Work to Do Before Medicare's Diabetes Prevention Program Is Set in Place

JUNE 12, 2017
Mary Caffrey
Nina C. Brown-Ashford, MPH, CHES, remembers when the Center for Medicare and Medicaid Innovation (CMMI) received the first field reports from the pilot of the National Diabetes Prevention Program (DPP) with the Y-USA. The results were so positive that another agency veteran said, “I think there might be something here.”

That set in motion calls to CDC’s Ann Albright, PhD, RD, the director of the Division of Diabetes Translation, and a process that would lead CMS’ actuary to certify that pilot participants saved Medicare $2650 a piece over 15 months. Ultimately, 83% of the participants would take part in at least 4 sessions, and the average weight loss was 9 pounds.

Back in March 2016, it was official: DPP would go national in Medicare, come January 1, 2018. “That felt really far away,” said Brown-Ashford, now the acting director of the Division of Health Care Delivery at CMMI.

On Saturday, she described Medicare DPP as starting “on or after” that January 1, 2018, target date. While no one is arguing the benefits DPP will ultimately offer, starting a government program from scratch—with features no one has ever used before—is proving a daunting task. Brown-Ashford led off a symposium at the 77th Scientific Sessions of the American Diabetes Association on success stories about the DPP, which has been shown in clinical trials to help those with prediabetes reduce their risk of progressing to type 2 diabetes by 58%.

Recent evidence published in Diabetes Care from 4 years of experience with DPP found major progress and offer hints on improving the program. Medicare DPP will involve many “firsts,” Brown-Ashford said: CMS must create a brand-new class of nonclinical suppliers in the community coaches. It will be fashioning an outcomes-based payment model on top of its fee-for-service reimbursement system. It must figure out how to pay groups that aren’t set up to bill Medicare (although an integrator, Solera Health, is positioned to take on this task).

For those fearful that an end to the Affordable Care Act might take the DPP down with it, Brown-Ashford offered good news: Medicare is scheduled to pay for DPP through the Part B trust fund. But Brown-Ashford could not give a publication date for the second round of rules, which would include critical guidelines for billing and participation for digital providers. She did offer more specifics on how CMS plans to avoid fraud by requiring coaches to have National Provider Identifier (NPI) numbers, and she said that community programs can have a preliminary status through CDC while they earn full recognition, so that there’s enough capacity to serve all the seniors who expect to take part. Brown-Ashford is optimistic. With 25% of seniors developing T2D, the prospect of saving $2650 for a quarter of the Medicare population will drive the DPP forward. “We’re talking about a lot of money,” she said.

While Medicare awaits its DPP rollout, it exists already through many outlets nationally. Nicole Johnson, DrPH, of the University of South Florida, shared highlights of a promotional plan used in that state to attract attendees and improve delivery to target audiences. Social marketing, she said, takes advantage of built in community networks to engage community leaders and influencers to encourage participation.

Dorothy Gohdes, MD, of the Montana Department of Health and Human Services, and Linda Weiss, PhD, of the New York Academy of Medicine, offered 2 different “Tales from the Trenches” perspectives from offering DPP in very different locations, each with unique challenges.

Gohdes has been working on DPP since 2008, and has seen it expand in distinct phases: (1) from 2008-2010, Montana health officials learned they could deliver DPP in a variety of settings using a 2-day training module with diabetes educators, (2) from 2011-2014, they learned that seniors were more likely to participate. and they gained insights about the Medicaid population, and (3) from 2015 to the present they are learning that telehealth can bring DPP to new populations they could never reach, including the entire southeastern corner of the state that is the size of West Virginia.

Back when Gohdes started, Montana health officials worked with primary care physicians for referrals. Only 24% were diagnosing “prediabetes” and fewer still were screening for glucose tolerance. But they could look for other indicators, like women who’d had gestational diabetes and a baby weighing more than 9 pounds.

Over time, Gohdes and her team have learned that the size of the education group taking DPP classes does not matter. But having a licensed lifestyle coach will help with reimbursement. When Montana began working with Medicaid clients, a study examined whether financial incentives would improve results. It worked, sort of—people came to more classes but didn’t lose more weight. “Monetary incentives increased participation, but this did not improve outcomes,” Gohdes said.

Like programs nationwide, Gohdes and Weiss have found that those who likely need the DPP the most can be the hardest to recruit and retain. Experts on DPP continue to work on ways to tackle this problem, such as the project Weiss worked on that tried to enroll a program of low-income men in New York City. Despite an extensive recruitment campaign—in public housing, churches, barber shops, and social media, the program attracted 29 recruits. This reflects national data that show men make up only 20% of the participants are men; digital providers believe they can help correct that imbalance.

Once enrolled, the men in the New York City program did well: two-thirds attended 9 or more sessions, and 21% attended 4 to 8 sessions. The men said they appreciated that they could talk openly about things that concerned them, without women in the room. Weiss has done other research about why people drop out of DPP programs. Often it involves fear of traveling at night in bad weather, lack of interest in the material, but most often it’s competing needs. “Life gets in the way,” she said. And once people miss a class or 2, they feel they can’t go back. “Outreach from coaches could have been helpful.” 

Reference
Brown-Ashford NC, Gohdes D, Weiss L.  Population Health, Affordable Care Act (ACA), and New Approaches for Dissemination/Implementation of the Diabetes Prevention Program (DPP)Presented at: American Diabetes Association 77th Scientific Sessions; June 9-13, 2017; San Diego.

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