligible Medicare beneficiaries would participate in the program in the first year, affecting a savings of $16 million in the 9 months of 2018 in which it would be available to eligible Medicare beneficiaries. We do not believe this level of adoption can be achieved without the inclusion of virtual DPP providers because of significant gaps in the geographic availability of in-person DPP, as well as the readiness of existing, CDC-recognized in-person providers to begin delivering the program at scale in Q2 2018. Virtual DPP providers such as Omada have the unique capability to scale quickly without loss of program effectiveness or integrity — a necessity to meet the utilization and savings projections contained within the proposed rule."

Focusing on Measures That Matter

Several comments find that CMS is fixated on tasks that create red tape while overlooking measures that the Council considers predictors of success.

For example, CMS seeks outdoor signage that might be costly or impossible given local zoning restrictions. Yet suppliers are not asked to record things like number of weigh-ins per week or number of steps per day.

Overall, the Council’s comments focus on making Medicare DPP scalable. “The Council asks CMS to consider the real costs of delivering DPP, especially in rural areas and for underserved populations,” the comment stated.

Educators Weigh In

The American Association of Diabetes Educators (AADE) also filed comments, calling on CMS to create a process to test program changes to boost access, achieve clinical goals, and generate savings for Medicare. AADE is among 6 groups that has an agreement with CDC to scale the original National DPP.

“We are ecstatic that CMS has committed to moving forward with the MDPP,” said AADE Vice President of Science and Practice Leslie Kolb, “Thanks to the potential for additional coverage, the opportunity exists to help thousands avoid or delay a type 2 diabetes diagnosis. We hope that CMS will consider looking at what works for Medicare beneficiaries, like virtual online platforms, and take it into account for a final rule.”

AADE also raised concerns about the payment schedule and asked CMS to consider making telehealth a covered service interchangeable with in-person delivery.