Although millions are at risk of diabetes, Medicare is struggling to expand its prevention program

Damon Diessner tried for years to lose weight from over 400 pounds, in part because his size embarrassed his wife, but even more because his doctors told him he was at risk of developing type 2 diabetes. His hemoglobin A1c level, a blood sugar marker, was 6.3%, just below the diabetes range of 6.5%.

Then, two years ago, one of his doctors helped him get accepted into a YMCA-run diabetes prevention program near his home in Redmond, Washington. The group courses, which were held first in person and then via Zoom during the Covid-19 pandemic, were led by a lifestyle coach. He learned to eat better, exercise more, and maintain an overall healthier lifestyle. He now weighs 205 pounds, with an A1c value of 4.8%, which is normal.

“This was a life changing program,” said Diessner, 68, environmental advisor. “My cardiologist said you clearly beat diabetes. I tell anyone who has blood sugar problems or just wants to lose weight that this is the right thing to do. “

Over the past decade, tens of thousands of American adults of all ages have taken these diabetes prevention courses with personalized coaching at YMCAs, hospitals, community health centers, and other locations. But of an estimated 16 million Medicare benefit recipients eligible due to their obesity and risky A1c level, only 3,600 have participated since Medicare covered the biennial Medicare Diabetes Prevention Program (MDPP) & Medicaid in 2018, according to the federal government’s Centers for Medicare -Services (CMS).

Researchers and people doing diabetes prevention efforts said participation is low due to the way Medicare set up the program. It pays too little to program providers: a maximum of $ 704 per student and typically much less for dozens of courses over two years. It also imposes cumbersome billing rules, inappropriately publishes the programs, and requires in-person courses with no online options except during the pandemic emergency period. Most Medicare Advantage private plans did not advertise the program to their members.

CMS has now proposed that some, but not all, of these problems be addressed by changing the rules. It predicted the changes would reduce the incidence of diabetes in the Medicare population and potentially lower federal spending to treat diabetes-related diseases.

Before losing weight, Damon Diessner’s doctors said that he was at risk of developing type 2 diabetes. (Laurie McKenzie)

On July 13, the agency proposed shortening the program to one year from 2022, as providers complain that too few beneficiaries are completing the second year. These and other changes proposed by Medicare would marginally improve reimbursement to providers. The government also plans to forego a one-time fee of $ 599 that groups offering the courses must pay to Medicare in order to participate in their program. CMS said the rule changes would make participation easier and more attractive for MDPP providers, including YMCAs and other local community organizations.

While providers welcomed the proposed revisions as slightly helpful, they criticized CMS for failing to offer Medicare benefit recipients courses or advice through online methods such as apps, video conferencing, and texting. Many health insurers that cover people under 65 offer similar classes of diabetes online, and they claim the success rates are comparable to those of face-to-face events.

“The proposed rule changes should have the intended effect on improving access for Medicare members,” said Dr. Liz Joy, Senior Medical Director, Wellness and Nutrition at Intermountain Healthcare in Salt Lake City. It offered face-to-face courses at many of its hospitals, but switched to online courses during the pandemic. “Virtual access would improve access and reduce inequalities for people with barriers such as transportation and distance,” said Joy.

A bipartisan bill in the House and Senate, the Prevent Diabetes Act, would allow virtual providers certified by the Centers for Disease Control and Prevention to participate in the Medicare Diabetes Prevention Program. Bill’s sponsors say virtual programs are needed to better serve lower-income, minority, and rural Americans.

The Diabetes Prevention Initiative is just one of several programs that have been shown to be effective in reducing or treating chronic disease, but underutilized due to the U.S. healthcare system’s lack of focus on disease prevention. For example, Medicares coverage of personal nutritional advice for people with diabetes or kidney disease is used by less than 1% of the 15 million beneficiaries with these conditions. Insurance companies, hospitals and doctors lack sufficient financial incentives to offer preventive services.

“Patients could switch providers next year, so why should a company invest in prevention if it doesn’t know it will benefit?” Said Maria Alva, an assistant professor of research at Georgetown University who studied the MDPP. “And doctors get paid more to prescribe diabetes drugs than they take the time to recommend the diabetes prevention program.”

CMS started paying for the diabetes prevention program in 2018. According to studies that showed its effectiveness in helping obesity, prediabetic patients lose nearly 5% of their body weight, which can reduce their risk of developing diabetes by 71%. The agency had estimated the Medicare program would save $ 182 million by reducing diabetes over 10 years. CMS had forecast that 110,000 beneficiaries would register.

An evaluation of the program by research group RTI International published in March found that there weren’t enough participants to determine whether participation improved health outcomes or reduced Medicare costs. With about 200 organizations offering MDPP courses in 762 locations across the country, CMS must give priority to enrolling additional providers, RTI said. Nationwide, around 1,900 organizations are CDC certified to offer diabetes prevention courses, but only a small percentage choose to participate in Medicare.

A major factor that has limited the participation of providers so far is that CMS has tied a bonus payment to the loss of at least 5% of their body weight, which only a minority of participants achieve. However, studies show that a weight loss of only 2% to 3% can significantly lower A1c levels and the associated risk of developing diabetes.

In contrast, the CDC recently updated its certification standards for diabetes prevention programs to include two alternative measures for successful program completion – a 0.2% reduction in hemoglobin A1c levels or a 4% weight loss combined with at least one 150 minutes of physical activity per week.

But under Medicare’s new proposed rule, MDPP providers would receive up to $ 635 if a participant reached the 5% weight loss goal and attended 13 sessions over a year, or $ 661 if the person had 9% of the Loses body weight. Provider payments would be capped at $ 338 if a participant missed the 5% weight loss goal.

Researchers and providers say the payment model harms organizations that serve low-income and minority groups whose members are less likely to attend all sessions and experience 5% weight loss for a variety of reasons, but who may still benefit from the program. Even without the penalty for not meeting the 5% target, Medicare’s payment rate doesn’t nearly cover the cost of running in-person classes, experts say.

“Five percent is a stretch goal and 9% is ridiculous,” said Dr. Amanda Parsons, who previously led the MDPP program at Montefiore Health System in New York City, which primarily services low-income Black and Hispanic beneficiaries. “I want to know how many people come anywhere near that goal.”

When asked for comment, CMS said the CDC standards require vendors to meet performance goals but did not explain why the CDC’s alternative measures of success were not adopted. On the subject of online courses, CMS said that MDPP was originally intended primarily to provide personal services.

Diessner, who far exceeded the 5% weight loss goal, said he was inspired to step into MDPP by seeing his little grandson’s brave efforts to cope with type 1 diabetes. Despite Diessner’s determination, his doctor had to lobby YMCA staff for several months to get him a place because the few available courses were fully booked. He was shocked to learn of the low attendance across the country.

“I see a lot of people on the street who could use some help,” he said. “The idea that so few people benefit from it is a travesty.”

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