With Medicare preparing to reimburse for the Diabetes Prevention Program in January 2018, companies are forming or expanding to make this evidence-based program scalable to reach 86 million people with prediabetes.
When HHS announced that Medicare would soon pay for the National Diabetes Prevention Program (DPP), it was welcome news for thousands of community groups looking to expand programs or offer DPP for the first time.
Offering the DPP to at-risk adults is one thing, however. Billing Medicare is something else entirely.
Bringing DPP to the 86 million Americans with prediabetes will take solutions in scalability, and several digital providers are gearing up to do so. But this format is not for everyone. To make billing seamless for community providers—whether it’s a local recreation center or an established force like Weight Watchers—a new entity, Solera Health, is ready for a revolution in healthcare delivery.
Solera is an “integrator,” a company set up to handle all the “back office” chores that could overwhelm the staff of a small provider. In an interview with The American Journal of Managed Care, founder and CEO Brenda Schmidt said Solera is ready to meet CMS requirements for electronic claims, auditing, fraud prevention, and compliance with the Health Insurance Portability and Accountability Act (HIPAA). By doing so, she said, “We let the DPP providers do what they do best, which is deliver the program.”
Last month, CMS proposed rules for billing Medicare for DPP, which call for every provider to have an individual number, along with scores of other technical requirements. Providers can start to register January 1, 2017, while reimbursement will start January 1, 2018. Solera is one of several companies that have formed or grown in recent months to make DPP scalable.
Filling a Need. The National DPP, run by the CDC, is a behavioral change program found to reduce the risk of progression to diabetes by 58%. A 2013 study published in The American Journal of Managed Care confirmed the program’s clinical value and cost-effectiveness over a 10-year period. A pilot run through the YMCA saved Medicare $2650 for every participant over 15 months. Although many employers now cover DPP, scores of small providers have developed programs without payer coverage—or any of the health IT or compliance procedures that come with it.
“Those delivery organizations were primarily non-clinical, non-credentialed providers,” said Schmidt, who spent years working with employers to offer lifestyle intervention programs. Without the small providers, DPP would never reach everyone who might benefit. Yet for these groups, learning to bill Medicare would be akin to learning a foreign language. “Those two worlds have a difficult time intersecting,” Schmidt said.
Solera was created to be a single point of contact, to deal not only with Medicare but also with other health plans. The business model calls for community groups to access Solera’s software for free; the integrator will submit claims to Medicare and retain a percentage of billings before paying the provider. Health plans can use the platform to contract with a single entity, instead of dozens or hundreds of small providers. Thus, Schmidt said, the DPP can remain the “high access, low cost” program that has made it successful so far.
Off-loading all these tasks could make the difference in whether community providers could bill for DPP, Schmidt said. For some, “The administrative burden would be so high it would limit access.”
The company formed in November 2015 and has raised $7 million in venture capital in 2 rounds of funding, the most recent in June 2016. Key partnerships include an agreement with Weight Watchers to offer the weight-loss company’s prediabetes program to Solera’s healthcare clients.
Matching Patients and Programs. Solera’s analytic capabilities can help both patients and physicians find a DPP outlet that will work best, Schmidt said. While the original DPP was based on in-person education, other platforms, such as Omada Health or Canary Health, have developed that offer a hybrid of digital instruction with personal coaching. Today, Schmidt said, about half of DPP participants use community organizations and half use a digital provider.
“We want to get the (health plan) member to the DPP provider that will best meet their unique needs and preferences,” she said. “That’s huge for the physician,” whom Schmidt said will be able to refer a patient to Solera’s website to find a good match.
This is especially important for men, because so far the successful DPP participants are 81% female, Schmidt said. “There is a huge opportunity for better delivery of DPP in men,” she said.
Big Data Capabilities. The company’s use of electronic health records (EHR) and algorithms developed at the University of Michigan can allow payers to find those enrollees who are likely to be prediabetic and get them into DPP. Solera also helps health plans comply with anti-fraud measures. “We’ve built out the predictive analytics” to spot potential fraud, Schmidt said, and the company also uses data sampling and site visits to prevent abuse.
The use of an integrator to make low-cost community providers part of healthcare delivery has potential beyond diabetes, and beyond prevention, she said. The model could be used to help prevent falls among the elderly, to aid cancer survivorship, and to increase the level of advanced care planning.
For now, however, there’s the opportunity to someday reach millions at risk of diabetes, which today affects 29 million Americans. Schmidt hopes that in 2017—even before Medicare reimbursement—250,000 people will take part in the program.
“DPP is in its infancy,” she said. “It’s really, really exciting.”