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Medicare Rule Change May Help Expand Diabetes Prevention Programs

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Medicare Rule Change May Help Expand Diabetes Prevention Programs

Medicare is aiming to increase the adoption of diabetes prevention programs by healthcare providers by making certain rule changes — but critics of how Medicare reimburses providers for these programs say the proposed changes aren’t nearly enough, according to a recent article at Kaiser Health News.

As noted in the article, Medicare — the U.S. federal health insurance program for people ages 65 and older, and certain other eligible groups — began reimbursement for what it calls the Medicare Diabetes Prevention Program (MDPP) in 2018. Many health care providers that already offered diabetes prevention programs signed up for the Medicare version, under which rules set by Medicare govern both how the program is run and how providers are reimbursed for the costs. But so far, only about 3,600 people have participated in the MDPP, even though an estimated 16 million people on Medicare are eligible based on their body weight and A1C level (a measure of long-term blood glucose control).

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Critics voice concerns with proposed changes to MDPP reimbursement

Critics of how Medicare has structured reimbursement for the program — including many administrators of diabetes prevention programs — say that Medicare’s rules make it risky for many potential providers to offer the program. It offers providers a maximum of $704 per participant for dozens of classes over two years — and that’s only if participants meet certain weight-loss goals. Until the COVID-19 pandemic, Medicare also required providers to offer the program only as in-person classes, without virtual alternatives for attending classes or sessions. It also charges providers a one-time fee of $599 to participate in the program.

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Under a proposed rule change unveiled in July 2021, Medicare would waive the $599 fee for providers and the program would be shortened to one year for participants starting in 2022. Since many people have dropped out of the program during the second year, shortening the program would most likely increase reimbursement to providers based on how well they retain participants. But critics say that more realistic reimbursement policies, virtual options, and much better outreach efforts are needed to entice more providers to take part in the MDPP. Medicare originally projected that 110,000 people would participate in the program during its first 10 years, saving Medicare $182 million by reducing the incidence of diabetes. But right now, the program is not on track to hit those numbers.

One key problem, critics say, is that even under its newly proposed rule changes, Medicare will pay providers $635 per participant only if they attend 13 sessions over the course of a year, and lose at least 5% of their body weight. This reimbursement rises to $661 if someone loses at least 9% of their body weight, but is capped at $338 if someone doesn’t reach the 5% goal. Some studies suggest that losing just 2% to 3% of body weight can reduce the risk for diabetes if someone is obese, and even the Centers for Disease Control and Prevention (CDC) says that diabetes prevention programs can be considered successful if participants reduce their A1C level by at least 0.2%, or lose 4% of their body weight while exercising at least 150 minutes per week. Yet Medicare has not adopted these standards as part of its proposed rule change.

So while the proposed rule changes for 2022 may increase participation in the MDPP, Medicare recipients may still face difficulty finding an eligible program to take part in — if they even learn about the program in the first place. And only a small fraction of the 16 million people who stand to benefit from this program are likely to get a chance to participate.

Want to learn more about diabetes prevention programs? Read “The Diabetes Prevention Program” and “Medicare’s New Diabetes Prevention Programs.”

Quinn Phillips

Quinn Phillips

Quinn Phillips on social media

A freelance health writer and editor based in Wisconsin, Phillips has a degree from Harvard University. He is a former Editorial Assistant for Diabetes Self-Management and has years of experience covering diabetes and related health conditions. Phillips writes on a variety of topics, but is especially interested in the intersection of health and public policy.

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