CMS takes next step to open up reimbursement for Diabetes Prevention Program, including digital versions

By Jonah Comstock
02:10 pm

CMS has proposed rule changes that would expand the Diabetes Prevention Program effective January 1, 2018. In March, CMS certified that the expansion of the program, including digital versions of the program, would reduce net Medicare spending, these new rules changes, announced last week, are the next concrete steps CMS needs to take to make the DPP reimburseable. 

“Today's proposals are intended to give a significant lift to the practice of primary care and to boost the time a physician can spend with their patients listening, advising and coordinating their care -- both for physical and mental health,” CMS Acting Administrator Andy Slavitt said in a statement. “If this rule is finalized, it will put our nation's money where its mouth is by continuing to recognize the importance of prevention, wellness, and mental health and chronic disease management.”

Assuming the rule is finalized, the Diabetes Prevention Program will become the first preventative service model to make the jump from the CMS innovation center into full, expanded coverage. The proposed rule would tie DPP reimbursement to the number of sessions attended and the achievement and maintenance of a minimum weight loss. It also provides for virtual versions of the DPP to be reimbursed the same way as in-person programs.

“Through expansion of the Diabetes Prevention Program, beneficiaries across the nation will be able to access a community-based intervention that prevents diabetes and keeps people healthy. This is part of our efforts for better care, smarter spending, and healthier people,” Patrick Conway, Acting Principal Deputy Administrator and CMS Chief Medical Officer, said in a statement. “Today’s proposal is an exciting milestone for prevention and population health.”

As we wrote back in March, Omada, which administers an online version of the DPP called Prevent, is the largest CDC-recognized DPP provider: it works with 45,000 individuals via employers, health plans, and health systems. Their stats are even higher than the in-person DPP stats, despite being a digital intervention offered to seniors. In a recent study, six months after starting the program, 84 percent of participants, with an average age of 69, remained engaged and lost an average of 7.8 percent of their body weight. 

Another digital health company that offers the DPP is Canary Health, a Los Angeles-based startup that uses digital health tools to help populations prevent and manage chronic diseases.

"We are very encouraged to see that the CMS is giving so much thought to digital providers of the DPP," Canary Health CEO Adam Kaufman said in a statement emailed to MobiHealthNews. "It shows that CMS understands that digital providers certainly need to be part of the existing network, but we need different billing mechanisms and fraud protection measures than other telemedicine providers. By troubleshooting these issues in advance, they’re ensuring a more successful rollout in the future. We look forward to providing comments to the CMS and working with our industry associations, such as the Population Health Alliance, to help refine its approach. We expect this announcement will further catalyze the private payer market to cover the DPP as well."

In addition to the DPP, the proposed rule includes a number of changes to the annual Physician Fee Schedule. New telehealth reimbursement codes would be added for end-stage renal disease services for dialysis, advanced care planning services, and critical care consultations furnished via telehealth. It also includes changes that will improve reimbursement for primary care and behavioral health.

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