HHS seeks Medicare benefit for diabetes prevention program

April 1, 2016

Lifestyle counseling program would be first to be eligible for expansion to all Medicare beneficiaries under the Affordable Care Act.

The Department of Health and Human Services (HHS) recently announced plans to expand its Diabetes Prevention Program, a model funded by the Affordable Care Act, now that results have shown that the program aimed at high-risk seniors not only improved health but also resulted in reduced net Medicare spending on beneficiaries.

Provisions in the Affordable Care Act established the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation to test new service delivery models. According to the law, if a tested model is successful “the [HHS] Secretary may, through rulemaking, expand (including implementation on a nationwide basis) the duration and the scope of a model that is being tested…”

A large study of the Diabetes Prevention was conducted through an almost $12 million grant given to the National Young Men’s Christian Association (YMCA) of the USA. Independent evaluators of the program found that participation resulted in weight loss for patients with prediabetes and a reduction in Medicare costs.

According to HHS, the administration supports the expansion of the Diabetes Prevention Program to include all Medicare beneficiaries. This would be the first time that a preventive service model from the CMS Innovation Center would become eligible for expansion into the Medicare program.

More information about how CMS could expand the Diabetes Prevention Program will be included in the CY 2017 Medicare Physician Fee Schedule proposed rule, which is anticipated to be released this summer, according to HHS.

 

“Quite a bit remains to be seen about the actual implementation details,” Shari Erickson, MPH, vice president of governmental and medical practice at the American College of Physicians told Medical Economics. “Assuming that there is smooth sailing – and that is a big assumption – I think the big challenge will be at the practice level as far as the time and ability of physicians to identify patients who could benefit from these programs and their ability to pass along that information.”

According to according to Wanda D. Filer, MD, FAAFP, president of the American Academy of Family Physicians, these details will play an important role in the ability of physicians to be able to confidently refer their patients. Because the Affordable Care requires coverage of preventative services, there is an assumption that this type of program would be fully covered, Filer said, but that remains to be seen.

Although the testing of these lifestyle counseling services was conducted through community-based YMCAs, it is also possible that in the future these programs could be available through physician offices or health care systems.

“Over time this could be the type of service that physicians may wish to bring into their practice, but the big question will be whether that makes sense for their patient population and the resources available to the practice,” Erickson said.

If a physician cannot offer these services at their practices, they should encourage participation in these programs using a variety of methods, Filer said.

“You can tell [patients] that they can take some pounds off and lower their chance for becoming a diabetic,” she said. “Many patients will respond to that, but if you need to give them a bit more evidence you can talk about how lowering their risk for diabetes could potentially save them from the cost of as many as three to four medications, and thousands of dollars in medical expenses. That often resonates with a person of any age.”