How Technology Can Make CMS' Diabetes Prevention Program Viable

April 1, 2018, will mark the beginning of the Medicare Diabetes Prevention Program (MDPP).¹ In theory, this should be unalloyed good news. After all, the National DPP has been shown to lower diabetes risk by 71% for those 60 years or older at high risk.² With more than two-thirds of seniors in the high-risk category, the potential benefits in both human welfare and Medicare costs are enormous. Specifically, a DPP pilot led by the YMCA found the program saved $2650 per Medicare beneficiary.³ However, that potential will be reached only if the program is made available in a manner that meets the diverse needs of different subpopulations and if program providers can deliver the program in a financially feasible manner.

Unfortunately, as was well documented by AJMC.com earlier this year, the rules ultimately adopted by CMS could well cause the program to fall short on both fronts.^4,5 First, the lack of coverage for virtual delivery means diabetes prevention will be a realistic option only for people who live near an in-person program and who have the time, inclination, and travel resources to attend about 2 dozen DPP sessions in the first year. CMS intends to run a pilot study to determine whether virtual programs can deliver health outcomes comparable with those of in-person DPPs. But as many comments filed with CMS pointed out, several virtual programs have already demonstrated such ability in the required outcomes data submitted to the CDC. Importantly, while the pilot is conducted and evaluated, thousands of people who need education and support to avoid developing diabetes will go unserved.

Many operational and compliance requirements, such as the need for all MDPP lifestyle coaches to have a National Provider Identification and the necessity to provide an additional 2

years of maintenance sessions for each program group, will make it difficult for program providers to cover their costs.

Perhaps the greatest challenge stems from the reimbursement model CMS chose, which allocates a much higher percentage of total reimbursement to weight loss than has been the case in commercially insured programs. This will produce truly perverse motivations—providers may lose incentive to serve some of the populations who most need the program if that population’s average weight loss has historically been below the 5% threshold required for most of the MDPP reimbursement. For example, African American women could face trouble finding programs because of lower-than-average weight loss in the DPP.⁶

Instead of reimbursing based on weight loss, particularly on weight loss in terms of outcomes-based remuneration, CMS could shift some of the reimbursement to validated attainment of the DPP’s physical activity targets. Although several studies have demonstrated that physical activity can improve insulin sensitivity and thereby lower glucose levels,⁷ DPP providers are not reimbursed for helping participants achieve the physical activity targets and therefore may focus on it less than they could. Moreover, given that so many people have trouble losing weight and can easily get discouraged and quit, providing another metric that could help patients envision their own progress could improve long-term attention.

While fully digital programs will not be covered by the initial MDPP, digital tools can nevertheless play a crucial role in addressing, at least partly, many of these challenges. The key is to focus on digital as an adjunct, rather than an alternative, to in-person program delivery.

The most obvious area where digital tools can help is with missed sessions. MDPP participants must attend 9 sessions in the first 6 months to remain enrolled and for DPP providers to even have the opportunity to earn a weight loss—based reimbursement. This makes sense given that, on average, participants who attend more sessions tend to lose more weight and keep it off longer. Specifically, for every additional session attended and every 30 minutes of activity reported, participants lose 0.3% of body weight. However, attending 9 sessions in person at preset times is not a practical reality for many participants (Table).

Fortunately, CMS is allowing up to 2 of those missed sessions to be made up “virtually.” While virtual delivery encompasses a variety of options, the most convenient choice for most participants and the most efficient for lifestyle coaches, is one in which the participant self-navigates an online version of the session at their own pace. HealthSlate8 and Solera Health,⁹ for example, partnered over a year ago to enable such a model through the SoleraONE platform for in-person DPP providers.

Another key way in which digital tools can contribute is by helping participants stay connected with one another and with their coaches between sessions. The Group page of the many DPP apps, including SoleraONE, typically offers a Facebook-like experience in which participants cheer one another’s success and remind fellow participants of the upcoming class. This is particularly valuable in the MDPP model, in which participants are expected to continue attending classes over a 3-year period.

Given the ability of physical activity to lower glucose, digital tracking of steps—whether by an app on the phone or a Fitbit-style tracker—could greatly improve participants’ outcomes, both directly and in self-perceived progress. Such digital step tracking is still not the norm in most in-person DPPs.

Perhaps the most significant contribution digital technologies can make to the MDPP is vastly improving our understanding of what’s actually working and what isn’t. Regardless of whether someone participates in person or virtually in a DPP session for 1 hour each week, their success is largely dependent on what they are doing during the other 167 hours of that week. By encouraging all MDPP participants log meals and weight via a mobile app, and having that app automatically track their steps, we provide lifestyle coaches with the data, insights, and tools to spot when participants are going off track and make it possible to intervene before it’s too late. This tracking is further enriched, of course, when participants have an activity tracker such as a Fitbit or a connected scale, which prevents data entry errors in the logs by the participant and automatically uploads the data.

While lifestyle coaches can use digital tools to spot trends at the individual and small-group levels, companies like HealthSlate and Solera can analyze large data sets at the population level to answer questions like “Who is enrolling, and who isn’t?” and “Who is succeeding and who isn’t?” and “Why?” Advanced statistical techniques and machine

learning algorithms can then be applied to this work, allowing continuous improvements in the delivery model.

All of this is standard operating procedure for digital vendors, but it is far from standard for in-person programs. Today, in-person DPPs remain largely operated, analyzed, and accredited in the same manner as they were before smartphones were invented. While Solera and HealthSlate are already empowering many in-person DPPs with digital tools, the national uptake of available technology is not happening fast enough. The missions of the MDPP and the National DPP would be well served if the CMS and CDC were to more aggressively promote, or even require, use of digital tools by in-person DPPs. Author Information

Dan Sheeran is CEO of HealthSlate LLC, a CDC-recognized provider of diabetes prevention technology, content, and coaching services. HealthSlate is based in Seattle, Washington.References

1. Fact sheet: final policies for the Medicare Diabetes Prevention Program Expanded Model in the calendar year 2018 Physician Fee Schedule final rule. CMS website. innovation.cms.gov/Files/fact-sheet/mdpp-cy-2018fr-fs.pdf. Published November 2, 2017. Accessed February 2, 2018.

2. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New Eng J Med. 2002;346(6):393-403. doi: 10.1056/NEJMoa012512.

3. Caffrey M. Medicare to fund diabetes prevention programs, Burwell says. The American Journal of Managed Care website. ajmc.com/focus-of-theweek/medicare-to-fund-diabetes-prevention-programs-report-says. Published March 23, 2016. Accessed February 15, 2018.

4. Caffrey M. CMS must add virtual providers, revamp payment for Diabetes Prevention Program. The American Journal of Managed Care website. ajmc.com/focus-of-the-week/cms-must-add-virtual-providers-revamp-payment-for-diabetes-prevention-program. Published September 12, 2017. Accessed February 5, 2018.

5. Medicare Program; Physician Fee Schedule and Other Revisions to Part B for CY 2018, 42 CFR Parts 405, 410, 414, 424, and 425 (2017).

6. West DS, Elaine Prewitt T, Bursac Z, Felix HC. Weight loss of black, white, and Hispanic men and women in the Diabetes Prevention Program. Obesity (Silver Spring). 2008;16(6):1413-1420. doi: 10.1038/oby.2008.224.

7. Bird SR, Hawley JA. Update on the effects of physical activity on insulin sensitivity in humans. BMJ Open Sport Exerc Med. 2017;2(1):e000143. doi:10.1136/bmjsem-2016-000143.

8. Solera Health announces SoleraONE mobile app to support in-person delivery of the National Diabetes Prevention Program [press release]. Phoenix, AZ: Solera Health; December 8, 2016. soleranetwork.com/solera-health-announces-soleraone-mobile-app-support-person-delivery-national-diabetes-prevention-program/. Accessed February 21, 2018.

9. Solera Integrated Health Network. Solera Integrated Health Network website. soleranetwork.com. Accessed February 5, 2018.

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