The Obama administration set in motion a process that called for Medicare to pay for the Diabetes Prevention Program starting January 1, 2018.
Experts are still deciphering what President Donald J. Trump’s executive order to ease the regulatory “burdens” of the Affordable Care Act (ACA) will mean while Congress works to repeal the law. But one area that quickly drew scrutiny was the order’s effect on the National Diabetes Prevention Program (DPP), which targets Americans with prediabetes and is set to launch in Medicare on January 1, 2018.
Rolling out DPP to America’s seniors was a signature project of the Obama administration—it took advantage of the ACA’s waiver process to put federal dollars behind a program to prevent disease, with the potential to save taxpayers a fortune. Today, 1 in 4 Medicare beneficiaries has diabetes, costing Medicare $42 billion a year. That’s roughly a sixth of the $245 billion annual cost burden of the disease, when one includes all healthcare costs and lost productivity.
Former HHS Secretary Sylvia Mathews Burwell announced in March 2016 that Medicare would fund DPP after the department’s actuary showed it would save $2650 per enroll after 15 months, based on a demonstration project with the YMCA. A final rule adopted in November spelled out eligibility criteria but left open the reimbursement details, as CMS has struggled to figure out how to include digital providers. Most experts agree digital providers need to be part of the picture if Medicare DPP is going to reach all who need it. How Medicare would pay for DPP was to be CMS’ project for 2017.
Except, the executive order—and a potential repeal of the ACA—put Medicare DPP at risk. As a newly formed Council for Diabetes Prevention warned, the ability of CMS to offer DPP to Medicare beneficiaries hinges on the waiver provision in the law. Brenda Schmidt, CEO of Solera Health and acting president of the Council, said in a statement to The American Journal of Managed Care (AJMC) that backstops are necessary “if Congress decides to repeal or sunset the HHS Secretary’s innovation waiver authority under 1115A.”
Schmidt, whose company is poised to provide technological and administrative services to community DPP providers, said 2 specific steps are needed in a budget reconciliation bill that would undo the ACA:
In her statement, Schmidt said that an ACA repeal would “inadvertently end 2 vital programs for the 86 million Americans—including 22 million Medicare beneficiaries—at risk for developing type 2 diabetes.” Not only would Medicare’s launch of DPP be jeopardized, but the National DPP within CDC would also be at risk.
AJMC was awaiting a response from CMS at press time.
While Schmidt’s statement assumes the effect of repeal on the DPP is not intended, not everyone is so sure. Jeanne Lambrew, PhD, senior fellow at The Century Foundation and the former deputy director of the White House Office of Health Reform under former President Barack Obama, wrote that the executive order’s call to eliminate “regulatory burdens” might provide a new opening for the pharmaceutical industry, which sought to derail Medicare DPP in the rulemaking process.
Lambrew reminded readers how drug makers criticized the DPP rule, saying it was based on preliminary evidence. “The program does not start until 2018, and could be rolled back through rulemaking to ‘relieve burden’ on the pharmaceutical industry by allowing it to continue to make higher profits.”
Also, she wrote, Trump’s nominee to head HHS, US Representative Tom Price, R-Georgia, is a critic of the Centers for Medicare and Medicaid Innovation, which ran the DPP pilot. On the flip side, the nominee to run CMS, Seema Verma, “has made a career of consulting for states to create flexibility by securing Medicaid demonstration waivers.”