Getting Seniors to Keep Weight Off Tied to Payment Under CMS' Diabetes Prevention Plan

Details of how Medicare will deliver the Diabetes Prevention Program include efforts to prevent fraud, ensure patient privacy, and tie payment to value-based principles.

Providers offering the National Diabetes Prevention Program (DPP) would have to get seniors to show up at sessions, lose weight, and keep it off to be fully reimbursed, under a plan CMS unveiled yesterday that calls for the program to start January 1, 2018.

The proposed rule comes after HHS Secretary Sylvia Mathews Burwell announced March 23, 2016, that Medicare would soon pay providers to offer the evidence-based program. This followed a successful pilot with the YMCA, which showed participants lost weight and Medicare saved $2650 for every person who enrolled over 15 months. Burwell highlighted the proposal at an event with the American Diabetes Association in Cleveland, Ohio, yesterday.

The National DPP is a series of 16 weekly core sessions followed by monthly maintenance sessions. It is designed to produce weight loss of 5% to 7% and get participants exercising at least 150 minutes per week. The original program was delivered only in classroom environments, but CDC now recognizes digital formats. Medicare has long been interested in the DPP because it spends $1 of every $3 on diabetes care; an estimated 50% of beneficiaries have prediabetes, so reducing the share that develop diabetes would save millions.

There had been speculation that CMS would try to get DPP running by early 2017, before the Obama Administration ends. However, the proposal unveiled yesterday features several regulatory steps to ensure patient privacy, prevent fraud, and require payment based on results—all part of Medicare’s shift toward value-based reimbursement.

Key features of the proposal include:

· Providers must become CDC recognized (many already are) and must enroll in Medicare starting January 1, 2017. The plan says that Medicare envisions requiring each person who offers services obtain a national ID number. CMS is also seeking comment on IT requirements, including the provider’s ability to submit bills electronically and manage patient records.

· Payment will be tied to both the number of sessions each participant attends and achievement and maintenance of a minimum weight loss. Providers would get some initial payment after participants attend core sessions and show weight loss, with the balance coming after additional attendance and weight maintenance.

· Criteria for participation include having a body mass index (BMI) of at least 25, or 23 for Asian persons in addition to one of the following: (1) a hemoglobin A1C of 5.7% to 6.4%, (2) a fasting glucose of 110-125 mg/dL within the last 12 months or (3) a 2-hour plasma glucose 140-199 mg/dL after the 75 g oral glucose tolerance test. Participants cannot have a prior diabetes diagnosis or mobility issues that would prevent participation.

· Fraud prevention steps will be developed, and CMS seeks comment on these.

· Availability will be both in-person and through virtual providers, but CMS is seeking comment on whether the rollout should occur in phases or all at once.

If payment for DPP starts on January 1, 2018, it will be 16 years after publication of the National Institutes of Health study in the New England Journal of Medicine, which showed the program reduced the risk of diabetes 58% over 3 years. While the study is one of the most cited in all of medical literature, Mike Payne, MBA, MSc, chief commercial officer for behavioral digital health provider Omada Health, told attendees at Patient-Centered Diabetes Care (PCDC) earlier this year that only 1% of those who could benefit from DPP have gone through the program. (PCDC is jointly presented by The American Journal of Managed Care and Joslin Diabetes Center.)

At Omada Health yesterday, Adam Brickman, director of Strategic Communications and Public Policy, said, “We’re very encouraged by the level detail and thoughtfulness,” in the proposal.

As the CMS proposal notes, this is only the second program from the CMS Innovation Center (CMMI), and the first preventive program, that meets the tests to expand throughout Medicare: it improves quality of care without limiting coverage or increasing costs. Thus, the rollout of DPP is creating a template for other programs, increasing the need for an open, deliberative process.

Already, CMMI tested the program at 17 locations starting in 2012, before the CMS actuary certified the savings level this spring. Participants had an average weight loss of 5%, and those who attended the most sessions lost more.