Enrollment in Medicare's Diabetes Prevention Program Has Been 'Pathetic'

 by Cheryl Clark

When it launched in April 2018, the Medicare Diabetes Prevention Program (MDPP) was championed as a key way to save billions by keeping millions of at-risk beneficiaries from developing diabetes.

Some 16 million overweight or obese beneficiaries with prediabetes were estimated to be eligible for the program.

But after 6 years, only 9,015 patients had enrolled in the program, according to a report prepared for CMS.

Indeed, less than 1% of eligible beneficiaries have participated in the program, CMS acknowledged in its final Physician Fee Schedule rule this year.

Several physicians who have been strong advocates of weight reduction, diet, and exercise programs to delay or prevent progression to diabetes said they were shocked by the low turnout.

"Pathetic," is how David Nathan, MD, of Harvard Medical School and Massachusetts General Hospital in Boston, who led the original Diabetes Prevention Program research that showed such efforts worked, described the low participation.

It "suggests that the programs have not been widely advertised and/or implemented ... like having a party and no one shows up," Nathan told MedPage Today.

The original Diabetes Prevention Program trials showed a 58% reduction in diabetes development over the first 3 years, and after 20 years or more, a 24% reduction, he noted.

"Considering the costly consequences of diabetes (human and economic), diabetes prevention is an excellent investment," Nathan said.

The MDPP is composed of 22 sessions of exercise and diet educational workshops in non-clinical settings, led by trained coaches. A special approval process developed by the CDC enabled 357 healthcare organizations or community groups to offer the program.

The providers involved would be paid by Medicare -- as much as $768 per enrollee in 2024 -- if specific attendance and/or at least 5% to 9% weight reduction targets were met by participants. All of this would be at no cost to the participant.

However, the report commissioned by CMS found that Medicare had spent less than $1 million in payments to the providers for about 3,480 fee-for-service beneficiaries. The average pay per beneficiary was $283, well below the maximum of $768.

Many MDPP suppliers interviewed for the report critiqued the program. "Current CMS administrative processes make it difficult to focus on recruitment, as a good deal of staff time is dedicated to billing, submitting reports, and coding claims," the report stated. "One partner organization noted that the billing process is especially burdensome for small community-based organizations."

"Several suppliers also noted that the current level of reimbursement for the program does not cover the costs to run the program and requested that CMS consider increasing the reimbursement rate," it continued.

About 40 medical associations and health systems wrote a letter last year to House of Representatives members calling the low participation "striking considering more than half a million participate in the CDC's National DPP program when offered through their health plan or employer."

Nearly one in three adults ages 65 and older have diabetes, the letter noted, and treating its complications cost the U.S. $205 billion in 2022 -- most of it paid by Medicare.

Endocrinologist Athena Philis-Tsimikas, MD, corporate vice president of the Scripps Whittier Diabetes Institute in San Diego, which enrolled about 20 to 30 Medicare beneficiaries in its MDPP programs each year, also was surprised at the low enrollment.

She acknowledged to MedPage Today that "the billing side has been very difficult," with several detailed steps required to document attendance and weight loss milestones to receive Medicare's full reimbursement. Additionally, a health system is not always set up for this type of billing, making claims submissions difficult.

Philis-Tsimikas suggested other possible explanations. Sometimes, she said, providers don't order the blood tests necessary to document prediabetes, necessary to qualify beneficiaries for enrollment. There are other priorities during the clinical visit, "and they forget to order it."

"We are likely missing people who meet the criteria but may not be identified yet," because a prediabetes diagnosis of an HbA1c of 5.7% to 6.5% must be confirmed by a lab, she said.

She also suggested that certain Medicare provider networks may not include the health system-run MDPP, and may not have an incentive to refer a patient to an outside provider.

Or it could be that physicians just aren't aware of the program. The agency and the programs might try harder to reach people who are at risk through health fairs or other settings, she said.

Bottom line may be that organizations offering the program may not find it worth it, considering the costs of hiring and training coaches.

"People say, if you don't see your return on investment within 3 or 4 years, some don't really want to make the investment," Philis-Tsimikas said.

A key barrier for the MDPP just 2 years after it began was the COVID public health emergency in 2020, which discouraged in-person attendance. But CMS changed the rules in January 2021, so that new beneficiaries could attend online, and weigh-ins were allowed virtually.

CMS has made other rule modifications to increase participation, in some cases extending the relaxed COVID-era rules. Starting in 2024, any participant could receive the program virtually.

And while the MDPP initially was a 2-year program, new beneficiaries now can complete it in 1 year.

Another change allows beneficiaries to record their weight at home with a date-stamped photo of their scale's reading. Because some beneficiaries are unable to do that due to physical limitations, CMS allows weight documentation from an official medical record if it is obtained within 5 days of a scheduled MDPP session.

The March consultant's report found that half of the beneficiaries who did end up participating in the program received a referral from a primary care physician or specialist, often when the provider was informing the patient they have prediabetes. The report added that clinicians' influence "underscores the important role healthcare providers play in connecting beneficiaries with the program."

Philis-Tsimikas said the low enrollment numbers were "sad to hear, especially for something that has been demonstrated to be so successful, and can prevent the chronic complications, the comorbidities, all these things that we try so hard to prevent."

https://www.medpagetoday.com/primarycare/diabetes/118849