Memorandum

CMS outlines concrete timeline for DPP reimbursement in 2017 Medicare Physician Fee Schedule – July 14, 2016

Executive Highlights

  • The Center for Medicare & Medicaid Services (CMS) recently outlined a plan to begin Medicare reimbursement for the Diabetes Prevention Program (DPP) beginning in January 2018.
  • CMS will begin certifying DPP providers in January, 2017.

In its recently proposed 2017 Medicare Physician Fee Schedule, the Center for Medicare & Medicaid Services (CMS) has outlined a concrete timeline to implement Medicare coverage for the Diabetes Prevention Program (DPP) – excellent news, all around. CMS will begin certifying DPP providers starting on January 1, 2017, and reimbursement is slated to begin on January 1, 2018 under the name Medicare Diabetes Prevention Program (MDPP). Payment for healthcare providers will be tied to the number of MDPP sessions a person attends and the additional payment levels can be attained with the person's achievement and maintenance of 5% weight loss. The proposed regulations require entities that offer the MDPP program to follow a specified curriculum for the MDPP benefit. CMS is still deliberating whether to launch coverage of MDPP across the nation at once or to phase the program in gradually, starting in select markets and expanding over time. The proposal will be open for public comment from July 15 until September 6.

Earlier this year, the Department of Health and Human Services (HHS) certified the pilot DPP program following evidence of its efficacy and cost-saving potential (on average, participants exceeded the desired 5% weight loss goal and Medicare saved $2,650 per participant in healthcare expenditures, easily covering the cost of the program in a span of only 15 months). In response to these results showing a positive short-term return on investment, HHS announced that Medicare would start reimbursing DPP, and we are very encouraged to now see more definite plans for this coverage. The announcement of actionable proposed regulations for implementation and a suggested timeline underscores CMS’ commitment to making reimbursement for diabetes prevention a reality. It is also encouraging that CMS recognizes digitally delivered DPP interventions are effective and are “contemplating” reimbursement for virtual programs. There are important logistical concerns and lingering questions that will need to be addressed in the coming months; that said, we’re hopeful that Medicare reimbursement for DPP will be a step forward in reducing type 2 diabetes and prediabetes. 

  • The CMS-defined eligibility for MDPP mirrors that of the DPP pilot. Medicare beneficiaries are eligible if they meet all of the following criteria: (i) BMI >25 (>23 for people of Asian descent); (ii) A1c of 5.7-6.4% or fasting plasma glucose of 110-125 mg/dl or 140-199 mg/dl plasma glucose after the 75g Oral Glucose Tolerance Test; (iii) No previous diagnosis of type 1 or type 2 diabetes. We expect the program will be most successful and reach the greatest number of people with prediabetes if it is coupled with efforts to scale up diabetes screening. For instance, it would be great to see A1c measured as a standard part of a physical examination for at least some sub-group of high-risk people, much like weight or blood pressure. Although the per-person cost of an A1c is greater than that of a weight or blood pressure measurement stands a partial barrier toward this vision, as does the time it takes to get the A1c measurement, and the equipment, the notion of “same-time” reporting on A1c would have some real backers, especially as the technology improves.
  • AADE president Hope Warshaw suggested that the AADE was pleased to see the CMS publish proposed regulations to the diabetes self-management education (DSME) program. She noted that the proposed resulation fro DPP allow people who fit the criteria to self-refer for the service. She pointed out that this may be a window of opportunity for AADE, as one of the two National Accrediation Organizations for DSME, to provide input during the public comment period. In contrast, DSME programs require a referral from the individual’s primary care provider, which has historically been a “stumbling block” to access to diabetes education. Ms. Warshaw suggested that perhaps as CMS was crafting the proposed regulations for the DPP their attention was drawn to several inequities between the two services, such as the referral requirement and the hours of service needed. We would love to see a system in which individuals can proactively seek DPP if they have prediabetes and DSME if they have diabetes without necessitating a physician referral and we expect this could go far in removing barriers toward enrollment in DPP or DSME.
  • We look forward to seeing whether this expansion of DPP will encourage further investments in diabetes prevention. DPP is the first diabetes preventative service model to be covered by Medicare and its coverage sends an encouraging message to the public that diabetes prevention is effective and worth investment. Echoing Dr. Timothy Garvey (University of Birmingham, Alabama), we would be excited to see Medicare coverage for prediabetes drug treatments, such as metformin or therapies approved for obesity which have been proven to reduce to progression from prediabetes to type 2 diabetes. We’d also love to see more commercial payers reimburse DPP, especially given the recently adopted AMA policy urging all public and private insurance to cover the program. We optimistic that people with prediabetes will eventually have easy, affordable access to these evidence-based programs that prevent or delay the onset of type 2 diabetes and Medicare is certainly taking a big step in the right direction.
  • Canary Health founder and chief medical officer Dr. Neal Kaufman praised reimbursement proposal: “CMS’s is making a great leap forward by paying for in-person and digital Diabetes Prevention Programs for Medicare beneficiaries.  This action reaffirms the importance of good science combined with well thought out program implementation leading to a ground-breaking CMS decision. It is expected that this approach will serve as a model for increasing access to other self-management support services so essential to obtaining good patients outcomes.”

Close Concerns Questions

Q: Due to the logistical difficulties of immediate national coverage, is it more likely that MDPP will be gradually phased in? If so, how will Medicare determine which local markets or geographic regions will be the first to receive MDPP coverage?

Q: How does Medicare plan to ensure and promote access to MDPP programs? Will the criteria for certified programs offer enough flexibility to fit into a patient’s busy lifestyle?

Q: Will Medicare reimburse both in-person and virtual programs at the same level?

Q: Given that settings other than a typical medical establishment – such as the YMCA – could play a pivotal role in scaling DPP, how will these nontraditional healthcare workers be factored into reimbursement?

Q: What will be the impact of expanded DPP access on diabetes incidence rates? What sort of decrease in diabetes incidence should we look to as a sign of success?

Q: Given the staggering rates of unawareness surrounding prediabetes (only ~10% of the estimated 86 million Americans with prediabetes know they have it), expanding Medicare coverage for DPP may not be enough. How can we spread information about diabetes prevention in order to connect high-risk patients to the preventative care they need?

Q: What steps can policymakers and providers take to reach people at risk for type 2 diabetes before age 65 who aren’t eligible for Medicare coverage?

Q: When might we start to see broader DPP reimbursement in the commercial insurance market? What incentives might kick-start momentum in this direction?

Q: DPP is the first Center for Medicare & Medicaid Innovation project to be slated for expansion into Medicare. What other promising new healthcare programs are in the Innovation Center’s pipeline?

-- by Abigail Dove, Payal Marathe, Helen Gao, and Kelly Close