A Leader in Diabetes Prevention Gets Ready to Help Medicare Reach Seniors Everywhere

Brenda Schmidt, MS, MBA, is a busy person these days. The CEO of Solera Health, Schmidt is gearing up for April 1, 2018, a kind of “D-Day” in the world of chronic disease prevention, when the Medicare Diabetes Prevention Program (DPP) will launch nationwide.¹

Schmidt is the CEO of Solera Health, which is neither a payer nor provider of chronic disease prevention, but an integrator that speaks the language of both. Solera does many things: it connects patients to the National Diabetes Prevention Program (DPP) by helping them choose a provider that will meet their needs and fit with their lifestyle. It helps employers, payers, and providers connect with each other, offering compliance, billing and technology services.

The advent of Medicare DPP opened new possibilities, as Solera Health was in place to serve as a “back office” for community-based programs that have offered the DPP for years but now had to decide if they wanted to seek Medicare reimbursement. That meant helping a new class of non-clinical providers meet regulatory requirements, connect with primary care physicians who might provide referrals, and meet a host of other standards spelled out by CMS in a final rule, which was completed as part of the Physicians’ Fee Schedule in November 2017.¹

Schmidt also serves as president of the Council for Diabetes Prevention, an umbrella organization that has dealt with regulatory and implementation issues of Medicare DPP, but more broadly, promotes the long-term sustainability and scalability of the National DPP.² This included dealing with the aftermath of CMS’ decision to not include virtual, or digital providers as full providers in the first year of Medicare DPP; instead, CMS has called for a test within the Center for Medicare and Medicaid Innovation (CMMI) that will lead to inclusion of these providers.

In late 2017, Schmidt visited The American Journal of Managed Care^® (AJMC^®) to discuss implementing Medicare DPP and her work with the Council of Diabetes Prevention. Watch the video of the interview.

The Importance of Adding the Diabetes Prevention Program to Medicare

AJMC^®: Can you describe the historic importance of adding the Diabetes Prevention Program to Medicare?

Schmidt: Prevention matters, and our older Americans matter. The inclusion of the Diabetes Prevention Program (DPP) as a Medicare benefit is both historic and significant for a few reasons. The first is, it’s the first preventive service coming out of CMS Innovation Center that meets the statutory requirements for expansion, and what that means is that it was demonstrated to both reduce net spending and improve or maintain patient care.

The second is, it’s delivered by non-clinical community organizations, and that’s a first. So now you have hyperlocal, non-clinical community organizations, who were traditionally funded by grant funding, now being able to pay through medical claims. The third is just the realization that our older Americans matter, and that they can make healthy lifestyle changes that can improve their health and prevent diabetes. So, inclusion of DPP as a Medicare benefit is not only important for seniors, it’s just important for the population of America.

AJMC^®: What are the key features of the final rule that are important to consumers?

Schmidt: What consumers should know about the Medicare Diabetes Prevention benefit is it is a required Medicare benefit for all Medicare beneficiaries, original Medicare fee-for-service, or Medicare Advantage plans and Medicare [supplement] plans members at no cost-sharing. So, this is a free benefit for all Medicare beneficiaries as of April 1, 2018.

The second is it’s delivered in community organizations; where people live, play, pray, and shop. And the third is, the goal of the program is to make long-term healthy lifestyle changes to lose a minimum of 5% of their body weight by attending these classes for up to a 2-year period.

AJMC^®: Can you discuss how the final rule affects Medicare Advantage plans and what these plans need to do to be ready to meet their clients’ needs by April?

Schmidt: There was a lot of confusion among the Medicare Advantage plans for whether, when, and how the finale rule would impact Medicare Advantage plans, but CMS is clear that Medicare Advantage plans have to offer the Diabetes Prevention Program as a preventive service effective April 1, 2018. There’s a couple of ways they can do that. The first way is for the plan to actually deliver the Diabetes Prevention Program themselves as a community provider. The second is to contract with community providers who meet the minimum Centers for Disease Control standards for being a Medicare DPP supplier.

At this point if a Medicare Advantage plan has not already implemented the DPP program, it’s way too late to implement April 1, so Solera has integrated those community providers and has broad contracts now with Medicare Advantage plans to allow them to access a broad, highly fragmented network of these community and person DPP programs.

Getting Ready for the Launch of Medicare DPP

AJMC^®: Now that the Medicare DPP rule is final, what are the priorities of Solera Health between now and April?Schmidt: Solera is really bust right now. We are contracting with almost all the Medicare Advantage plans because they’ve realized that, again this is a highly fragmented market, there are 1500 diabetes prevention programs, and they’re nonmedical and nonclinical. So, inherently it’s hard for a health plan to contract with a nonclinical, non-credentialed provider, and the other reality for health plans is that all of them would have to have a national network because part of the rule states that people can switch program providers at any time for any reason.

There’s a lot of seniors that live in one part of the country part of the year and another part of the country a different part of the year. The opportunity to network these providers together and offer some fluidity around their data and their experience covered by a health plan that may be covering them but is located in a completely different part of the country is fueling a lot of the realization that a network model makes sense to efficiently rollout the Medicare DPP benefit April 1. So, we’re working on making sure that our providers are ready so that DPP network partners become both Medicare suppliers and Medicare DPP suppliers, and we’re helping them work through that process. With our health plan clients, working out all the details around beneficiary eligibility and denials and CMS regulations to make sure that this benefit is rolled out in a way that is compliant with all the CMS regulations.

AJMC^®: If a primary care physician has someone walk into their office on April 1 who meets the criteria for prediabetes and could be enrolled, what should that physician do?

Schmidt: We have recognized that there’s a need in the marketplace to establish a national referral and enrollment site for DPP because that’s exactly the problem. I think physicians want to identify screen tests and refer their patients to a diabetes prevention program, but they don’t know what to do. So, we’ve registered a couple of URLs; MedicareDPP is one of them, and 1800Prevent is another. We’re now doing the market research around what would be a national DPP referral and enrollment site that could enroll people efficiently in a national network of programs or find grant funded programs for those people who may come to that site and not be covered by their program; perhaps they’re not Medicare beneficiaries, but they don’t have commercial coverage, and also create a directory of grant-funded programs. So, we will find a home for everyone. Right now, if they have someone we have wide coverage in a couple of states including California and Florida. Send them to Solera4me.com and we will do the same thing; we will find a home for them and a best fit DPP partner to help them on their journey to a healthy lifestyle.

Partnership with American Diabetes Association

AJMC^®: Discuss the partnership between Solera Health and the American Diabetes Association to help people with prediabetes find a DPP provider.

Schmidt: Solera’s really excited about our partnership with the American Diabetes Association, and what we recognized is that there was a lot of energy around educating consumers around their risk for type 2 diabetes and there was a program available to them to reduce their risk and improve their health. But, what we also noticed was that there wasn’t an efficient way for people to identify where a high-quality, local community DPP provider was, and whether they were covered by their insurance.

So, the partnership with the American Diabetes Association allows those people who are identified as high-risk for type 2 diabetes through the American Diabetes Association’s screener to be sent over to Solera for us to actually find a program for them that best meets their unique needs and preferences, verify their eligibility, and enroll them in a program so they can get started on improving their health.

CMMI’s test for virtual DPP providers

AJMC^®: Do you know any details of plans for the Center for Medicare and Medicaid Innovation (CMMI) to run a test for virtual DPP providers?

Schmidt: We’ve had several conversations with CMS about the expanded model pilot to include virtual and digital DPP providers. At this point, they’re looking at how they’re designing that program and doing the actuarial analysis on those programs and that will not be available for public comment. They do plan to release that and allow virtual and digital DPP providers to apply to be included in that expanded model that we’re hoping will be implemented sometime next year for inclusion of virtual and digital DPP providers in the future as Medicare DPP suppliers.

AJMC^®: Is there a timeframe for when it will be released?

Schmidt: I think some of it depends on the administration and CMMI, frankly. The decision for CMMI to move forward in an expanded model pilot for Medicare DPP is also dependent on the long-going and longer-term strategy for CMMI and the types of programs that they would like to evaluate.

The Role of the Council for Diabetes Prevention

AJMC^®: What is the Council for Diabetes Prevention’s role in DPP?Schmidt: The Council for Diabetes Prevention was launched September 2016 with the realization that these diabetes prevention partners are largely hyperlocal, community organizations that don’t have a voice in Washington. So, as Washington was considering not only making the Diabetes Prevention Program covered benefit a covered benefit, but how that was being rolled out, they needed a voice. We thought, we need to bring them all together and not only just be an advocacy voice; so, the Council for Diabetes Prevention is a 501(c)6 with a separate executive leadership and board of directors. It’s also a way to share best practices, promote quality, and just also be a voice in America for saying why the Diabetes Prevention Program is important and why it should be covered, and the community organizations and virtual and digital providers are the right providers to be offering this program.

So, we’ve been excited about the traction. We have over 100 different stakeholder groups; some of them are DPP providers, some are not. We have health systems like Johns Hopkins, we have states like the state of Tennessee. We have lots of different providers and stakeholders that are just interested in this space, and I think it’s been interesting to see that we’ve been able to gain so much credibility in a short period of time. As soon as the CMS final rule was released, CMS called and said, “Would you like a listening session with us for the councilmembers on Monday?” So, we had a listening session with CMS … where we had an opportunity for them to review the rule, but also ask some outstanding questions that we clarified some of the language that was perhaps a little unclear in that rule that was released on November 2.

References

1. Caffrey M. Final Medicare DPP rule adjusts maintenance period, excludes digital providers. The American Journal of Managed Care® website. http://www.ajmc.com/newsroom/final-medicare-dpp-rule-adjusts-maintenance-period-excludes-digital-providers. Published November 3, 2017. Accessed January 8, 2018.
2. Council for Diabetes Prevention. About Us. https://nationaldpp.org/about-us/. Accessed January 8, 2018.