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CMS Gives Green Light to Digital Health Diabetes Prevention Program

The program, proposed to go nationwide by 2018, would reimburse providers for a health and wellness platform that could include virtual visits and monitoring.

By Eric Wicklund

- A diabetes-based preventive health program that would reimburse providers who use digital health has received the full blessing of the Centers for Medicare & Medicaid Services.

CMS is proposing to expand its Medicare Diabetes Prevention Program (DPP) to a full-fledged national program by the beginning of 2018, making it the first preventive service model to be certified for expansion out of the CMS Innovation Center.

The decision follows a March announcement by the CMS Office of the Actuary that the program’s pilot had helped reduce Medicaid spending, at the same time that officials “determined that the program demonstrated the ability to improve the quality of patient care without limiting coverage or benefits.” Officials are now determining how to begin enrolling providers by 2017.

The DPP reimburses providers for enrolling pre-diabetic Medicare recipients in a program based on body-mass index and blood-glucose levels, with reimbursements based on session attendance, weight loss and continued health maintenance. Those sessions could be delivered in-person or via telehealth, a ruling that enables providers to reach out to a much larger population.

As proposed, providers would be reimbursed after one year of the program at a rate of no more than $450 per enrollee, with $185 of that based on weight loss of 9 percent.

READ MORE: Bill Seeks Medicare Reimbursement for New Telehealth Programs

“Through expansion of the Diabetes Prevention Program, beneficiaries across the nation will be able to access a community-based intervention that prevents diabetes and keeps people healthy. This is part of our efforts for better care, smarter spending, and healthier people,” Patrick Conway, Acting Principal Deputy Administrator and CMS Chief Medical Officer, said in a press release. “Today’s proposal is an exciting milestone for prevention and population health.”

The pilot program, launched in 2013 with an $11.8 million CMS Health Care Innovation Award to the National Council of Young Men’s Christian Associations of the United States of America (Y-USA), invited eligible Medicare beneficiaries at high risk of developing type 2 diabetes to attend weekly meetings with a lifestyle coach, who trained the participants on diet, exercise and healthy lifestyle. Those weekly sessions eventually became monthly sessions.

According to federal officials, about 6,000 people participated in the 15-month program, with 25 percent attending more than 17 sessions, 37.5 percent attending nine to 16 sessions, 37 percent attending less than nine sessions and more than 80 percent attending at least four sessions. Those attending at least four sessions lost an average of 4.73 percent of body weight, while those attending at least nine sessions lost an average of 5.17 percent of body weight.

The Department of Health and Human Services estimated that the program saved $2,650 in Medicaid costs per enrollee.

The expansion is one of several proposed changes to the Physician Fee Schedule designed to put more of a focus on care management and behavioral health – two concepts embraced by advocates of telehealth and mHealth technology.

READ MORE: Providers Must Negotiate Telehealth Reimbursement With Payers

“Today's proposals are intended to give a significant lift to the practice of primary care and to boost the time a physician can spend with their patients listening, advising and coordinating their care—both for physical and mental health,” added CMS Acting Administrator Andy Slavitt. “If this rule is finalized, it will put our nation's money where its mouth is by continuing to recognize the importance of prevention, wellness, and mental health and chronic disease management.”

While the American Medical Association was critical of several of the changes, calling them a "mix of meritorious and flawed proposals," it did praise the DPP proposal.

"The AMA commends the decision to expand coverage of the Medicare Diabetes Prevention Program (DPP) model to Medicare patients at risk of developing type 2 diabetes," the AMA said in a release. "Expansion of the DPP model will help at-risk seniors and people with disabilities lower their risk factors and prevent their condition from advancing to type 2 diabetes.  We are pleased that CMS has acted swiftly to begin the rule-making process to expand access to the DPP model for Medicare beneficiaries with prediabetes.  Earlier this year, CMS concluded that the expanded coverage would result in significant cost savings. The proposal also underscores the important role of prevention in stemming the tide of chronic disease, and we look forward to working with the Administration to advance this effort."

The proposed DPP rule is due to appear in the Federal register on July 15, and CMS will be accepting comments on the proposed expansion through Sept. 6 before issuing a final rule.

Among the issues still to be decided is whether the program will be rolled out nationally or in phases, as well as the quality metrics required for public reporting and the exact payment structure.

READ MORE: mHealth Management Tools Sought by Younger Diabetic Patients

Dig Deeper:

An mHealth Investment Puts the Focus on Care Coordination for Diabetics

mHealth Adopts the Patient-Centered Medical Home Approach


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