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CMS Expands Promising Medicare Diabetes Prevention Program

CMS will provide reimbursement for chronic disease management through the Medicare Diabetes Prevention Program in 2018.

Chronic disease management for diabetes

Source: Thinkstock

By Jennifer Bresnick

- CMS has announced a final rule expanding the availability of the Medicare Diabetes Prevention Program (MDPP) starting in 2018. 

The model, which pairs a classroom-style support group with CDC-approved patient education guidelines, has undergone several successful pilots resulting in better chronic disease management for diabetes patients.

Participants in the MDPP must undertake a four-month program of weekly meetings for education and coaching, followed by six months of monthly maintenance check-ins to ensure adherence to healthy lifestyle choices.

Under the 2018 Physician Fee Schedule (PFS), providers will receive Medicare reimbursement for delivering these services to eligible patients.

The changes aim to control the skyrocketing costs of diabetes management by preventing the development of the disease in high-risk or pre-diabetic patients. 

“We estimate that Medicare spent $42 billion more in the single year of 2016 on beneficiaries with diabetes than it would have spent if those beneficiaries did not have diabetes,” says CMS on the MDPP website.

“Per-beneficiary, Medicare spent an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services, and $2,700 more in physician and other clinical services for those with diabetes than those without diabetes (estimates based on fee-for-service, non-dual eligible, over age 65 beneficiaries).”

MDPP, a relatively low-cost initiative for providers to bring to their communities, has shown potential to reduce spending while improving outcomes for patients.

In March of 2016, HHS noted that individuals who followed the program reduced their body weight by around 5 percent while lowering their spending by $2650 per patient over 15 months.

“The Diabetes Prevention Program can prevent disease and help people live healthier lives,” said former CMS Deputy Administrator and Chief Medical Officer Dr. Patrick Conway.

Patients who attended more sessions saw higher amounts of weight loss, the pilot program also revealed.  Weight loss is a primary outcome measure for the program, indicated an accompanying fact sheet, and will impact reimbursement rates.

“The final payment structure values beneficiary weight loss most significantly, as weight loss is a key indicator of success among individuals participating in a DPP due to the strong association between weight loss and reduction in the risk of type 2 diabetes,” CMS said.

“The final payment structure also values beneficiary attendance throughout the first year core services because, in the DPP model test, session attendance was associated with greater weight loss. Suppliers will receive payment for beneficiaries who attend at least two out of three monthly sessions within a core or ongoing maintenance interval, given other payment requirements are satisfied.”

Providers whose patients do not meet the requirement minimum weight loss goals will receive lower reimbursement rates during the maintenance internal, and will lose out on $160 per patient who achieves the 5 percent weight loss threshold.

If a patient meets all of the program’s goals, including a bonus metric of 9 percent weight loss, each individual could bring $670 to the healthcare organization. If a patient fails to meet the 5 percent weight loss goal, but attends all sessions, he or she will help accrue a $195 reimbursement for the provider.

Providers will have to meet with their Medicare patients in person, however, as the PFS does not include reimbursement for services conducted remotely or through telemedicine tools.  The decision has disappointed telehealth advocates, who view the high-impact coaching program as a prime use case for expanding access through remote care.

CMS has indicated, however, that a telehealth-based version of the MDPP may become a Center for Medicare & Medicaid Innovation (CMMI) demonstration project in the future, allowing providers to reach more patients more easily.

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