Background
Over the last decade, type 2 diabetes has been labeled a global health crisis. According to the Centers for Disease Control and Prevention (“CDC”), one out of three adults has prediabetes. Reaching epidemic levels in the Medicare population, care for Americans aged 65 and older with diabetes accounts for roughly $104 billion annually and diabetes prevalence is projected to double by the year 2050 if the current trend continues.
Preventive interventions to encourage weight loss, increased physical activity, and healthy eating, can considerably reduce progression to type 2 diabetes as demonstrated by the CDC’s National Diabetes Prevention Program (“NDPP”). Adopting a similar model, a two-year test program, hailing from the Innovation Center at the Center for Medicare and Medicaid Services (“CMS”), enrolled 7,804 Medicare beneficiaries in a diabetes prevention program (“DPP”). Providing practical training in a group environment, the scope of the program focused on long-term dietary changes, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle. An independent evaluation of the Innovation Center’s DPP model test revealed high rates of participation and sustained engagement. Lifestyle changes resulting in modest weight loss were found to sharply reduce the development of type 2 diabetes in people at high risk for the disease. Asserting a statistically significant reduction in inpatient admissions following the interventions of the DPP model, CMS decided to expand the model to potentially reduce expenditures by advancing prevention.
Medicare Diabetes Prevention Program (“MDPP”)
Specifically intended to prevent prediabetes from advancing to type 2 diabetes, MDPP was incorporated as a preventive service under Medicare Part B as finalized in the 2017 Medicare Physician Fee Schedule (“MPFS”). The framework of the MDPP is an expansion of the Innovation Center’s Diabetes Prevention Program model tested previously and will be compensable under a performance-driven payment model beginning April 1, 2018.
Following a CDC-approved curriculum, healthcare coaches will provide training in structured group sessions. Promoting lasting behavioral changes to encourage weight loss through healthy eating and increased physical activity is foundational to the model. Spanning a two-year program cycle, eligible beneficiaries will receive instruction surrounding sustained weight loss strategies.
Beneficiary Eligibility
Participation in the MDPP is a once per lifetime benefit and beneficiaries are eligible if they meet the following criteria:
- Body Mass Index (“BMI”) of at least 25 (23 if self-identified as Asian) on the date of the first core session.
- Meet 1of 3 blood test requirements within 12 months prior to first core session: A hemoglobin
- A1c test with a value between 5.7% and 6.4%, or
- A fasting plasma glucose of 110-125 mg/dL, or
- A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
- No previous diagnosis of diabetes prior to the date of the first core session (with exception of gestational diabetes).
- Do not have end-stage renal disease (“ESRD”).
- Have not previously received MDPP services.
Overview of MDPP Services
Due to the strong correlation between weight loss and reduction in risk of type 2 diabetes, a weight loss goal of at least 5% is integral to the MDPP. Healthcare coaches encourage lifestyle modifications in group sessions, though CMS is not explicit relative to requirements concerning class size. Three distinct program segments, the initial core sessions, core maintenance sessions and ongoing maintenance sessions structure the program:
1. Core Sessions – Months 0 to 6
- A minimum of 16 sessions offered at least a week apart.
- Available to eligible beneficiaries regardless of weight loss and attendance.
- In-person and virtual make-up sessions available, must meet specific requirements
2. Core Maintenance Sessions – Months 7 -12
- A minimum of 6 monthly sessions.
- Available to eligible beneficiaries regardless of weight loss and attendance.
- In-person and virtual make-up sessions available, must meet specific requirements
3. Ongoing Maintenance Sessions – Months 13- 24
- Monthly maintenance sessions for an additional 12 months only available to eligible beneficiaries who achieve/maintain weight loss and attendance goals.
- Eligible beneficiaries have coverage for 3 month intervals of monthly maintenance sessions for up to 1 year.
- In-person and virtual make-up sessions available, must meet specific requirements.
Payment
- First 6 month core sessions, payment is based on attendance only. Incentive payments may subsequently be awarded when the beneficiary achieves 5% and 9% weight loss targets.
- Achievement of 5% weight loss during the core maintenance sessions (months 7 – 12) provides a higher payment than attendance alone, but suppliers are still eligible for payment if beneficiaries only meet attendance goals.
- Beneficiaries lose eligibility if they do not maintain 5% weight loss during the ongoing maintenance sessions (months 13 - 24).
The structure of the reimbursement model correlating payment to outcome and engagement is contained in the MPFS Final Rule.
Supplier Enrollment
Achieving and maintaining enrollment as an MDPP supplier requires compliance with standards established not only by the CDC relative to curricula, but also requirements set forth by CMS. An MDPP supplier must meet and maintain either MDPP preliminary recognition or full CDC Diabetes Prevention Recognition Program (“DPRP”) recognition. Interim preliminary recognition bridges the gap until the CDC preliminary recognition can be established, allowing supplier enrollment in Medicare during this period. Organizations who wish to furnish and bill Medicare for these services must enroll in Medicare expressly as an MDPP supplier.
The enrollment process requires prospective suppliers to complete a MDPP-specific application and further stipulates that they must pass enrollment screening at the high categorical risk level. A list of MDPP coaches who will lead sessions must be furnished at the time of enrollment and any subsequent changes to the coaching roster must be reported within 30 days.
Coach Eligibility
CMS established that eligible individuals should meet the criteria outlined by the CDC’s DPRP standards, and the CDC maintains that community healthcare workers and lay people may be effective coaches. While coaches may have credentials, such as Registered Dietician or Registered Nurse, they do not have to be licensed healthcare professionals, nor must they be supervised by licensed medical professionals.
Coaches must obtain an National Provider Identifier (“NPI”), but are not necessarily enrolled in the Medicare program. Furthermore, an individual is only eligible for furnishing MDPP services after being screened by CMS or its contractors. Coaches identified on a MDPP supplier’s roster will be screened by way of background checks as part of the enrollment process for suppliers.
Reimbursement of MDPP services is driven by outcomes as a performance-based payment model. It incentivizes beneficiary engagement, rewarding suppliers for ongoing patient attendance as well as patients achieving target weight loss as follows:
Additionally, the NPI of coaches rendering MDPP services will be required on claims. Based on both criminal background as well as state and federal healthcare program exclusions, CMS finalized a list of ineligibility criteria that would preclude individual coaches from directly furnishing MDPP services.
Supplier Standards
MDPP Suppliers must maintain compliance with specific administrative standards and location requirements. Community settings may be used to render MDPP services, but having at least one administrative location is required. In addition to maintaining documentation of MDPP sessions, coach information, date and place of service, as well as beneficiary information is expected to be collected and furnished to the CDC for evaluation of performance under the DPRP.
Incentives for Patient Engagement
Demonstrated in the DPP model tested previously, sustained attendance and weight loss correlate to high levels of beneficiary engagement. The performance-based payment methodology for MDPP services, which ties payments to outcomes, incentivizes suppliers to be engaged in beneficiaries’ weight loss efforts.
To cultivate patient engagement, MDPP suppliers are permitted to provide incentives that will foster success. Items or services that advance outcomes and the clinical goals for the beneficiary may be appropriate to encourage participation. Incentives must be reasonably connected to the diabetes prevention curriculum and consistent with the nature of the program. In addition to restrictions and limitations surrounding administration of incentives, MPDD suppliers must comply with all record keeping requirements.
Summary
Without preventive intervention, many people with prediabetes are likely to develop type 2 diabetes. The inaugural policy year commencing in April, establishes the first preventive service of its kind under the Medicare program giving Medicare beneficiaries access to MDPP services in both community and healthcare settings to encourage wellness and potentially mitigate disease progression.
SunStone offers services specifically geared to assisting hospitals, health systems, and independent multi-specialty physician groups manage the ever-changing regulatory environment. If you have any questions regarding the new MDPP program, please contact Vonda Moon, Principal at vondamoon@sunstoneconsulting.com or Cathy Archuleta, Manager at cathyarchuleta@sunstoneconsulting.com.