Medicare Diabetes Prevention Program: Why has its promise not been fulfilled?

The Medicare Diabetes Prevention Program (MDPP) is a milestone for innovation. First, it was the first Center for Medicare and Medicaid Innovation (CMMI) model test that was expanded as a standard benefit in the CMS 2018 Physician Fee Schedule. Second, it was the first program model that used non-clinically trained coaches and community health professionals to deliver value-based care that is reimbursed based on health outcomes. Third, MDPP directly addressed one of the biggest causes of Medicare costs through prevention. In 2017, when CMS expanded the model, more than 50,000 recipients were estimated to use the benefit and would generate an estimated $ 10 million in savings in 2021 (82 Fed Reg. 33950, 34188 (July 21, 2017) from reduced utilization. Theoretically) , with broad really broad enrollment in the program (considering that nearly 1 in 3 Medicare recipients could qualify for MDPP benefits), savings can reach tens of thousands of billions of dollars over time.

But there was a critical limitation. When CMS extended the CMMI model, it failed to include telehealth providers as MDPP providers and only allowed personal visits to be eligible for reimbursement – although the actuarial certification for CMS cost savings included all CDC-recognized DPP providers, which include telehealth providers that meet the CDC’s strict criteria.

Missed opportunity

We raise this concern after seeing the great potential of the DPP up close. One of us, Savage, leads the privacy and regulatory efforts at Omada, a provider of telehealth diabetes prevention services. One of us, Sanghavi, oversaw the DPP expansion at CMS during the Obama administration, and is the top doctor for Babylon, a global tech-enabled healthcare provider.

We believe that by refusing to include video and virtual DPP in the Medicare program CMS, telehealth was simply too likely to encourage billing abuse, and therefore was excluded from the initial expansion. But CMS has never actually directly addressed or discussed program integrity with video and virtual DPP providers, even though such providers already serve hundreds of thousands of patients a year through contracts with commercial insurance companies that apply the same anti-fraud standards.

As a result, an important option for prevention has been overlooked. As reported by Harris Meyer in Health mattersDue to low reimbursement rates, complex regulatory requirements and the exclusion of highly scalable digital providers from MDPP, very few people benefit from the program. By March 2021, only 3,300 recipients had used the program – although an estimated 29.5 million classic Medicare members have pre-diabetes. This short-sightedness has left one of Affordable Care Acts’ key tools unused and on the shelf. Commercial insurance companies and Medicare Advantage plans, on the other hand, jumped at the chance, and some digital DPP providers saw explosive growth. For example, in 2021 alone, Omada delivered DPP to over 100,000 individuals. While traditional Medicare recipients suffer from undercutting, commercial insurance companies like Cigna report saving an average of $ 972 per person net over two years, and self-insured employers do the same, reporting savings of over $ 1,000 in the first year.

Where MDPP is today

Below, we illustrate some of CMS’s most important MDPP design choices that potentially restricted access to MDPP for Medicare members. These choices can also exacerbate health inequalities, contrary to the Biden administration’s stated goals for Medicare.

Appendix 1 illustrates the lack of physical location-based MDPP providers in certain states and large urban areas with a majority or majority of non-white populations – these states and large cities had no physical DPP providers according to the CMS 2021 report.

Appendix 1: Lack of MDPP providers affecting selected regions and populations

Note: * Medicare population estimate for metropolitan area based on ADA rates of prediabetes applied to city population data per capita. U. S Census

Sources:

[1] RTI International, “Evaluation of the Medicare Diabetes Prevention Program – First Annual Report,” March 2021

[2] CMS. Research Data Assistance Center

[3] Calculated using data from Diabetes.org

[4] 2020 census data

Appendix 2 illustrates how the lack of access to DPP from traditional Medicare can affect minority populations disproportionately, as pre-diabetes is more prevalent among non-whites, according to the Centers for Disease Control and Prevention. The incidence of diabetes in non-white populations is 20-100% higher than in whites.

Appendix 2: Diabetes rates by race / ethnicity

Source: National Diabetes Statistics Report, 2020

Taken together, these factors have led to a surprising difference in the inclusion of MDPP under the existing CMS programs. As of the March 2021 evaluation report, 72% of the total of 3,308 people who had signed up were white women. In recognition of this challenge, the CMS concluded in its own drafting of rules on the MDPP: “[If] we are not doing anything, we will not be able to scale MDPP as intended. “

The political choices that led to the current situation

The CDC recognition program does not place digital providers in a separate provider category, and CDC fully recognized programs, whether virtual or personal, deliver similar results to patients. As a result, the original CMS message that the model would cover included CDC-recognized DPP programs broadly. Specifically, the 2016 report from the CMS actuary indicated that “Based on evidence from evaluations of [DPP programs] and independent modeling of savings forecasts … an extension of this considered DPP would not result in an increase in spending. “The chief actuary’s letter goes on to detail the specific protocol he certified, which included” programs recognized by the CDC’s Diabetes Prevention Recognition Program (DPRP ). “

But when CMS expanded the model, it excluded virtual / telecom providers to beneficiaries, and instead, in its final rule from 2018, it proposed another model test of virtual DPP, which it has never implemented. Furthermore, CMS actually deviated from what CMMI tested, imposing new program requirements that were not actually tested, as illustrated in Table 3 below. As a result of divergent program rules, any company wishing to offer DPP to both persons under 65 and to Medicare recipients will need to administer two programs. For example, the original test for a 1-year program was; The extension of the CMS was a two-year program. According to the YMCA, the organization that sponsored the first CMMI test of DPP, for the community-based organizations that make up the majority of personal DPPs, “the challenge of managing two separate programs of community organizations was a deterrent to many qualified organizations from to become MDPP vendors. “

As a result, we have an almost insurmountable supply of DPP to Medicare recipients amid a nationwide, competitive market for DPP services for people under the age of 65, serving hundreds of thousands annually.

Appendix 3 highlights some of the most significant ways in which the CMS MDPP program deviates from the CDC Full Recognition standards, based on analysis submitted to the CMS by the Diabetes Advocacy Alliance in its commentary on the 2021 proposed physician fee plan.

Appendix 3: Key Differences Between Diabetes Prevention Programs

Source: Authors’ analysis.

It is five years since the extension of the MDPP model was made official and 3 and a half years since it came into force in April 2018. Since then, advocates ranging from the YMCA in the US, the American Diabetes Association and the American Medical Association to Omada have all repeated times raised these discrepancies with the CMS. CMS, on the other hand, has repeatedly said that it can not deviate from the tested model (in YMCA buildings), even though Table 3 shows just such deviations. We do not think it should be so. Indeed, given that the CDC already sets standards for recognition based on documented clinical results (page 15 of the 2021 DPRP Guidelines), and given the fact that the CMS Actuary certified a model test using CDC criteria, not the two -year CMS program shown in Table 3, we do not understand at all the need for differences between the two programs. Given that CDC fully recognized DPPs serve hundreds of thousands annually, while CMS has earned less than 4,000 since 2018, one cannot help but conclude that CMS divergence from CDC program design causes low enrollment in a health-enhancing benefit.

In fact, there are a few things CMS could do right now to fulfill the promise of this first extended CMMI model.

First, it should allow any fully-recognized DPP to apply to become a Medicare provider even under current MDPP rules. These rules include the category of “high fraud” and other strict program integrity rules to protect public finances. Under these rules, MDPP providers are subject to Medicare’s highest level of program integrity control, a level much higher than that of physicians, nurses, and other qualified health care professionals. We suggest that these rules already offer protection to limit concerns about inappropriate billing. In fact, a bill on two comrades, the Prevent Diabetes Act (HR 2807 (Rice / DeGette) / S 2173 (Scott / Warner)) would do just that: require the CMS to allow any CDC fully recognized DPP to apply to serve Medicare beneficiaries, and all other program rules apply.

Second, the CMS could return the model to match the clinical eligibility criteria and program duration established under the CDC DPRP standard. For example, this would allow people to qualify without having to take an HgbA1c test, which Medicare does not cover.

Third, the CMS should cover all HgbA1C testing without patient co-payment or co-insurance. This approach would be consistent with the USPSTF’s Grade B Diabetes and Pre – Diabetes Screening Assessment, which under the Affordable Act indicates that when offered, the screening should not incur any cost to a member.

Future opportunity

Medicare released the pre-publication version of its final doctor fee plan for 2022 on November 2 (the official copy is scheduled to be released on November 19) with effect from January 1). We now know that while CMS has completed a few changes to its program, it has not fully adapted MDPP to the CDC program. Although CMS prospectively reduced the duration of the program to 12 months and allowed an exemption from application fees, CMS maintained its idiosyncratic clinical eligibility rules, including the glucose test it does not pay for, and it did not allow any organizations that provided DPP through video or virtual means to apply about being suppliers. As reported by Harris Meyer, the CMS did not do as much as possible to correct the MDPP undersupply. Although it is too late for further rule-making for 2022, there is bipartisan interest in a legislative solution through the Diabetes Prevention Act (HR 2807 / S2173), and we hope it will be part of the conversation when management prepares a year-end package.

The opportunity is now. We hope the politicians take it.

Authors’ notes:

Lucia Savage is an executive at Omada Health, which provides virtual first aid for people with diabetes, hypertension and to prevent diabetes, as well as virtual first physiotherapy. Ms. Savage joins Omada Health in the Diabetes Advocacy Alliance, which has supported Medicare in adapting its DPP to the program overseen by the CDC. Darshak Sanghavi is a full-time Babylonian, providing technology-enabled healthcare across the globe, and former senior CMMI / CMS leader who helped oversee the DPP expansion under the Obama administration.

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