Medicare to Roll Out Diabetes Prevention Program in 2018

Kristin Jenkins

November 17, 2016

The US Centers for Medicare and Medicaid Services (CMS) has announced that, as of January 1, 2018, it will be expanding the Diabetes Prevention Program (DPP) out from its current pilot to provide coverage for all eligible at-risk beneficiaries with prediabetes who are aged 65 years or older.

Medicare beneficiaries who have had gestational diabetes and are at high risk for developing type 2 diabetes will also be eligible.

When the landmark trial of this intensive lifestyle-intervention program concluded in 2000, results showed that patients with prediabetes who exercised every day and lost 5% to 7% of their body weight could cut their risk of developing type 2 diabetes by 58%.

It is estimated that more than 11 million people, or about 26% of people 65 years of age and older in the US, have diabetes and face higher risks of heart disease, kidney failure, limb amputations, and blindness. It is also estimated that in 2016, Medicare will spend an estimated $42 billion more on beneficiaries just because they have diabetes.

"I think this program is going to open things up quite a bit, and not only in the diabetes world, but in other areas as well," said Robert Gabbay, MD, PhD, chief medical officer at Joslin Diabetes Center in Boston, Massachusetts, in a press release from his institution.

One of the key aspects of this rollout will be the fact that, for the first time, CMS "is going to be reimbursing for diabetes prevention based on this evidence-based program," added Dr Gabbay. "Currently, the challenge is that when we identify people who are prediabetic, which is easy to do with a simple blood test, we don't have a program to enroll them in that is reimbursed."

Coverage for Prevention Programs Should Boost Physician Use

Many busy clinicians haven't been performing the simple blood test to diagnose prediabetes because of the lack of coverage for care, and therefore it has been "a matter of not knowing what to do when the diagnosis comes back," Dr Gabbay elaborated.

Having an effective — and insured — treatment to offer will change all that, he believes.

"There is effective treatment for prediabetes, and physicians should strive to make the diagnosis."

And despite the uncertainty that now prevails about healthcare policy under president-elect Donald J Trump, which "puts some things in question marks in terms of the future and whether there will be any significant changes," Dr Gabbay told Medscape Medical News he believes the DPP's cost-effectiveness will mean the program ultimately prevails.

Since this program is cost saving, "it's hard to imagine why one wouldn't want to support something like this," he added.

A cost analysis of the DPP model test by CMS revealed that it saved an estimated $2650 per person over a 15-month period.

This is "more than enough to cover the cost of the program," according to the CMS blog post "Preventing Diabetes and Protecting the Medicare Trust Fund."

Since 2000, the DPP has been modified and studied in community settings, and this "has given us real-world evidence that there is significant potential to improve health, prevent diabetes, and reduce long-term medical costs incurred by this disease," Dr Gabbay added.

The evidence-based, validated program is already available in some areas, he noted, although it is not yet reimbursed.

DPP Booster if 5% or More Weight Loss After 1 Year

The DPP 1-year lifestyle intervention includes stress reduction, dietary coaching, and moderate physical activity.

It consists of at least 16 weekly core hour-long sessions for the first 6 months and monthly core maintenance sessions for the last 6 months. These sessions are provided whether or not there is weight loss.

Patients who achieve and maintain the minimum weight loss of 5% after the 12-month core program are eligible for 3-month intervals of ongoing maintenance sessions, which are also insured. "People call it a 'booster,' " Dr Gabbay explained.

It is hoped that other insurers will follow the lead of CMS and offer diabetes-prevention programs to other groups at risk. "There is precedence for this across other coverage changes," Dr Gabbay pointed out.

"Services like diabetes education and nutrition therapy are examples of services where CMS really helped spearhead the change and commercial payers started covering it. And I think providers are likely to home in on it more because they now have a treatment to offer."

This is vitally important given that "one-third of teens will develop diabetes in their lifetime.…We have a tsunami of diabetes," Dr Gabbay told Medscape Medical News.

Eligibility Criteria for Medicare Diabetes Prevention Program (MDPP)

To be eligible for MDPP services, Medicare beneficiaries must:

  • Be enrolled in Medicare Part B.

  • Have a body mass index (BMI) of at least 25 (if not self-identified as Asian) and a BMI of at least 23 (if self-identified as Asian) at the first core session of the program.

  • Have a HbA1c test with a value between 5.7% and 6.4%, a fasting plasma glucose of 110 to 125 mg/dL, or a 2-hour plasma glucose of 140 to 199 mg/dL (oral glucose-tolerance test) within the 12 months prior to attending the first core session.

  • Have no previous diagnosis of type 1 or type 2 diabetes with the exception of gestational diabetes.

  • Have no end-stage renal disease.

Any healthcare provider certified by the Centers for Disease Control and Prevention will be eligible to administer the diabetes prevention program.

More about the Medicare Diabetes Prevention Program expanded model and primary care, is available here.A fact sheet on the Medicare Diabetes Prevention Program expanded model is available here.

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