New CMS Diabetes Prevention Program for Rural Health Introduced

A Medicare Diabetes Prevention Program (MDPP) expanded model has been proposed for the 2018 Medicare Physician Fee Schedule (MPFS). This is a lifestyle change program designed to prevent the onset of Type 2 diabetes among certain Medicare beneficiaries diagnosed with pre-diabetes.

Background

Beginning in 2018, Medicare will provide coverage services under the MDPP expanded model as a preventive service furnished in community and healthcare settings by designated health coaches such as diabetes coordinators, community health workers, and other trained health professionals. 

A Rural Imperative

Today, diabetes affects more than 25 percent of Americans 65 or older, and the numbers are expected to grow rapidly for adults in the U.S. (ages from 18-79) by 2050. The MDPP model is an imperative for rural healthcare, where there is a higher prevalence of diabetes and fewer opportunities for preventive care practices.  

Financially Unsustainable Costs

The healthcare industry and rural healthcare are desperate for a solution to help curb the costs of diabetes treatment. According to the Centers for Medicare & Medicaid Services (CMS), Medicare spent $42 billion more in one year (2016) on patients with diabetes than it would have if those patients didn’t have diabetes. Additionally, Medicare spent approximately $1,500 per beneficiary more on Part D prescription drugs; $3,100 more on hospital and facility patient services; and $2,700 more in provider services for those with diabetes. 

Model Purpose and Components

Through the expansion of this model, Medicare beneficiaries will be able to access evidence-based diabetes prevention services, which could result in a lowered rate of progression of Type 2 diabetes, create improved health/wellness/well-being, and reduce healthcare costs.

An Expanded Model

The MDPP expanded model is a structured intervention with the goal of preventing progression to Type 2 diabetes in individuals with an indication of pre-diabetes. 

National Institutes of Health (NIH) research, which provided the basis for this model, consisted of 16 intensive “core” sessions of curriculum in the form of Centers for Disease Control and Prevention (CDC)-approved session information delivered over six months. This information is delivered in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control.

Upon completion of the initial core sessions, there will be less intensive follow-up meetings, provided monthly, that will help support and enable patient participants to maintain healthy behaviors. The primary goal of the expanded model is at least a 5-percent average weight loss by participants.

Behind the Scenes

The 2017 final rule on the MPFS was published in November 2016, and it established the expansion of the model and policy elements. The 2016 MPFS proposed that policies needed to be included for suppliers providing MDPP services nationally beginning in 2018 – the supplier enrollment requirements, MDPP payment structure, and supplier compliance structure for program validity and integrity.

Model Highlights

• The original recommendation was set for Jan. 1, 2018, but now the recommendation is April 1, 2018 to allow sufficient enrollment time after the final rule.
• Additionally, eligibility originally excluded patients with a previous diagnosis of diabetes (except gestational). Now, the proposed thought is that if a patient develops diabetes during the MDPP service period, it wouldn’t prevent the patient from continuing participation in the MDPP service model.
• There is a proposed two-year limit of ongoing maintenance sessions for a total of a three-year program of services. (This is based on attendance and weight loss performance goals being met.) This would consist of one year of core and core maintenance sessions, depending on eligibility.
• It continues to be proposed that patients participating in the program must attend three sessions and maintain 5-percent weight loss at least once in the previous ongoing maintenance session interval to be eligible for additional program intervals.
• This model is a performance-based payment structure that ties payment to performance goals based on attendance and/or weight loss. 
• Since session attendance has demonstrated greater weight loss, the providers may use corresponding Healthcare Common Procedure Coding System (HCPCS) G-codes to submit claims for payment when all requirements for billing the codes have been met.
• The Federal Register includes the proposed 2018 Physician Fee Schedule, which includes several fees ranging from $25 to $160, based on programmatic elements.
• There are strict supplier standards to provide program integrity and mitigate fraud.
• Providers may provide in-kind patient engagement incentives.
• The current DPP model test doesn’t include virtual-remote or telehealth options, but the CMS Innovation Center is developing a model exclusively for virtual participation.

Key Potential Elements for Rural Participation, Sustainability and Results

1. Provision of a variety of education and program elements for interaction and learning styles
2. Expansion of telehealth models or use of other platforms for patients to gain access to attend, including expanded future broadband capabilities
3. Collaborations with public health entities, faith-based organizations, or other appropriate groups important to participants that would provide program cohesiveness, participation, and attendance, as well as build trust and rapport
4. A “buddy system” to ensure greater success and results
5. Flexibility of modules providing additional opportunities to view or repeat the information
6. Involvement of family members
7. Additional areas of concern regarding diabetes, such as food security, stress, anxiety, other behavioral factors, access to care, individual health status, support system, medication, etc.
8. A crossover of the CCM – Chronic Care Management model – and greater “healthy support”
9. Program cap at for participation/attendance?
10. Precision medicine to help as a wrap-around of services
11. Increased reliance of community health workers, providing even better support for clinicians in outreach and program support
12. Incorporation with a community healthy living center or community exercise center
13. Home visitations for “rounding” to help participants with program concerns and questions that they wouldn’t otherwise ask in a group setting
14. Incorporation into the CPC+ model
15. Incorporation into the ECHO model for outreach
16. DSME Diabetes Self-Management Program
17. Additional support via grants for technology, such as computers for participants
18. Vouchers for a gym membership, food coupons, transportation access, etc.
19. A Medicaid setting via block grants

Personal Satisfaction and Program Savings

Will a supplemental payer group such as a Blue Cross or Medicare Advantage plan provide verbiage for accountability to keep participation goals and coverage intact so that participating patients have some skin in the game in creating personal success and responsibility?

For the provider, does this program impact results in another innovation project or initiative, or activities within an Accountable Care Organization (ACO), for example?

Decimate Diabetes

We have already noted that rural healthcare has growing diabetes numbers. To that end, the CDC has identified what it calls a “diabetes belt” in 644 counties in 15 states – primarily rural areas of the Midwest and Southeast. Some of the states cited included Mississippi, Alabama, Tennessee, and Louisiana.

While we can’t eliminate rural hospital closures or some other unequitable realities affecting the vibrancy of rural life, we can all get on board that at the root of healthcare is the elimination of chronic diseases. We have the necessary data, via a variety of organizations and researchers, beginning with the CDC and including state offices of public health, minority health, and rural health, to name a few. So let’s leverage strength in numbers to our advantage to decimate diabetes – that’s a model we can all embrace.