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CMS Won’t Cover Telehealth in Medicare Diabetes Prevention Program

CMS declines to reimburse providers for virtual coaching on weight management in MDPP programs, but says the program may show up in a CMMI demonstration project.

Source: ThinkStock

By Eric Wicklund

- The Centers for Medicare and Medicaid Services has once again declined to cover virtual coaching platforms in the Medicare Diabetes Prevention Program, saying the mHealth and telehealth platform isn’t reliable enough to warrant reimbursement.

The decision, included in more than 1,000 pages of payment rules released by CMS late Thursday, strikes a blow to telehealth programs that use online weight management coaching to help Medicare members avoid type 2 diabetes. Several have argued that virtual programs reduce access and provider shortage issues and improve engagement for millions of Americans at heightened risk of developing the chronic disease.

"Without the inclusion of virtual providers in the benefit, millions of clinically eligible Medicare beneficiaries will not have viable options to access a service which could improve their lives based solely on the zip code in which they reside," Adam Brickman, a spokesman for Omada Health, told Politico shortly after the CMS announcement came down.

The agency did throw digital health advocates a bone, however. CMS apparently will consider testing the platform in a Center for Medicare & Medicaid Innovation (CMMI) demonstration project.

CMS had unveiled a proposed MDPP Expanded Model this past July and accepted comments through September. The agency fielded several comments from mHealth groups – including the Council for Diabetes Prevention – urging CMS to include coverage of virtual weight-loss coaching.

“A program is a program whether it’s being delivered in person or [on a telehealth platform] – the only difference is the delivery method,” Mary Pigatti, CEO of RetroFit and a member of that collation, told mHealthIntelligence.com earlier this year.

CMS “has expanded coverage that will help reduce chronic diseases” and healthcare costs associated with type 2 diabetes, added Pigatti, also the working lead for the Council for Diabetes Prevention’s Digital Working Group. “That’s great. They’re already part-way there. They just need to get all the way there.”

Omada CEO Sean Duffy noted the lack of a digital health platform would hit rural populations especially hard.

“Diabetes and diabetes-related treatment is one of the biggest drivers of rising healthcare costs for every payer—with Medicare spending more on treating those with the disease every year,” he wrote in an Aug. 14 commentary in Morning Consult. “This is particularly true in rural America, as the prevalence of diabetes and coronary heart disease is approximately 17 percent and 39 percent higher in rural areas than urban areas.”

The California Medical Association and Diabetes Advocacy Alliance also made a plea for telehealth services.

“Virtual delivery of MDPP is essential for beneficiary choice as well as access - particularly for vulnerable populations, individuals with transportation needs or those in rural areas with no access to an in-person program,” the DAA wrote in a Sept. 11 letter to CMS.

“With the influx of nearly 6 million potential MDPP enrollees in California, we believe that allowing virtual MDPP services is a necessity,” CMA officials added in a separate letter.

According to CMS, Medicare spent $42 billion more in 2016 on beneficiaries with diabetes than it would have spent if they hadn’t developed diabetes. That amounts to, per beneficiary, an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services and $2,700 more in physician and other clinical services.

The MDPP is a year-long, CDC-approved program consisting of 16 weekly core sessions, then monthly sessions. The program’s goal is to get participants to lose 5 percent to 7 percent of their body weight, a modest lifestyle change that drastically reduces one’s chances of developing type 2 diabetes. That figure is based on a landmark National Institutes of Health study that showed a 58 percent reduction in participants progressing to diabetes.

Following a pilot program developed by the CMS Innovation Center and the YMCA that showed a savings of $2,650 per beneficiary over 15 months, the MDPP was launched in 2016 and is scheduled to become a fully reimbursed Medicare program in April 2018.

CMS has long maintained that virtual programs that focus on self-reported weight loss won’t be covered because “self-reported weight loss is not reliable for the purposes of performance payment."

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