Medicare Compliance & Reimbursement

Growing diabetes epidemic is costing Medicare staggering amounts.

The innovative 2012 diabetes program undertaken by the Young Men’s Christian Associations of the United States of America (YMCA) has spurred some long-awaited changes to the way Medicare handles diabetes prevention and care. So what results were so impressive that they made the Centers for Medicare & Medicaid Services (CMS) want to launch such a groundbreaking reimbursement model?

The results of the model program are telling — here’s what CMS hopes will happen on a nationwide scale under the National Diabetes Prevention Program (NDPP):

• Weight Reduction: The Medicare beneficiaries enrolled in the program lost, on average, 4.73 percent of their body weight — a substantial enough weight loss to reduce their risk of future diabetes. This average weight-loss percentage was for participants who attended at least four weekly sessions. For those who attended at least nine weekly sessions, the average weight loss was greater — 5.17 percent of their body weight.
• Patient Involvement: More than 80 percent of participants attended at least four weekly sessions.
• Cost Savings: Over a 15-month period, the estimated Medicare cost savings was $2,650 per enrollee when compared with similar beneficiaries not in the program. This amount was more than enough to cover the program’s cost.

Estimates of Medicare spending on diabetes are staggering, with one in every three Medicare dollars spent on care for beneficiaries with diabetes, according to the American Diabetes Association. And healthcare costs in general are 2.3 times higher for individuals with diabetes than those who don’t have diabetes.

If current trends persist, the CDC estimates that one in three American adults may develop diabetes by 2050, a worrisome increase from the 9.3 percent of adults and children in the United States who currently have diabetes (29 million).

Another 86 million Americans have prediabetes, 15 to 30 percent of which will develop type 2 diabetes in the next five years, says Michael Barry, CAE, Executive Director of the American College of Preventive Medicine (ACPM). The NDPP is especially crucial to those with prediabetes, because a lifestyle change program could help prevent type 2 diabetes and associated diabetes-related illnesses like heart disease and stroke.

Prevention and detection go hand-in-hand, so the NDPP would also impact the 90 percent of patients with high blood glucose levels who don’t know they have prediabetes, Barry notes. Currently, one in every three American adults has prediabetes. But U.S. Centers for Disease Control and Prevention (CDC)-recognized providers are reporting a more than 50-percent reduction in type 2 diabetes risk among NDPP enrollees.