Medicare to implement national diabetes prevention program

A successful YMCA diabetes program has prompted the Obama administration to expand Medicare to cover programs to prevent diabetes among those at high risk of developing the disease.

In 2011, the Centers for Medicare and Medicaid Services (CMS) gave YMCAs nearly $12 million to launch the Diabetes Prevention Program, which includes nutrition and fitness counseling and lifestyle coaching for Medicare recipients. The funding was provided by the Affordable Care Act, which also recently marked its sixth anniversary.

Overall, when compared with similar beneficiaries not it the program, the program led to a Medicare estimated savings of $2,650 for each enrollee in the Diabetes Prevention Program  (DPP) over a 15-month period, more than enough to cover the cost of the program.

“These findings are encouraging as they make the case for National DPP based on rigorous actuarial analysis,” says Brenda Schmidt, CEO and founder of Solera Health. 

DPPs are an example of shifting the focus of care to more preventative care, rather than simply providing more services, says Rulon Stacey, PhD, managing director of the Navigant Leadership Institute, Navigant Healthcare. 

“This is a path toward value and away from fee-for-service,” Stacey says. “This could result in more cost savings than in cost outlay. More importantly, it could result in people finding out about their condition at a time when they could still work to prevent diabetes or have a better chance of treating the disease.”

The benefit of a "fee-for-value" system as opposed to a "fee-for-service" system is that it aligns the financial incentives of the provider with the health of the patient, Stacey explains. “For years, the financial best interest of the provider has been to treat people when they were sick.  More sick people meant more money. But, under a fee-for-value system, the incentive is to keep people healthy. That means that spending money to prevent, which seems to be the plan here, furthers that alignment,” he says.

The Obama administration’s decision to cover the program for Medicare beneficiaries does not require Congressional approval, and is expected to be implemented in 2017. Following this initiative, the nation’s estimated 11.8 million at-risk seniors will now have access to the over 750 digital, national and hyper-local DPPs which will be made available as a covered benefit.

Currently, about 30 million Americans have type 2 diabetes, resulting in two deaths every five minutes in this country. Additionally, 86 million Americans have a high risk of developing diabetes, because one in every three adults has prediabetes, a condition that arises when blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes.

Prediabetes means a person is at increased risk for developing type 2 diabetes, as well as for heart disease and stroke. Many people with prediabetes develop type 2 diabetes within 10 years.

Next: Other DPPs available

The YMCA DPP is not the only treatment available, according to Schmidt. Currently there are more than 750 CDC-recognized community organizations and digital technology solutions with the capacity to deliver the DPP.

SchmidtCDC-recognized DPP’s can range from community health and wellness programs to Weight Watchers and digital health management programs such as HealthSlate and Blue Mesa Health.

“This is important to offer member choice among a variety of DPP delivery options, and meet the demand of the number of individuals who would qualify for the program,” she says. “DPPs available to patients today are demonstrating similar rates of treatment success in weight loss and diabetes prevention.”

For some patients, the YMCA program may be the best option, but other programs may be better suited to each individual’s unique needs and preferences, including the many digital DPP providers that offer nutrition and wellness coach support via texts and nutrition tracking through apps, according to Schmidt.

“In our role as a health community integrator, we know that seniors have unique requirements and that certain DPPs have proved to be more successful in serving the needs of this population,” she says. “With the [CMS] program expected to implement in 2017, we welcome the opportunity to be part of the chronic disease prevention solution for this unique demographic.”

Several large commercial payers have already made the DPP an ACA-covered preventive benefit for their members, according to Schmidt. 

“These health plans have recognized that it is cost effective to prevent chronic health conditions and recognize that a single DPP provider does not meet the need of their extremely heterogeneous member population,” she says. “CMS’ support for the DPP program validates the importance of patient choice when it comes to treatment options for chronic disease prevention.

“We are seeing a great shift in term of patient empowerment and engagement and often that change is happening outside the walls of a doctor’s office,” Schmidt continues. “Most DPP providers are non-traditional care providers that can reduce the burden on existing healthcare resources while receiving claims-based payments as a sustainable revenue model.”

By recognizing the national DPP as a medical benefit, community and digital providers can now serve as a lower-cost, high-access network as an adjunct to primary care.

“Prediabetes in particular is unique in that not only can patients take responsibility for identifying their risk but they can ultimately have a hand in reversing their condition altogether,” Schmidt says. “As a country, people are becoming more aware of what they’re eating and how many steps they have taken in a given day. What’s so great about the national DPP is that it has harnessed this growing interest in wellness to drive lifestyle changes that have a long-term impact on health. With so many programs being made available today the initiative has turned into a way to manage and prevent chronic disease within people’s comfort zones and in a place and at a time that’s convenient for them.”

Next: What executives can expect in 2017

What executives can expect in 2017

Executives can look forward to limiting seniors’ healthcare expenses while enabling at-risk patients to take a proactive approach to health, and ultimately, servicing a population of healthier patients who require minimized care, according to Schmidt.

“Through a national network of community and digital DPP program providers, managed care organizations and doctors can refer their patients to a trusted resources to reduce their risk of developing type 2 diabetes.”

Executives need to realize that when possible, a patient’s ability to choose a treatment will ultimately have a substantial impact on enrollment, engagement, and overall wellness success, Schmidt says.

“Although Medicare members are in the same age demographic, 65 years and older, every patient has different health needs and preferences. Forcing a single solution on a diversified population may not always prove to be successful,” she says. “Contrary to popular belief, digital DPP providers fare no worse than in-person or national DPPs when it comes to overall treatment engagement and success for the 65-plus demographic. Many seniors want digital options they can use from home as opposed to in-person meetings or community walking groups.”

This proposal will necessitate further review, according to Stacey. 

“Of course, there are details that we can't see, such as how much will be spent on the prevention and if there is actually a scientific link between the actions being promoted and a reduction in the disease,” he says. “But, if those areas have been addressed, it is in the best interests of payers, providers, and most of all, patients, to see if this works out to the degree we all collectively hope.”