Medicare to pay $450 to help seniors lose weight, avoid diabetes
Oscar and Teri Lara shop for fresh food more frequently in their quest to lose weight and avoid diabetes. June 27, 2017. Megan Wood, inewsource.

Medicare to pay $450 to help seniors lose weight, avoid diabetes

Oscar and Teri Lara of Rancho Bernardo were diagnosed with prediabetes a few months ago, a condition 86 million Americans share.

That means the retired couple live with a greater chance they’ll develop diabetes, which can lead to heart, nerve, kidney and eye disease, and an early death.

Some 86 million Americans live with prediabetes, which can progress to diabetes, a costly and debilitating disease. A new program can help people lose weight, a proven way to reduce the risk of getting the disease.

The Laras are lucky.  Nine in 10 Americans don’t know they have prediabetes, but the Laras were caught early. They have an opportunity to alter their diets, reduce their sugar intake and lose weight, and likely  postpone or prevent that trajectory.

On advice from their doctors, they enrolled in a special lifestyle class, part of the Scripps Diabetes Prevention Program, much like the curriculum that will be offered to Medicare beneficiaries across the country, free of charge, starting Jan. 1.

“This class changed my thinking about what I eat, how much I eat, how to stay focused, and how to maintain a healthy regimen of proper nutrients to put into my body,” Oscar Lara said. Instead of chomping down on bread and burritos, it’s broccoli, brussel sprouts and salads.

$450 for a few pounds of flesh

Providers who run Medicare’s year-long programs will receive up to $425 per participant if attendees take all the classes and lose 5 percent of their body weight during the year; $450 if they lose 9 percent. If attendees miss classes, drop out, or fail to lose that much — or gain it back — the programs will be paid incrementally less.

Teri and Oscar Lara load their healthier grocery items at the Sprouts checkout. Both have lost weight since they began watching what they eat. June 27, 2017. Cheryl Clark, inewsource

Teri and Oscar Lara load their healthier grocery items at the Sprouts checkout. Both have lost weight since they began watching what they eat. June 27, 2017. Cheryl Clark, inewsource

In 2012, the direct medical costs for 29 million people diagnosed with diabetes in the U.S. was an estimated $176 billion, including hospital, drug, and physician services. That’s why the issue is so critical, and why the agency that runs Medicare wants to put a dent in that spending.

After all, 21 percent of patients with diabetes are Medicare eligibles diagnosed after they turn 65.

Numerous studies going back 16 years have shown that people can delay or prevent diabetes by losing weight; a drop of a few pounds improves the body’s ability to manage sugar intake.

Looking out for fraud

The Centers for Medicare and Medicaid Services (CMS) has made it clear it will be looking for cheaters: those providers who enroll people without documented prediabetes, or who falsify weight loss or attendance. CMS can track much of that through inconsistencies in subsequent billing. It referenced the word “fraud” 13 times in the latest rules for the program.

What you need to know about prediabetes

  • In general, prediabetes can be detected in blood tests such as A1C at levels between 5.7 and 6.4 percent, or a fasting plasma glucose test at levels of 100 or 110 to 125 mg/dL.
  • 86 million adults, or one in three, have prediabetes – 90 percent of them don’t know it.
  • 51 percent of people 65 and older have prediabetes.
  • Most are overweight or obese. A BMI of 25 or greater, or 23 or greater for Asians, is associated with a greater risk of progression to diabetes.
  • The cost of prediabetes is estimated at $44 billion annually.
  • 5 percent to 10 percent of people with prediabetes will progress to diabetes each year.
Source: Centers for Disease Control and Prevention, American Diabetes Association

But federal officials believe the program is worth the risk because weight loss in a population with prediabetes has the potential to save that much more money.

For Ann Albright, PhD, RD, director of the diabetes program at the Centers for Disease Control and Prevention (CDC) which is helping to write the program’s rules, said the incentive payments are long overdue.

“We have a medication distribution system in this country, but not a lifestyle distribution system, and that’s what this program is going to do,” she said.

Dr. David Nathan, a Massachusetts General Hospital diabetes expert whose 2002 study proved the lifestyle intervention concept works, called the program “extremely extraordinary.”

Researchers in his multi-center study randomized thousands of overweight people with prediabetes. They were divided into three groups. One third received a series of individualized lifestyle sessions, one third received the drug metformin, which controls blood sugar levels,  and one-third received no intervention.

The result? Lifestyle intervention not only resulted in greater weight loss, but it also delayed or prevented many people from progressing to diabetes, and had an even greater beneficial impact on seniors.

“We know our program works,” Nathan said.

Churches and supermarkets

Some 1,425 settings — including 13 in San Diego County — have applied for certification. They include hospitals systems, physician practices and clinics, pharmacies, wellness centers, hospital systems, county governments, Jenny Craigs, and even churches and Albertson’s supermarkets.

What you need to know about diabetes

  • 29 million people in the U.S. have diabetes (95 percent of them type II and 5 percent type I).
  • Average medical expenses for a person with diabetes total $13,700 per year, with $7,900 of that due to diabetes. That total cost is 2.3 times higher than for people who do not have diabetes.
  • Direct medical costs nationwide for people with diabetes: $176 billion.
  • Productivity losses: $5 billion more is lost in increased absenteeism, $20.8 billion for reduced work productivity, $2.7 billion for reduced productivity for those not employed and $21.6 billion as a result of inability to work.
Source: Centers for Disease Control and Prevention, American Diabetes Association

CDC diabetes communications specialist Josh Petty said many others are being processed to meet what is hoped to be a huge national demand.

The centers must have CDC certification, but the rules to date do not specify how instructors should be trained.

Diabetes prevention programs have used federal grants or private insurance in the past. The YMCA-USA version used an $11 million federal grant to enroll 7,000 Medicare beneficiaries in eight states for a three-year program. It realized savings of $278 per person in costs for hospitalizations and emergency room visits.

But the new program is the first to tackle all Medicare beneficiaries with blood glucose levels indicating prediabetes and who have a BMI of at least 25, or for Asians, at least 23.

Is the money enough?

It’s hard to get some people to schedule time or feel comfortable discussing weight gain and intimate health problems in group settings.  And many physicians worry that programs will fall apart if patients don’t enroll and stick to the plan.

Oscar Lara had a lot of incentive. Awhile back, he had a stroke, and has survived cancer.  “Prior to this program, I felt I could eat whatever I wanted.  Sugar, carbohydrates, the things that spike glucose,” he said.  “Now this class has kept me focused. It’s really been a lifestyle change.”

Athena Philis-Tsimikas, MD, vice president of the San Diego-based Scripps Diabetes Care and Prevention program in La Jolla, is optimistic, and now is running a year-long trial program with 100 participants, which the Laras now attend.

But she’s frankly worried that $450 won’t pencil out to hire enough staff to support, phone and remind participants, and there’s data collection and submission requirements too.

“There’s a lot of ifs in this,” she said. “And it’s hard to tell right now, with $450 per participant, if we’re going to be able to do that. It would mean we would have to run a really lean operation.”

Dr. Paul Speckart, thinks the best way to get people to lose weight to prevent diabetes is to pay them directly.

“It’s almost an article of faith that talking and lectures don’t work to get patients to lose weight,” he said “People don’t. We almost always have to move to pharmaceutical solutions.”

What might be more effective, he said, is to give people with prediabetes brochures about diet and exercise, but pay them $200 every month their observed weight drops another 1 percent from baseline for a year. His rule: Failure in any one month would get them expelled.

The Medicare rule says what providers will be paid for each beneficiary who takes lifestyle classes and loses weight.

The Medicare rule says what providers will be paid for each beneficiary who takes lifestyle classes and loses weight.

More patients screened

A key to success of the program is to ensure that physicians aggressively screen Medicare beneficiaries for prediabetes.

People who read their blood test results should look for a fasting glucose of 100 and 125 mg/dL or an A1c between 5.7 and 6.4 percent to see if they have prediabetes.

A element critical to the program is that doctors explain the the seriousness of the condition and refer patients. Counseling people to lose weight is not something doctors like to do, and some question whether they would be paid for the extra time.

But Elizabeth Joy, MD, clinical champion for the Intermountain Diabetes Prevention Program at Intermountain Health in Salt Lake City, said she thinks physicians should welcome the extra help to support at-risk patients to lose weight.

“It’s pretty unethical to screen people for a condition for which we have no treatment,” she said. “Now we actually have a treatment with proven efficacy.”

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Doctors can keep it simple, saying that based on a patient’s weight and testing, they scored as high risk. “You scored a 10. I would like you to go to this program, and my care manager is going to help set that up.”

Dr. R. James Dudl, a diabetes expert with Kaiser Permanente Research in San Diego, said patients who develop prediabetes should get the word directly from their physician in person, rather than from a staff person. That conveys the urgency of the situation, he said, advising physicians “Doctor, you do not get off the hook.”

American Diabetes Association president-elect Dr. Jane Reusch is hopeful this program can work.

A variety of prevention programs have been tried, with or without insurance payments, co-payments and deductibles, and federal and state funding, she said.

“But a lot of them fail to stick because there hasn’t been a carrot there. Now, with $450, there’s a monetary resource.”

For the Laras, the program has gotten results.

Oscar Lara goes to the gym three times a week, plays softball and golf, and has lost 35 pounds. And vegetables and lean meats have replaced a lot of the carbohydrates he and his wife used to eat. The sugar levels in his blood are back to normal range.

Teri Lara has also lost weight and she walks every day as much as arthritis permits.

“I’m not on a diet,” Oscar Lara said. “I’ve just changed the way I look at things and changed the way I look at food.”

shadow-ornament

We'll let you know when big things happen.

About Cheryl Clark:

Cheryl Clark
Cheryl Clark is a senior healthcare reporter at inewsource. To contact her with questions, tips or corrections, email cherylclark@inewsource.org.
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