Blog Post Suggests Medicare Diabetes Prevention Program Capacity Crunch, but CMS Is Short on Details

No one has said, “I told you so,” at least not publicly.

But CMS’ failure to heed warnings last year, as it crafted rules for the Medicare Diabetes Prevention Program (MDPP) were signaled in Monday's blog post from Administrator Seema Verma. The post, which came 30 days after the historic program officially began, calls on qualified providers of the National DPP to become government contractors, so that Medicare can save $180 million by keeping at-risk seniors from developing type 2 diabetes (T2D).

There have been reports that CMS’ rules and fee structure have made traditional DPP providers wary, and CMS has not publicized the program to seniors, who do not have to pay for it if they meet the criteria. But Verma’s blog post is the first public sign that Medicare’s long-awaited attack on prediabetes is, for the moment, a war in search of an army. A private company that is shepherding providers through Medicare's supplier certification may ultimately save the day, and its CEO predicts more will complete the process by summer.

On Thursday, 2 days after The American Journal of Managed Care^® (AJMC^®) asked CMS if Verma's blog post meant there was a capacity problem, the agency declined to answer the question directly. Instead, a spokesperson said CMS was focusing on supplier enrollment, and that it was a "long-term goal" for all Medicare beneficiaries to have access to a MDPP supplier "in their area."

MDPP is based on a 2002 study in the New England Journal of Medicine, which found specific diet and lifestyle changes leading to at least 5% weight loss could reduce progression to T2D by 58% (and 71% in seniors). The Obama administration proposed MDPP after a pilot study through the Center for Medicare & Medicaid Innovation (CMMI) showed it could save $2650 per participant.

For years, CDC has certified community programs that operate in places like senior centers or hospitals, as well as digital programs that serve both employers and individuals. But putting DPP in Medicare meant qualifying non-clinical providers to be paid by the government, and things got complicated. First, operators of community programs warned that CMS had created a program with too many requirements and liability for their shoestring budgets. While many agreed Medicare needed some value-based element for reimbursement—in this case attendance and proof of weight loss—some felt it would be too hard to keep tabs on clients for 2 years to be paid $670 per person.

Second, digital providers—who had plans to scale up for Medicare’s DPP expansion—were left on the sidelines. CMS rules allow only a few virtual makeup sessions. These companies argued strongly, and still do, that they can help CMS reach seniors who live in rural areas or have irregular schedules. If Medicare relies solely on the traditional in-person format, they say, the program will never reach the estimated 22 million seniors who have prediabetes.

So, even though by rule CMS started the program on April 1, 2018, after 2 rounds of rulemaking that lasted more than a year, the agency said in its emailed statement, "We did not expect to have MDPP suppliers throughout all areas of the country as of April 1, as this is a new Medicare service and a new Medicare supplier type."

Another challenge for community programs: many seniors do not live in the same location year-round, and CMS rules require that MDPP programs accommodate those who relocate midway through the 16 core sessions.

Verma does not address the capacity rumors in her post, and writes, “For the first time, community-based organizations can enroll in Medicare to provide evidence-based diabetes prevention services after achieving preliminary or full recognition through the CDC. These organizations can enroll in Medicare to become an MDPP supplier today, and CMS will continue to accept supplier applications on a rolling basis.”

Reporting by AJMC^® and others suggests that CMS will eventually get MDPP up to scale, but it won’t happen right away. CMS told Kaiser Health News on April 19, 2018, it had enrolled 3 suppliers for a program that started April 1, 2018. Solera Health has built a nationwide technology and regulatory network to support the program and told AJMC^® in a statement that it is working with 15 National DPP partners to assist them in becoming suppliers. Solera is under contract with 30 Medicare Advantage plans to match their beneficiaries with an appropriate provider.

“To support scaling the program, Solera launched MedicareDPP.org, a national MDPP referral and class selection website that makes it is easy for individuals to verify their program eligibility, document blood test results, confirm health insurance coverage and select and enroll in a DPP class that meets each individual’s needs and preferences,” the company said in a statement emailed to AJMC^®.

Solera’s statement said that “while there is industry concern about network adequacy,” the providers now in the CMS approval pipeline “will provide broad national coverage for the program.”

The Physicians’ Fee Schedule, finalized in November, calls for a 90-day approval process, so providers who began certification after the launch should be done by July. Groups that have not previously offered the National DPP must complete CDC's recognition process before becoming a Medicare supplier.

Will CMS revisit its decision on digital providers? Previously, officials have said there would be a separate CMMI pilot, but companies that have CDC recognition say there is plenty of data already. CMS said, "to date, we have not proposed any policies related to fully virtual MDPP services." Omada Health released this statement on Verma’s blog post:

“Administrator Verma's blog is encouraging, as it demonstrates that CMS is dedicated to making the Medicare Diabetes Prevention Program work. Qualified virtual DPP providers like Omada are an obvious way to expand access to this program. We are eager to continue our work with CDC, CMS, and HHS to make sure qualified virtual providers have the opportunity to deliver DPP services to eligible Medicare beneficiaries, and look forward to being part of the solution to this problem.”

Brenda Schmidt, CEO of Solera Health, said she is “enthusiastic” about the program.

“The Medicare DPP is a groundbreaking milestone in the history of Medicare. For the first time, an estimated 22 million Medicare beneficiaries at high risk of developing type 2 diabetes have access to evidence-based, diabetes prevention services at no cost. We expect supply and demand for the program to increase significantly in the coming months as referral models launch and additional suppliers are approved by CMS,” she said.