Though tens of millions are susceptible to diabetes, Medicare is combating to increase the prevention program – Every day Breeze

By Harris Meyer,

Kaiser health news

Damon Diessner tried for years to lose weight from more than 400 pounds, largely 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 into a YMCA-led diabetes prevention program not far from his home in Redmond, Washington. The group courses, which were held first in person and then via Zoom during the coronavirus pandemic, were led by a lifestyle coach. He learned to eat better, exercise more and lead a healthier lifestyle overall. He now weighs 205 pounds, with an A1c value of 4.8%, which is normal.

“This was a life changing program,” said Diessner, 68, an environmental consultant. “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 out of an estimated 16 million Medicare beneficiaries whose obesity and risky A1c score qualify them, only 3,600 have participated since Medicare covered the two-year Medicare diabetes prevention program in 2018, according to the federal government’s Centers for Medicare & Medicaid Services.

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 usually 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.

Now the Centers for Medicare & Medicaid Services have proposed a rule change to address some, but not all, of these issues. It predicted the changes would reduce the incidence of diabetes in the Medicare population and potentially lower federal spending on the treatment of diabetes-related diseases.

Last month, the agency suggested 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. The rule changes would make it easier and more attractive for MDPP providers, including YMCAs and other local community organizations, to participate, Medicare & Medicaid Services said.

While providers welcomed the proposed revisions as slightly helpful, they criticized the agency for failing to provide Medicare benefit recipients with courses and advice through online methods, including apps, video conferencing, and SMS. Many health insurers that cover people under 65 offer similar diabetes courses online and say the success rates are comparable to classroom courses.

“Virtual access would improve access and reduce inequalities for people with barriers such as transportation and distance,” said Dr. Liz Joy, Senior Medical Director, Wellness and Nutrition at Intermountain Healthcare in Salt Lake City.

A bipartisan bill in the US House and Senate, the Prevent Diabetes Act, would allow virtual vendors certified by the US 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 personal nutritional coverage for people with diabetes or kidney disease is used by less than 1% of the 15 million beneficiaries with these conditions. Insurers, 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 they don’t know it will benefit?” Said Maria Alva, an assistant professor of research at Georgetown University who studied the MDPP. “And doctors are paid more to prescribe diabetes drugs than they take the time to recommend the diabetes prevention program.”

When Medicare & Medicaid Services started paying for the diabetes prevention program, the agency estimated that it would save Medicare $ 182 million over 10 years by reducing diabetes. The federal agency had forecast that 110,000 beneficiaries would register.

However, 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. The agency must give priority to registering additional providers, said RTI; approximately 200 organizations offer MDPP courses in 762 locations across the country, a small percentage of the approximately 1,900 organizations that are CDC certified to offer diabetes prevention courses.

A major factor that has so far limited the participation of the providers is that the federal government has tied a bonus payment to the loss of at least 5% of their body weight, which only a minority of the participants achieved. However, studies show that a weight loss of only 2 to 3% can significantly reduce 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 successfully completing the program – a 0.2% reduction in hemoglobin A1c levels or a 4% weight loss combined with at least 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, for various reasons, are less likely to attend all sessions and achieve 5% weight loss, 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.”

The Centers for Medicare & Medicaid Services asked for comment that the CDC standards required care providers to meet performance goals, but did not explain why they did not adopt the health authority’s alternative success measures. Regarding online courses, Medicare & Medicaid Services said that MDPP was originally intended to primarily provide personal services.

Diessner, who far exceeded the 5% weight loss goal, said he was inspired to step into MDPP by watching his little grandson 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 as 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.”

Kaiser Health News is a non-profit news service on health topics. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

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