To prevent overweight Medicare recipients with prediabetes from progressing to diabetes, federal officials have proposed a significant funding boost for health care providers and others that offers a new program aimed at helping people lose weight, a proven strategy to thwart the disease.
An estimated 20 million Americans — and some 200,000 in San Diego County — have prediabetes, which puts them at greater risk of diabetes and multiple other serious and costly illnesses.
Participating providers — from hospital systems and physician groups to wellness centers, supermarket chains and even churches — could receive up to $785 for each participant who loses 5 percent of their body weight. It goes up to $810 for 9 percent weight loss. Participants also must participate in a comprehensive lifestyle curriculum.
Previously, the maximum payment Medicare had proposed was $450 for one year, with an optional $180 offered in a second year if participants completed 12 additional classes and maintained weight loss.
In San Diego County, 13 groups have applied to participate in the program. Among them are healthcare providers Scripps Health, Sharp Rees-Stealy and UC San Diego, along with Jenny Craig and several community clinics.
The revised Medicare Diabetes Prevention Program was outlined Thursday in a proposed rule to be published in the Federal Register this week. The program is designed to offer intense face-to-face sessions that teach diet, nutrition and exercise strategies.
Participants will attend classes at weekly intervals within the first months, tapering off to less frequent intervals during the three-year program. The federal Centers for Medicare & Medicaid Services, the agency known as CMS that is administering the program, has structured it so participants would have no co-pay or fee. The program would start on April 1.
Dr. Athena Philis-Tsimikas, vice president of the San Diego-based Scripps Diabetes Care and Prevention program in La Jolla, which plans to offer the program, praised the proposed rule because it raises rates and extends the program one year longer.
That will allow programs to “maintain staff to teach the classes and provide at-risk participants a long enough intervention to really drive on-going behavior change,” Philis-Tsimikas said in an email. “The weight change of 5 percent that needs to be documented for reimbursement is reasonable.”
Diabetes costs Medicare $42 billion more than it costs for similar beneficiaries without diabetes, and the agency believes a program that can avoid some of that cost is worth trying, even if it doesn’t work for some of those who enroll. Without intervention, studies show people with prediabetes will progress to diabetes at the rate of 5 percent to 10 percent annually within three years, and possibly longer.
To be eligible, Medicare enrollees must have a blood test showing evidence of impaired ability to process glucose, defined as having an HgA1c result of 5.7 percent to 6.4 percent or a fasting glucose of 110 to 125 mg/dL. Participants also must be enrolled in Medicare Part B and meet standards that define them as medically overweight.
The latest language for the program contains numerous provisions to protect beneficiaries from unscrupulous programs and lifestyle and nutrition coaches. It also has elements to protect Medicare from fraud that wastes taxpayer dollars.
In another proposed change, CMS would extend beneficiaries’ participation to 36 months of face-to-face diet and exercise instruction curriculum; initially it was to be 24 months. The new rule offers two years of longer, ongoing maintenance sessions instead of one.
The payments are to be made incrementally to a range of companies that provide lifestyle instruction. Payment is tied to the number of courses beneficiaries attend and whether they can lose at least 5 percent of their body weight in the first year and maintain it in the next two. Weight loss is associated with a reduced risk of progression to diabetes.
An estimated 20 million people in the United States age 65 and older have prediabetes, or 50 percent. According to the Centers for Disease Control and Prevention, which is helping CMS roll out the program, nine out of 10 may not know it. Extrapolated to San Diego County, an estimated 200,000 Medicare beneficiaries may be eligible for the program.
Such a large-scale systematic effort to help people modify their diet to reduce carbohydrates and control their glucose levels may stimulate physicians across the country — especially those in healthcare systems that are running the program — to be more diligent about screening their patients for prediabetes.
The program is said to be a big help to clinicians who complain they don’t have time now in their practices to counsel patients about the need to change their lifestyle, or how to do it with greatly modified intake of carbohydrates and sugar.
Under the latest proposed rule, continued participation in the program after the first 12 months is contingent on participants losing at least 5 percent of their body weight from baseline and keeping it off.
To date, some 1,450 companies nationally have applied to the CDC to be a recognized provider in the diabetes prevention program.
CMS said those granted “pending” recognition will be allowed to submit claims if they meet several requirements, such as submission of performance data from similar diabetes prevention programs they have offered in the past.
If the rule proposed Thursday is made final in November, as expected, it would:
- Establish payments for providers depending on the number of one-hour courses participants attend (see table).
- Delay the program’s start date from Jan. 1 to April 1 to give more time for organizations to prepare.
- Allow beneficiaries who develop diabetes during the months they are participating in the program to stay in the program.
- Refuse to allow the curriculum to be offered online without face to face interaction, except as a limited number for make-up classes.
- Permit organizations to offer “in-kind beneficiary engagement incentives” such as gym memberships, onsite child care or transportation, as long as they relate to the goals of the program, but not theater tickets or retail gift cards.
- Prohibit programs from offering free meals or meal replacement services in the curriculum because they do not help beneficiaries make their own decisions to better manage their own health.
- Allow programs to furnish participants with technological items for temporary use, such as a tablet loaded with fitness apps or a fitness tracking watch, as long as the total amount of the devices does not exceed $1,000 per beneficiary. Also, the organization must retrieve those items after the course is completed.
- Prohibit giving participants technology items for their permanent use if their value exceeds $100.
- Prohibit lifestyle companies from advertising incentive offerings. Companies must offer them after the beneficiary enrolls so as to prohibit selective bias in attracting participants who are more likely to succeed.
The proposed rule spells out an extensive number of fraud prevention and oversight activities intended to prevent Medicare from paying for services not provided, and to prevent lifestyle coaches from harming patients through such crimes as embezzlement or extortion. For example, it would:
- Require that organizations submit National Provider Identifier numbers, birth dates and Social Security numbers for their lifestyle coaches who teach the classes. Coaches would also have to undergo background checks.
- Prohibit coaches from program employment if they have had Medicare or Medicaid billing privileges revoked, been convicted of serious crimes including rape, murder, or assault, or financial crimes such as extortion, embezzlement, or income tax evasion, insurance fraud.”We propose that CMS will screen each individual identified on the roster of coaches included with the supplier’s enrollment application to verify that the individual coach does not meet any of these conditions,” CMS said in its proposed rule. “We have selected these types of felony convictions based on the risk we believe they could pose to the Medicare program and our beneficiaries.”
- Require that ownership change, changes in coaches or adverse action history be reported to CMS.
- Require program applicants to pay a fee of $560 for program integrity efforts and to cover cost of screening.
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