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Medicare Diabetes Prevention Program Offers Model for Chronic Care

The Medicare Diabetes Prevention Program is expanding, offering private payers a model for chronic disease prevention and management.

The Medicare Diabetes Prevention Program offers a model for chronic disease care.

Source: Thinkstock

By Thomas Beaton

- CMS’s Medicare Diabetes Prevention Program (MDPP) aims to address diabetes prevalence within the Medicare program, and may help other payers develop a model for chronic care, based on the MDPP’s promising initial results.

Diabetes is a pressing concern for CMS because of rising diabetes care costs within Medicare. In 2016, CMS estimated that Medicare spent $45 billion more on caring for members with diabetes than on costs for members without the disease.

Nationally, rates of diabetes and prediabetes are high. The CDC’s 2017 National Diabetes Statistics Report found that 20.8 percent of the nation’s 65 and older population has been diagnosed with diabetes and 4.2 percent have undiagnosed diabetes. The report also found that prediabetes affects nearly 23.1 million elderly adults.

CMS leaders have high hopes that the early success of the MDPP can be scaled to improve Medicare outcomes and reduce costs, which may guide preventive care efforts in the commercial payer sector.

The model first began as a prevention program supported by local and community organizations.

CMS piloted  the diabetes prevention program (DPP) from 2013 to 2015 through the agency’s Health Care Innovation Awards program. The initial program was organized through a partnership between CMS, the YMCA, and other public and private partners.

Piloting organizations hired and trained educators to teach classes focused on wellness behaviors such as healthy eating, exercise, and proper medication use. Educators taught a maximum of 24 classes each that reached 7000 Medicare beneficiaries.

As a result of the program, 45 percent of beneficiaries reached the weight loss target of 5 percent of starting body mass. Average weight loss per beneficiary equaled between five to seven pounds, which is a clinically significant measure to prevent diabetes, according to CMS.

The early success of the DPP lead CMS to develop a payment model during 2016, and the agency announced that the expansion of the MDPP would begin in 2018.

The MDPP final rule determined provider reimbursement rates, based on educational reach and  beneficiary weight loss goals, and also set guidelines for beneficiary eligibility.

Weight-loss goals, adapted from the DPP, set a minimum target of a 5 percent reduction in body mass per beneficiary. Eligible beneficiaries for the program include Medicare B and Medicare Advantage members with a body mass index (BMI) of 25 or higher.

Eligible beneficiaries also need to meet blood test requirements. They cannot have a diagnosis of diabetes before participation and cannot have end-stage renal disease.

CMS awards MDPP providers $25 for each beneficiary that attends a “core session,” or a class that teaches members about preventive care behaviors.  Providers can then earn $50 for each beneficiary that attends four classes and up to $90 for each member that attends nine classes.

CMS also awards providers a higher reimbursement amount for beneficiaries that attend two out of three “ongoing maintenance sessions.” These sessions are recurring classes that focus on critical preventive care objectives.

Healthcare organizations that get members to reach weight loss goals can earn significantly more incentives, according to the final rule.

Providers earn $160 for every beneficiary that meets the five percent weight loss goal. CMS reimburses an additional $25 if beneficiaries achieve nine percent weight loss. Physicians can earn an additional $60 per beneficiary that completes two ongoing maintenance sessions during month seven and month nine of the program.

CMS also reimburses providers another $60 per beneficiary if the individual completes ongoing sessions in months 10 to 12 of the program.

The agency will reimburse the most successful providers $670 per Medicare beneficiary for maximum performance outcomes. Providers that simply reach educational goals without weight loss requirements can earn a maximum of $195 per beneficiary.

CMS Administrator Seema Verma recently announced the expansion of the MDPP in a blog post and encouraged new community and traditional healthcare providers to participate in the model.

Participation in model will help CMS save an estimated $180 million a year related to diabetes care and decrease the number new diabetes cases within Medicare.

“Diabetes exerts an unacceptable toll on our beneficiaries, their families, and the Medicare program, which spends more than $104 billion every year treating patients with this preventable disease,” Verma said.

“The Medicare Diabetes Prevention Program is leveraging innovation to bring valuable preventive services to our beneficiaries, and I urge eligible organizations across the country to enroll today in this exciting performance-based payment opportunity.”

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