Medicare finalizes policies to expand its Diabetes Prevention Program Model

An expansion of the Diabetes Prevention Program model to more Medicare beneficiaries was among the changes recently enacted by CMS's 2017 Physician Fee Schedule final rule.

The program is a behavioral change intervention for patients with prediabetes that aims to prevent the onset of type 2 diabetes. Beginning on Jan. 1, 2018, eligible beneficiaries will be able to access diabetes prevention services in community and health care settings furnished by coaches who are trained community health workers or health professionals.

The 12-month intervention consists of at least 16 weekly hour-long sessions over months 1 to 6 and at least 6 monthly maintenance sessions over months 6 to 12, provided regardless of weight loss. In addition, beneficiaries will have access to 3-month intervals of ongoing maintenance sessions after the 12-month intervention if they achieve and maintain the required minimum weight loss of 5% in the preceding 3 months. Medicare cost-sharing will not apply to these services.

Coverage will be available for beneficiaries who meet the following criteria:

• Medicare Part B enrollment;
• as of the date of attendance at the first session, a body mass index (BMI) of at least 25 kg/m² if not self-identified as Asian or a BMI of at least 23 kg/m² if self-identified as Asian;
• within the previous 12 months, an HbA1c test with a value between 5.7% and 6.4%, a fasting plasma glucose level of 110 to 125 mg/dL (6.11 to 6.94 mmol/L), or a 2-hour plasma glucose level of 140 to 199 mg/dL (7.78 to 11.06 mmol/L) on an oral glucose tolerance test;
• no previous diagnosis of type 1 or type 2 diabetes with the exception of gestational diabetes; and
• no end-stage renal disease.

CMS hopes that the expanded model will encourage employers and insurers to initiate diabetes prevention programs in their populations as well, according to a press release. The agency estimated that it will spend $42 billion more in 2016 on fee-for-service beneficiaries with diabetes who are not dual-eligible and are over age 65 than it would spend if those beneficiaries did not have diabetes.

More information about the Medicare Diabetes Prevention Program expanded model is available on the CMS blog and in a fact sheet.

In related news, Griffin P. Rodgers, MD, MACP, director of the National Institute of Diabetes and Digestive and Kidney Diseases, issued a press release as part of National Diabetes Month reviewing in-progress research, such as the ongoing Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness study, which is recruiting 5,000 people with type 2 diabetes to compare 4 diabetes drugs as an addition to metformin to determine which drug is best and for whom, and Type 1 Diabetes TrialNet, which screens more than 16,000 people with a family history of type 1 diabetes annually to find ways to delay or prevent the disease.