Will pay up to $810 for 3-year program, with strict rules to prevent fraud
Participating providers may now receive up to $785 for each patient who loses 5% of their body weight and $810 if they lose 9% and complete other aspects of a comprehensive lifestyle intervention. Previously, the maximum payment was just $450.
The Medicare Diabetes Prevention Program (MDPP) offers frequent face-to-face sessions that teach diet, nutrition, and exercise strategies to high-risk beneficiaries. 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 the participants who enroll.
In another change to the program, outlined in a proposed Physician Fee Schedule Thursday, 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 lifestyle instruction companies as beneficiaries increase the number of courses they attend, and as they lose more weight. Weight loss is associated with a reduced risk of progression to diabetes.
An estimated 20 million people age 65 and older have prediabetes, and nine out of 10 may not know it. The MDPP, however, 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 in their practices to counsel patients about the importance of lifestyle change. CMS plans to pay for MDPP services with no cost sharing on the part of the beneficiary.
Under the latest proposed rule, continued participation in the program after the first 12 months is contingent on participants losing at least 5% of their body weight from baseline, and keeping it off.
To date, some 1,450 companies -- from hospital systems and physician groups to wellness centers, supermarket chains, and churches -- have applied to the CDC to be a recognized MDPP provider. CMS said those granted "pending" recognition will be allowed to submit claims if they meet several requirements, such as submission of certain performance data on past MDPP-like diabetes prevention programs.
Eligible participants are those with HbA1c of 5.7% to 6.4% or fasting glucose between 110 and 125, who are enrolled in Medicare Part B, and have a BMI of 25 or greater, or for Asians, 23 or greater.
Thursday's proposed rule went into great detail about how the program will work, taking up almost 20% of the Physician Fee Schedule's 815 pages.