Senators Ask CMS to Change Course on Virtual Medicare DPP

October 31, 2019
Mary Caffrey
Mary Caffrey

The 19 signers of the letter to HHS Secretary Alex Azar and CMS Administrator Seema Verma include Senate Finance Committee members and lawmakers from states with high rates of diabetes and obesity.

More than a year after the low-key launch of Medicare’s diabetes prevention benefit, a bipartisan group of US senators wants CMS to rethink its resistance to letting seniors take the yearlong program online. They say the shift would let health plans reach many more people, including those in rural areas hard hit by the disease.

The letter could rekindle debate over how to deliver the Medicare Diabetes Prevention Program (DPP), a 16-session intervention some hoped could be a game changer in government spending on diabetes. Of the extra $42 billion that Medicare spends on diabetes, CMS projected $180 million in savings from avoided costs once the program was up and running.

Led by US Senators Tim Scott, R-South Carolina, and Mark Warner, D-Virginia, both members of the Finance Committee, the 19 signers of a letter to HHS Secretary Alex Azar and CMS Administrator Seema Verma, MPH, include longtime diabetes advocates Senators Susan Collins, R-Maine, and Jeanne Shaheen, D-New Hampshire; other signers include lawmakers who hail from states with high rates of type 2 diabetes (T2D) and obesity, such as Senator Shelley Moore Capito, R-West Virginia, and both senators from Mississippi, Republicans Roger Wicker and Cindy Hyde-Smith.

“A Medicare beneficiary’s access to this life-improving program should not, and cannot, be determined solely by the ZIP code in which he or she lives,” the letter states. “Furthermore, lack of access for eligible beneficiaries has the potential to not only depress enrollment, but also to reduce potential cost savings.”

Medicare DPP grew out of a 2002 study by the National Institutes of Health that found a specially designed lifestyle intervention—with support—could help people with prediabetes reduce their risk of developing T2D by 58%; among those aged 65 and older, the reduction was 71%.

A recent report by POLITICO, which commissioned a claims analysis by open data startup CareJourney, found that only 202 beneficiaries enrolled in the program in 2018. The report also found large areas of the country not covered by a Medicare-qualified supplier, despite the presence of DPP providers who meet CDC criteria, which commercial plans and employers look to for guidance.

The senators addressed these geographic gaps in their letter: “CMS has done outstanding work developing online resources to show where [Medicare] DPP suppliers are located, but these resources make clear that there are geographic regions where eligible beneficiaries lack access to a qualified supplier.”

CMS declined comment on the POLITICO report. The American Journal of Managed Care® spoke with several sources familiar with the DPP program; while it is possible that suppliers may be slow to submit claims and the 2018 enrollment numbers will rise, it seems unlikely that total enrollment will reach early-year projections of 50,000 participants when CMS issues its fall 2020 evaluation report.

Indeed, in the weeks after the April 2018 launch—which came and went with no fanfare from CMS—Verma wrote a blog post calling for qualified DPP providers to sign up to become Medicare suppliers. This came as there were rumblings that burdensome regulations had turned off the community groups that had long formed the backbone of the program.

During the regulatory comment period, health industry veterans and groups like the American Association of Diabetes Educators had predicted problems: CMS had designed a program that didn’t pay enough to allow small nonprofits to break even, given the administrative headaches. And the class that might be able to scale to meet those challenges—the online or “virtual” providers—were excluded, except to offer make-up sessions.

Since that time, the number of Medicare suppliers has increased to at least 640, according to a list on the CMS website. However, a check of the site shows that the distribution doesn’t necessarily match need; for example, there are no suppliers within 100 miles of New Orleans, despite the obesity rate of 39% for those aged 50 to 64, the group approaching eligibility for Medicare.

Mississippi offers a particularly interesting case, because the state is a national leader in telehealth and in the use of tools such as iPads to help high-risk patients with T2D avoid repeat hospitalizations. State laws require insurance coverage for telemedicine in both commercial and employer plans. While virtual DPP and telehealth are not the same, the state’s embrace of technology-driven care and its diabetes burden suggest strong opportunities for online providers. But a map of qualified Medicare DPP suppliers shows that the state’s Gulf Coast residents must drive to Milton, Florida, for the closest supplier.

High Hopes Under Obama. After the Affordable Care Act passed, the Center for Medicare and Medicaid Innovation tested the DPP in the Medicare population, and in 2016 then—HHS Secretary Sylvia Burwell announced it had produced sufficient savings that CMS would develop rules to cover a preventive benefit—a revolutionary concept for Medicare. But creating regulations to bring a program that had been delivered by nonclinical providers in YMCAs and churches proved quite a lift for CMS, and some say the turnover that came with the change of administration did not help.

In the meantime, a group of digital health providers sprung up to deliver the program through commercial health insurers and employers, and by 2015 they were being certified by CDC as meeting the same standards as the traditional, in-person providers. So, after working alongside the Obama administration to develop the concept of scaling Medicare DPP for the masses, the virtual providers were stunned when the 2017 regulations left them out of the reimbursement picture.

The senators’ letter goes on to state that “virtual suppliers could empower these beneficiaries with feasible options for preventive, value-based care.”

Asked to comment on the senators’ letter, Adam Brickman, senior director of Strategic Communication for Omada Health, said, “Whatever the exact number of enrollments, it is clear that the Medicare Diabetes Prevention Program isn’t reaching as many eligible beneficiaries as it could. This is especially true of individuals living in rural or suburban communities, which are significantly less likely to have access to an in-person MDPP supplier.”

“Enabling virtual providers to deliver MDPP is one of several, concrete solutions CMS could take in order to ensure more people engage with MDPP and improve their health,” Brickman continued. “We’re gratified to see that a bipartisan group of senators, led by 2 members of the Finance Committee, agree. We look forward to working with members of Congress, as well as CMS, to ensure we are empowering Medicare beneficiaries with the preventive care that suits their lives, delivers results, and saves taxpayers money.”