Cost of Medicare diabetes prevention program may exceed reimbursements

For some healthcare providers -- especially those serving racial/ethnic minority and low-income patients -- the costs of delivering a new Medicare diabetes prevention program, or MDPP, may be much higher than the expected reimbursement, reports a study in the November issue of Medical Care.

MDPP is a program designed to prevent diabetes in Medicare beneficiaries. It targets

older adults meeting criteria for "prediabetes" -- estimated to be present in about 48 percent of U.S. seniors.

IMPACT

Payments may cover as little as one-fifth of the costs of delivering recommended diabetes prevention services in safety-net healthcare settings, the findings showed.

Whether reimbursement cover the costs of MDPP services for minority and low-income populations, which have a disparately high risk of diabetes, is of particular concern.

THE TREND

In April, CMS said it would allow community-based organizations to join traditional healthcare providers in enrolling as Medicare suppliers of health behavior change services. CMS said at the time the model was expected to save the Medicare program more than $180 million by keeping beneficiaries healthy and averting new cases of diabetes.

A previous report on the National Diabetes Prevention Program suggested that educational and coaching sessions over one year reduced the risk of older adults at high risk from developing Type 2 diabetes.

Under the pay-for-performance scheme announced last year, healthcare providers would be reimbursed for MDPP services based on patients' attendance and weight loss. The program targeted a 5 percent reduction in body weight, which can delay or prevent Type 2 diabetes. 

The authors analyzed the costs of and expected reimbursement for providing MDPP services to 213 Medicare beneficiaries with prediabetes or other diabetes risk factors in Denver, Colorado's safety net healthcare system. Most patients were of minority race/ethnicity (41 percent Hispanic, 32 percent black) and classified as low-income (about 70 percent).

The average projected reimbursement was about $139 per patient, based on coverage rules issued by the Centers for Medicare and Medicaid Services. Consistent with previous studies, outcomes of the MDPP intervention were not as good in this group of largely minority, low-income Medicare beneficiaries.

Average weight loss was just under two percent, which may still be beneficial for reducing diabetes risk. Less than 5 percent of participants met all milestones (attendance and weight loss) needed to reach the maximum payment of $470 for a full year of services.

By comparison, the costs of delivering the program were estimated at $800 per patient. Subtracting the average payment of $139, there was a $661 gap between the costs of the program and the expected payments. Expenses for coaching staff accounted for a little over half of the costs of providing MDPP services.

THEIR TAKE

Reimbursement provided by Medicare will fall short of covering the costs for providing MDPP services, especially for healthcare providers serving diverse, underserved patient populations. The payment gap could limit access to recommended diabetes prevention services and contribute to widening health disparities.

Reimbursing the full beneficiary cost of $800 per patient would pay for itself within the first year due to healthcare expenditures avoided -- and bring an even larger return on investment in subsequent years.

ON THE RECORD

"The high economic and societal costs of diabetes and the importance of reducing health disparities suggest that financially sustainable payments are necessary to ensure benefit access, while yielding cost-savings for Medicare," the authors wrote.

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com