Final Medicare DPP Rule Adjusts Maintenance Period, Excludes Digital Providers

CMS has agreed to limit the maintenance period of the Medicare Diabetes Prevention Program (DPP) to reduce burdens and financial risk on providers, but regulators did not budge on other key concerns when they finalized the program rule late Thursday.

Medicare DPP will launch April 1, 2018, more than 2 years after former HHS Secretary Sylvia Mathews Burwell announced that a pilot by the Center for Medicare and Medicaid Innovation (CMMI) had shown the DPP would save $2650 per beneficiary over 15 months. An estimated 84 million Americans have prediabetes, including 22 million age 65 years and older.

"Yesterday CMS released the Medicare Diabetes Prevention Program final rule which will guide the implementation of the Medicare DPP services next year. It is clear that CMS has closely listened to stakeholder feedback in several areas, including alignment and greater clarity for Medicare Advantage, which is now confirmed to start on April 1, 2018," said Brenda Schmidt, CEO of Solera Health.

The DPP is a yearlong, evidence-based lifestyle change program with a CDC-approved curriculum. The original program featured 16 weekly core sessions followed by 7 monthly sessions. Evidence shows the program stops prediabetes from progressing as participants make modest changes and lose 5% to 7% of body weight. In a landmark study by the National Institutes of Health, the program showed a 58% reduction in participants progressing to diabetes.

But as seen in the rulemaking process, what passes muster with CDC for efficacy with patients and what’s needed to prevent fraud with Medicare are not the same. Providers that today offer DPP through community groups and employers have raised concerns that CMS is creating so many barriers—without enough compensation—that many successful programs will pass on Medicare DPP.

Digital Providers Left Out. By contrast, virtual providers, including the growing number of digital ones, will see their participation limited when Medicare DPP launches next spring. Virtual providers were taken by surprise when CMS excluded them from the April launch. The rule’s final language says CMS will looking for signs that in-person programs are abusing a provision that allows 4 virtual “make-up” sessions, to make sure this is being use to shift beneficiaries to virtual formats. While several digital providers insist CDC has enough evidence for them to participate from day 1, the final rule states, “we are considering a separate model under CMS’ Innovation Center authority to test and evalutate virtual DPP services.”

“We are quite disappointed in this decision as it will needlessly delay millions of prediabetic seniors from getting the help they need," said Adam Fawer, chief financial officer of Noom Coach. "Multiple virtual DPP providers have proven in medical journals that their results are equivalent or superior to face-to-face intervention, so to say that further study is needed is simply not true. Moreover, there is no way that face-to-face interventions will be able to scale — too many seniors don’t live close enough to a DPP provider or lack the transportation necessary to attend weekly meetings. It is widely accepted that DPP will only be able to scale through virtual programs.”

Maintenance Period Shortened. CMS did concede that its original concept for a 24-month maintenance period, which would follow the initial 12-month CDC curriculum, would create undue burdens for keeping track of patients undermine tying reimbursement to program performance. Instead, CMS proposes a 2-part goal, with one part tied to weight loss of at least 5% and another part tied to the participant achieving attendance milestones.

But regulators did not abandon the idea of follow-up.

“Upon consideration of the comments received, we agree that limiting the ongoing maintenance sessions to 12 months following the 12-month core program will reduce the administrative burden and financial risk for suppliers while still providing 1 year of ongoing support and maintenance to help solidify behavior change in MDPP participants,” the rule stated.

One-Time Only. Medicare also rejected requests that beneficiaries be able to try DPP more than once. The rule states that beneficiaries have flexibility in the use of make-up sessions and in the first year of core services following the first core session. Providers (called suppliers in the rule) are encouraged to help seniors gauge how ready they are to commit before enrolling them.

“The beneficiary can take a break and begin attending MDPP sessions again within the first year,” the rule stated, and still be eligible for maintenance sessions, “as long as the beneficiary begins attending sessions again and meets the 5% weight loss goal in months 10-12.” CMS said, however, that it would continue to evaluate the once-per-lifetime limit.

Medicare Advantage (MA). There had been some confusion how MA would handle DPP, and the final rule makes clear that (1) MA programs must offer DPP in nearly all circumstances, and (2) the rule states that MA plans must offer coverage “on at least the same terms” as original Medicare; Schmidt wrote Thursday night in a post that this means MA plans must offer Medicare DPP through community providers.

The final rule further states: “We note that Medicare health plans may generally also provide more generous coverage,” than original Medicare as a supplemental benefit.