Part 1 of 2

On March 23, 2016, the Affordable Care Act turned six years old. Signed into law in 2010, the Affordable Care Act was passed to tackle massive costs to the American healthcare system and to ensure that Americans receive high quality healthcare by focusing on preventive care, “pay for performance,” and improved care coordination. So far, however, initiatives focused on preventive medicine have not shown major cost savings to the healthcare system at large.

That stands to change, though, since the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary announced that the Diabetes Prevention Program (DPP) is now eligible for reimbursement for Medicare beneficiaries. Along with new initiatives to provide reimbursement for individuals with two or more chronic illnesses (chronic care management) and healthcare practitioners who provide telemedicine, reimbursement for the DPP shows that CMS is taking the increased incidence and prevalence of non-communicable diseases in the United States seriously. The DPP will now consist of “16 sessions delivered by lifestyle coaches approximately weekly followed by six sessions delivered approximately monthly that promote healthy lifestyle changes and weight loss.” The memorandum from the CMS Office of the Actuary adds: “maintenance sessions would be offered after the first year of the program to aid participants in maintaining their healthy lifestyle and weight loss.”

The CMS decision to provide reimbursement for the DPP is based on three years of clinical trial evidence provided by the YMCA and the Center for Disease Control and Prevention (CDC), as well as other programs similar to the DPP recognized by the CDC dating back to 1996. The DPP Curriculum is delivered to groups of 8 to 15 participants and sessions cover topics related to healthy eating, exercise, and healthy lifestyle. Average weight loss after 12 quarters was 4.73 percent for participants who attended at least four core sessions and 5.17 percent for participants who attended at least nine sessions.

Participants in the DPP demonstrated significant healthcare system savings and had significant reductions in hospital inpatient admissions. In each of the clinical trials of the DPP, the majority of participants were over 50 years old, even when the inclusion criteria allowed individuals over 25 years to enroll. This shows that older adults can be the target of a health and lifestyle intervention like DPP and demonstrate success. Indeed, the results of the various DPP clinical trials are so compelling that the CDC recently added the DPP to its 6|18 Initiative as a data-driven intervention for one of six burdensome health conditions.

The Joslin Diabetes Center nutrition guidelines offer specific guidance on structuring meal plans with and without meal replacements that are aligned with the DPP recommendations for portion control, weight reduction goals, and working with a registered dietician or other healthcare provider for guidance. There are a variety of meal plan and lifestyle change ideas online to get started with the DPP, including options from the NIH and YMCA. Integrating meal replacement medical foods into the DPP is easy to do and is advocated by DPP providers, including the Perelman School of Medicine at the University of Pennsylvania. In the second part of this blog post, we will discuss the role of meal replacements and medical foods in the DPP in greater depth.

The new reimbursement protocols for the DPP through CMS offer an exciting opportunity for more healthcare providers to get involved in disease prevention and early- to mid-stage disease management. For more details on seeking reimbursement for your work in the DPP, see below, or check out the full curriculum from the CDC.

In order to be eligible for reimbursement through CMS, the DPP program participants must:

  • Be an enrolled beneficiary of Medicare
  • Have a body mass index (BMI) of 25 or greater
  • Have A1C of 5.7 percent to 6.4 percent (39 to 46 mmol/mol), or Impaired Fasting Glucose: Fasting plasma glucose of 110-125 mg/dl (5.6 to 6.9 mmol/L), or Impaired Glucose Tolerance: 2-hour plasma glucose after the 75 gram Oral Glucose Tolerance Test of 140 mg/dl-199 mg/dl (7.8 to 11.0 mmol/L)
  • Have no previous diagnosis of diabetes
  • Have no life-threatening conditions, mobility issues, etc. that would prohibit them from participating in the program

The payment schedule for the full DPP:

Service Provided Payment
Core Sessions
1 session attended $25
4 sessions attended + $50
9 sessions attended + $100
5 percent weight loss from baseline + $160
9 percent weight loss from baseline + $25
Maximum Total for Core Sessions in Year 1 $360
Maintenance Sessions (Maximum of 6 monthly sessions over 6 months in Year 1)
3 maintenance sessions attended with maintenance of 5 percent weight loss $45
6 maintenance sessions attended with maintenance of 5 percent weight loss +$45
Maximum Total for Maintenance Sessions in Year 1 $90
Maximum Total for Year 1 $450
Maintenance Sessions After Year 1 (Minimum of 3 sessions attended per quarter with no maximum)
3 maintenance sessions plus maintenance of 5 percent weight loss $45
6 maintenance sessions attended plus maintenance of 5 percent weight loss + $45
9 maintenance sessions plus maintenance of 5 percent weight loss + $45
12 maintenance sessions attended plus maintenance of 5 percent weight loss + $45
Maximum Annual Total After Year 1 $180

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