Update on Diabetes Prevention Program Seeks Progress on Referrals, Reimbursement

More than 15 years after the first study on the National Diabetes Prevention Program (National DPP), long-term evidence shows that it works, even if the effects wane over time. But before this tool can make a dent in the 30 million people with diabetes or 84 million with prediabetes, more doctors must refer people to the program and more payers must fund it, according to panelists who appeared Saturday at the 2018 meeting of the American Association of Diabetes Educators (AADE), being held in Baltimore, Maryland.

The officials represented 3 agencies, the National Institutes of Health (NIH), CDC, and CMS, which have federal key roles in the development and execution of DPP. This year brought a milestone when Medicare began offering DPP to eligible seniors on April 1, 2018. But it appears there are still enrollment hiccups, based on questions that educators had after the session for Nina Brown Ashford, MPH, CHES, deputy director for the Prevention and Population Health Group at the Center for Medicare and Medicaid Innovation at CMS.

Amid concerns that Medicare DPP lacks adequate capacity because many qualified providers did not sign up to become Medicare suppliers, Ashford showed one slide that said a map of local suppliers was “coming soon.”

Ann Albright, PhD, RDN, who is director in the Division of Diabetes Translation at CDC’s National Center for Chronic Disease Prevention and Health Promotion, said there’s been growth in the number of commercial payers willing to cover the National DPP, including Humana, Anthem, Blue Cross Blue Shield of Florida, Blue Shield of California, and Priority Health of Michigan; in addition, 3.4 million state employees and dependents in 18 states now have National DPP as a covered benefit. But state employees in areas with high levels of type 2 diabetes (T2D) and obesity, including Mississippi, Alabama, Arkansas, and West Virginia, lack coverage, according to Albright’s information.

What’s new, according to Judith Fradkin, MD, director of the Division of Diabetes, Endocrinology, and Metabolic Diseases at the National Institute of Diabetes and Digestive and Kidney Diseases, part of the NIH, is that scientists are learning more as the original DPP cohort hits the 15-year mark. The NIH study that appeared in the New England Journal of Medicine studied the lifestyle intervention now known as the National DPP in overweight adults compared with 2 groups—one taking placebo and the other taking metformin. As Fradkin explained, overall results showed that DPP reduced the likelihood of progression to T2D by 58% relative to placebo, beating metformin, which reduced progression by 31%. But while the lifestyle results were clearly superior among patients 65 years and older, reducing progression to diabetes by 71%, metformin was nearly as effective as lifestyle among young adults, and “metformin saves healthcare costs,” she said.

The DPP is a yearlong lifestyle intervention that asks participants to make a series of cumulative lifestyle changes, which are designed to help them change eating habits, increase exercise, and learn coping skills in ways that will last after the program ends. The goal is 7% weight loss and 150 minutes a week of physical activity. Often, the spouse or the family member who prepares the food is invited to participate, so that the person trying to avoid developing T2D receives support in the effort. Sixteen weekly core sessions are followed by monthly sessions in the classic National DPP; the Medicare version allows beneficiaries to attend a second year of support sessions, although this does not affect a provider’s CDC recognition, Ashford said.

Read more: A Blog Post Suggests Medicare Lacks Enough DPP Suppliers

“Diabetes is not inevitable,” Fradkin said. Fifteen years after receiving the DPP, Fradkin said, “The benefits decreased over time but remain substantial.” Still, the most recent evidence shows that 55% of those in the lifestyle intervention group and 56% of those in the metformin group had developed T2D mark, compared with 60% in the placebo group.

New research is examining the effects of vitamin D on T2D prevention, as well as the effects of metformin in prevention of cancer and cardiovascular disease, Fradkin said. One study, called RISE, is examining early use of metformin with either insulin glargine or liraglutide in patients with impaired glucose function, to preserve B-cell function before patients develop diabetes. “We want to give people as many tools as possible,” she said.

CDC’s elements of success. Albright said there are 4 key elements of success for National DPP: high-quality programs, demand from participants, referrals from providers, and reimbursement from payers. Despite the numbers of people with prediabetes and the costs on the horizon—Ashford said that diabetes already costs Medicare $104 billion a year—90% of people with prediabetes don’t know it, and providers are just starting to learn that they can send patients with certain blood glucose benchmarks to programs to make lifestyle changes.

“We all really need to join forces. One of the beauties of the National DPP is that it unites us,” she said. The prospects of diabetes and its cost complications are so daunting that Albright predicted people would look back at this period and ask, “Did we stand up and really work to turn the tide?”

Albright said it’s taken time to build the local infrastructure to deliver National DPP, but it’s getting better, and the addition of virtual programs has helped (although Medicare will not cover them, a point not raised by the panelists). The addition of Medicaid 1115 waivers in many states will help reach some of the most at-risk people with prediabetes, as will the start of a National DPP customer service center.

Rules and reimbursement for Medicare DPP. Ashford covered the particulars of how to become a Medicare supplier, and there are several steps: Each coach must have a National Provider Identifier, or NPI number; a health system that already bills for Medicare must separately register as a Medicare DPP supplier; and groups must use the CDC curricula and have at least preliminary recognition. Reimbursement follows an outcomes-based sliding scale tied to attendance and weight loss, with a floor of $195 and a ceiling of $670 for participants who may stay in the program as long as 2 years.

She called on attendees to encourage those CDC-recognized providers who are not part of the Medicare program to become suppliers, and she repeated Albright’s call for doctors to “screen, test, and refer” patients to the program. Everyone, she said, can “promote awareness among the Medicare population.”