We’ve all heard the rhetoric: Diabetes is preventable.
Sometimes, it causes us to roll our eyes, or even get a bit more emotional depending on the context in which that claim is made.
That being said, however, nothing much has been done about this simple fact. Until now. Just this month on April 1, Medicare began rolling out its big guns and for the first time has begun paying for a disease prevention program that puts type 2 diabetes in the crosshairs.
A Successful Trial Run
As anyone with diabetes knows, it’s an expensive disease. The government knows this, too. All too well, in fact. In 2016 alone, Medicare estimates that the government spent $42 billion-with-a-B more on beneficiaries with diabetes than they would have spent if those beneficiaries had been diabetes-free. (“Beneficiary” is a fancy word for someone who is on Medicare.)
Well, that’s enough money to make someone sit up and say, “Hey… maybe we should try spending some money trying to prevent this preventable disease. It might be cheaper for us in the long run.” I know that sounds obvious, but the idea of using health insurance dollars to prevent, rather than to treat, is actually revolutionary. And very un-American. Still, in this environment of never-ending increases in healthcare costs, that’s exactly what happened.
The Centers for Medicare & Medicaid Services (CMS), through an arm called the CMS Innovation Center, gave the YMCA about $12 million to see if the well-documented approach of the Centers for Disease Control and Prevention’s (CDC)
This pilot project, the recipient of a Round One Health Care Innovation Award, was called the Diabetes Prevention Program. It ran for two years, was offered in 17 locations, and enrolled over 5,000 seniors at risk for type 2 diabetes.
And it worked. In March of 2016 it was declared a success. Success in this case being defined as costing CMS less money than doing nothing, or in government speak, “a cost savings program that reduced net Medicare spending.”
When you are the government, spending less is saving money.
But that, by itself, wasn’t enough. Next came the politics. CMS was legally obligated to show that “the program demonstrated the ability to improve the quality of patient care without limiting coverage or benefits.” That’s crazy, of course, but luckily it did, and thus the DPP became the first ever preventative service model certified for expansion to the full Medicare population.
Now no longer a pilot model, but Medicare-wide and renamed MDPP, for Medicare Diabetes Prevention Program, it may well be available at a location near you.
If not, it will be soon.
A Whole New (Diabetes) Industry
I won’t bore you with the details, but the rules and laws that make the MDPP a reality for folks on Medicare are wrapped into something called the Final Rule Physician Fee Schedule, and CMS has done something pretty amazing: They’ve created a whole new category of Medicare suppliers—suppliers whose sole purpose will be to provide MDPP services to Medicare beneficiaries.
The YMCA has jumped on this bandwagon, and so too have 1,500 other organizations. It’s a diabetes Gold Rush. Want to join the fun? Start with the 149 pages of instructions on what you need to do to become an MDPP supplier. Then fill out the 33-page application.
What’s Being Funded?
Wait a sec. Just what is being paid for here? The MDPP is a two-year-long program officially called “a structured lifestyle intervention.”
Intervention? As in captured off the curb by a cult and reprogrammed in a dark church basement?
Luckily not. The structured intervention isn’t as hardcore as it sounds; it’s just an in-person group class. It can be taught in community environments or in medical centers. The program includes dietary coaching, a lifestyle tool kit, and moderate physical activity — all with the goal of having participants lose that critical 5% of body weight that’s been shown to thwart type 2 diabetes. Two years is a long time of course, but weight loss is a slow process.
In the first six months, MDPP suppliers are required to offer a minimum of 16 sessions, at least one per week, taught by supplier “coaches.”
More on those coaches in a bit.
The classes in the first six months are called “Core Sessions,” and focus on weight loss and “healthy behavior,” whatever that is. The class curriculum must be approved by the CDC’s Diabetes Prevention Program, on which all of this is based. Then, within months 6-12 suppliers must offer “Core Maintenance Sessions,” at the rate of at least once a month, also using a CDC-approved curriculum.
After the first year is completed, suppliers are additionally required to offer monthly “Ongoing Maintenance Sessions” for eligible beneficiaries—those who achieve and maintain weight loss goals and meet attendance requirements, which brings us to the crux of the matter for suppliers. The reimbursement for the program is largely based on outcomes, rather than the traditional fee-for-service model.
Here’s how the money flows…
Getting Paid for Outcomes (!)
How much money any of the new MDPP suppliers will earn for teaching the classes depends on how well their attendees do. The first time a senior shows up, a supplier can bill $25 to CMS. There is no cost-sharing or co-pay for the participants. If the person comes to four more classes, another $50 bucks can be charged. The first nine classes are billable based on attendance, and attendance is required. The law is pretty strict on this front, although there are provisions for “make up” classes. At this time all of the classes are in-person, although virtual / remote classes may be approved in the future.
After the first nine classes, the supplier has to start demonstrating weight loss in order for the money to keep flowing at the best rate. Remember that weight loss is really the prescription here when it comes to preventing type 2 diabetes. Without getting into all the levels, the bottom line is that the maximum amount a supplier can bill CMS over the two-year period is $670. If that doesn’t sound like much, consider the old Medicare lifetime diabetes education benefit (which, granted, is a slightly different thing) tops out around $150 bucks, and must be used in full in the first year after diagnosis.
So CMS is now spending more to try to prevent diabetes than they are willing to spend on trying to help people who already have it manage it well.
Meanwhile, however, the market is almost unlimited. According to the American Diabetes Association, more than 50% of Medicare beneficiaries have pre-diabetes, and CMS is predicting that MDPP will save $182 million over the next 10 years by decreasing diabetes-related health care costs.
Who’s Eligible for the Program?
So which folks on Medicare are eligible to enroll in this new program? You need to have an at-risk weight plus a blood sugar measurement consistent with pre-diabetes. That means you’re eligible if you have:
- A BMI of 25 or greater (or 23 for Asians), which is the official cutoff for being overweight. For
perspective, 77.9% of the entire U.S. population have BMIs in excess of 25
- An A1C between 5.7% and 6.4%
- Or a fasting blood glucose level between 110-125
- Or a two-hour post-prandial glucose level between 140-199 based on an oral glucose tolerance test
And you can’t have a previous diagnosis of diabetes (type 1 or type 2), except for gestational diabetes. And if you have end-stage renal disease you are barred from taking the class. I guess they figure you won’t last long enough to make it worth their while.
What happens if you get diabetes during the program? You get to stay in. But if you drop out, you can’t come back. The program is a one-time benefit for those on Medicare.
Doctors can refer their patients to the suppliers, or the law allows for patients to self-refer and for the suppliers to give them the blood tests needed to determine eligibility. I suspect this would be a good time to be in the business of selling tabletop A1C test machines.
Of note, private plan contractors, such as Medicare Advantage plans, must also offer MDPP, as it is created as a Part B benefit (the outpatient part of Medicare).
Who Are These “Diabetes Coaches”?
Who can be a coach? Well, unlike official diabetes education, which can only be provided by a limited number of licensed and certified clinical professionals, anyone can be a MDPP coach. Well, anyone not convicted of a short list of felonies maintained by CMS, most of which are financial crimes.
There’s no clinical certification required to be a MDPP coach, nor even formal training. The coach needs only a National Provider Number, which, sadly, you can’t get as a freelancer. You can only get one through a supplier.
On one hand, I applaud this openness in qualifications, but it also scares me, too. Will MDPP coaching end up being a dead end, minimum wage job with the profits being hoarded by the supplier companies? I hope not, because without good coaches teaching the curriculum, I’m not sure the program will succeed on wider roll-out.
On the other hand, if the suppliers choose to leverage the experience of PWDs (people with diabetes) to serve as coaches, I think amazing things can and will happen. With the right coaches, the MDPP has the potential not only to save money, but to impact many thousands of lives in a positive manner. That’s work I wouldn’t mind doing myself.
MDPP, if it works on a national level, could also serve as the stepping-stone to other preventative health programs, and that could recreate healthcare as we know it, making us a healthier, wealthier nation on the whole.