Medicare Compliance & Reimbursement

Physician organizations are backing Medicare coverage expansion for NDPP.

Generally lauded as great news in the healthcare world, the Centers for Medicare & Medicaid Services (CMS) says it will soon start paying for diabetes prevention services that you provide to Medicare beneficiaries.

For the first time, CMS will expand a preventive service model from the CMS Innovation Center into the Medicare program. On March 23, CMS announced that its independent Office of the Actuary has certified the expansion of the National Diabetes Prevention Program (NDPP). CMS contended that this model reduces Medicare spending while improving quality of care.

Prevention as a Weapon to Combat Diabetes

The U.S. Centers for Disease Control and Prevention (CDC) developed the NDPP, a year-long lifestyle-change program involving dietary, behavioral, and physical activity mentoring by local CDC-recognized providers with trained counselors. CMS wants to expand Medicare coverage to support the NDPP.

Background: This coverage expansion came about under the Affordable Care Act of 2010 (ACA), which provided a federal grant in 2012 to the Young Men’s Christian Associations of the United States of America (YMCA) of nearly $12 million. The funding went toward creating a model program that enrolled eligible Medicare beneficiaries at high risk for diabetes. The model aimed to reduce these beneficiaries’ risk for developing type 2 diabetes and diabetes-related illnesses.

The program involved weekly meetings with a lifestyle coach in which beneficiaries learned dietary strategies, ways to increase physical activity, and behavior changes to control their weight and reduce their diabetes risk. Following these weekly sessions, beneficiaries could continue to attend monthly follow-up meetings to help maintain these healthy habits.

The test program, which took place in eight states, showed promising results, which led CMS to expand the coverage for such lifestyle change programs to prevent diabetes (for more on the demonstration model’s results, see “Model Program Results: Understand The NDPP’s Overall Potential” on page 59).

Physician Organizations Have Long Been On-Board

Physician organizations like the American College of Preventive Medicine (ACPM) support the Medicare coverage expansion to support the NDPP. Recognizing that the NDPP model has proven that it can bolster healthcare quality while at the same time decreasing healthcare costs is a crucial step in providing Medicare coverage to address type 2 diabetes through preventive services, says ACPM Executive Director Michael Barry, CAE.

ACPM has partnered with the CDC, YMCA, American Medical Association (AMA), and others to provide physician awareness of the NDPP program and to provide activities like the “Preventing Diabetes” panel discussion for preventive medicine specialists. ACPM is also launching a series of Lifestyle Medicine Trainings (see www.acpm.org/?page=WISEWOMANLMtraining) for practitioners who provide cardiovascular screening services to low-income and underserved women, Barry notes.

Additionally, ACPM and the American College of Lifestyle Medicine are releasing their Lifestyle Medicine Core Competency Online Program, which contains modules on pre-diabetes and diabetes, and using evidence-based therapeutic techniques for preventing, treating, and reversing lifestyle-related chronic diseases.

Likewise, the Endocrine Society also lauded CMS’ announcement of Medicare coverage expansion for the NDPP. The Endocrine Society has been calling for such Medicare coverage for the past five years, lobbying Congress, federal agencies and diabetes advocates. On March 23, the Endocrine Society released policy recommendations (see http://press.endocrine.org/doi/10.1210/jc.2016-1047) to improve care for diabetics.

And according to a recent statement by the AMA, this coverage expansion creates an opportunity for wider availability of the NDPP to Medicare fee-for-service beneficiaries, with the potential to make a significant impact on the huge burden of chronic disease among the Medicare population.

Look Ahead: Details are Still Foggy

Prevention overall should play a bigger role in today’s healthcare systems, especially when population health and preventive medicine are more valued than ever before, Barry stresses. Yet, the role of preventive medicine specialists is still relatively obscure.

The exact coverage and reimbursement details are still in the works for the NDPP, however, as CMS is considering how it will expand the model throughout Medicare. CMS plans to include more information about the program in the Calendar Year (CY) 2017 Medicare Physician Fee Schedule proposed rule, to be released this summer.

The coverage proposal must go through a public comment period, but it doesn’t need approval from Congress, according to an April 6 analysis by Scott Cameron of the law firm King & Spalding. This is thanks to the 2010 change in Medicare in which the CMS Secretary and the Medicare Actuary can agree on a change that would reduce spending without reducing quality of care.

Prediction: “Because the proposal does not need Congressional approval, there is little doubt it will be expanded nationwide,” Cameron said.

Resources: To read the CMS Innovation Center’s evaluation report of the YMCA model program, go to https://innovation.cms.gov/Files/reports/hcia-ymcadpp-evalrpt.pdf. You can also access the CMS Office of the Actuary certification of the NDPP at www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/Diabetes-Prevention-Certification-2016-03-14.pdf. And a listing of local CDC-recognized providers is available at https://nccd.cdc.gov/DDT_DPRP/Programs.aspx.