Medicare Diabetes Prevention: Enrollment Short Of Projections
Staying healthy: Following his initial participation in the local Diabetes Prevention Program, Tony Vlamis remains focused on keeping his hemoglobin A1c levels in check and continues to exercise regularly at the Spurlino Family YMCA, in Riverview, Florida.
Photographs by Amber Sigman
Tony Vlamis of Apollo Beach, Florida, admits he had a hard time coping with the social isolation of the COVID-19 pandemic. For much of 2020 the seventy-two-year-old, who’s mostly retired but still does some telemarketing work each day, would eat breakfast and then sit on his recliner in front of the television and watch the clock, waiting for lunch. After lunch, he’d repeat that process until it was time for supper.
As a result, his weight ballooned to more than 250 pounds, and his fasting blood glucose count hit 116 mg/dL. His doctor told him he was at high risk of joining the estimated eighty-eight million other Americans who are on their way to developing type 2 diabetes.1 Similar to an estimated 84 percent of people with prediabetes, he hadn’t known he was at risk.2
Then Vlamis read an article in a local newspaper about the Diabetes Prevention Program at the nearby Spurlino Family YMCA, just east of Tampa Bay and the thrumming traffic of I-75. He learned that a two-year version of the program, called the Medicare Diabetes Prevention Program (MDPP), was a no-cost covered benefit through his Medicare Advantage (MA) plan.
In February 2021 Vlamis filled out the MDPP enrollment forms, requiring him to show he had a body mass index of 25 kg/m2 or more plus a hemoglobin A1c level of 5.7–6.4 percent or a fasting plasma glucose of 110–125 mg/dL. In March he started weekly classes, taught via Zoom by the Tampa Metropolitan Area YMCA’s Healthy Living director, Dawn Kita.
The curriculum for the program’s first year was developed by the Centers for Disease Control and Prevention (CDC), which certifies providers if they meet its Diabetes Prevention and Recognition Program standards.3 There is no certified curriculum for the second year of the program. Classes, which are available to Medicare beneficiaries and others, focus on improving eating habits, increasing physical activity, handling stress, sleeping better, and dealing with social pressures to eat and drink. The Spurlino Family YMCA’s Zoom classes include breakout discussion sessions allowing smaller groups to talk about what’s working for each participant, Kita said.
Encouragement: The Tampa YMCA’s Healthy Living director, Dawn Kita (right), continues to provide encouragement and guidance to Tony Vlamis (left) during his regular visits for ongoing classes and exercise.
Once a week, participants must either come into the YMCA for a weigh-in or else take a video of themselves weighing in at home. Class members are encouraged to use the YMCA’s exercise facilities and pool, walk or do other physical activities on their own, or take part in online exercise classes, with a target of 150 minutes a week of physical activity.4 Vlamis goes to the YMCA four times a week to take water aerobics classes and use the recumbent exercise bike. As of September 1 he said his weight had dropped from 247 pounds to 220, a decline of nearly 9 percent, and his fasting plasma glucose had declined to 92. But his HbA1c measured 5.7 percent, at the low end of the prediabetic risk range—the same as in February. He hadn’t talked to his doctor yet.
“My wife and children are really proud of me,” he said. “I told my daughter I’d lose thirty pounds by her wedding in October. I’ve just about lost that already. But my wife isn’t too happy about my obsession with water aerobics and working out too much,” he added ruefully. “She’s worried that I get hurt when I overextend myself.”
Kita, whom Vlamis calls a “wonderful” instructor, said that at least half of the participants in the YMCA’s classes typically hit the 5 percent weight loss target. One key to success, Kita said, has been helping people understand their true motivation for change. Some patients, she said, may be driven by a desire to avoid additional medications that are known for being hard on your stomach. Other patients “want to be around to play with [their] grandkids.” Finding that core motivation, Kita explained, is “important for determining how successful someone will be.”
“I’ve seen a lot of Medicare people do really well with the program because they have more time than younger people who are working or raising children,” she said. “But Medicare folks may have a harder time making [lifestyle] changes because they’ve been doing things the same way for a long time.”
Challenges such as these and a number of other small but important policy details help explain the mixed results and the limited uptake so far of the MDPP. Of the two dozen other people in Vlamis’s class, for example, most were women over forty with private insurance. Just a few were Medicare beneficiaries such as himself.
Medicare started covering the Diabetes Prevention Program in 2018 after studies showed that the program model was effective in reducing the incidence of the disease. It was the first-ever Center for Medicare and Medicaid Innovation demonstration of a preventive care model to be expanded to the full Medicare program, using a pathway established in 2010 by the Affordable Care Act.
Since that coverage expansion three years ago, however, only 3,600 Medicare beneficiaries nationally have taken advantage of the benefit, the Centers for Medicare and Medicaid Services (CMS) reported in July 2021.5 Fewer than 200 organizations such as local YMCAs, hospitals, and community health centers offer the program to beneficiaries, RTI International found in a recent evaluation of the program conducted for CMS.6
Advocates hope that CMS finds a way to boost take-up because type 2 diabetes is one of the nation’s biggest public health challenges. More than thirty-four million Americans have been diagnosed with the disease, according to the CDC. Diabetes is associated with higher rates of heart disease, stroke, kidney failure, leg amputations, and blindness, and the risk for early death for adults with diabetes is 60 percent higher than for those without it. Medical costs and lost work and wages attributable to the disease total an estimated $327 billion a year.7
During the past twenty years diabetes risk has risen along with the growing obesity problem in the US, which is bound up with changes in Americans’ lifestyles. “Our culture is [that] everything has to be automatic and quick,” said Kita, who changed careers from teaching elementary school students to educating adults with diabetes because she wanted to help people become healthier. “We just don’t physically move as much as we used to, and we grab whatever is most convenient to eat, which may not be [the] healthiest choice.”
‘The Biggest Challenge’
The seeds of what would become the National Diabetes Prevention Program were planted in 1996, when the National Institutes of Health launched a randomized clinical trial comparing a lifestyle intervention focusing on diet and exercise, a medication-based intervention, and no intervention. The study, published in 2002, found that the structured lifestyle program reduced diabetes incidence in high-risk people by 58 percent.8 A ten-year follow-up study published in 2009 found that diabetes incidence declined 34 percent in the lifestyle group and 18 percent in the drug intervention group compared with the placebo group.9
During this period many commercial health insurers, employer health plans, and state Medicaid programs covering younger Americans began paying for their enrollees to participate in the National Diabetes Prevention Program. Today, that list has grown to include UnitedHealthcare, Aetna, Cigna, and Blue Cross Blue Shield plans in California, Florida, and Michigan. At the same time, for-profit vendors such as Omada Health, Noom, and others joined YMCAs and other not-for-profit organizations in providing similar programming to the health plans’ enrollees through in-person and online courses.
In 2010 Congress authorized the CDC to establish the National Diabetes Prevention Program, a public-private initiative to prevent type 2 diabetes. In 2012 the CDC awarded grants to six national organizations, including YMCA of the USA and America’s Health Insurance Plans, to boost the number of diabetes prevention program providers. The grants helped the organizations establish program sites, hire and train staff, and enroll participants around the country.
The National Diabetes Prevention Program was found to be effective in helping prediabetic people lose nearly 5 percent of their body weight, which can cut the risk of developing diabetes by as much as 71 percent.10 One study reported that average Medicare savings per quarter for beneficiaries participating in the YMCA’s Diabetes Prevention Program was $278 as a result of decreases in hospital admissions and emergency department visits.11
In 2012 the Center for Medicare and Medicaid Innovation gave a grant to YMCA of the USA to test expansion of its Diabetes Prevention Program to Medicare beneficiaries. The work took place at seventeen local YMCAs across the country. Based on successful attendance and weight loss for a population of nearly 8,000 beneficiaries,12 the CMS Office of the Actuary projected that expansion of the program to beneficiaries would reduce Medicare spending by $2,650 per person over the course of fifteen monthsand would improve the quality of care.13
In light of mounting evidence of the program’s effectiveness, Medicare aimed to catch up with its private-sector peers. In late 2016 CMS finalized a rule to fully cover the Diabetes Prevention Program for all qualified beneficiaries, starting in 2018, and the MDPP was born. CMS projected that 110,000 beneficiaries would enroll over the course of a ten-year period and that the program would save Medicare $182 million in that time by reducing diabetes incidence.14
But the MDPP has languished since then, remaining little known among beneficiaries and health care providers alike. “Somehow beneficiaries are not aware of this benefit, and that’s the biggest challenge,” lamented Sindhu Rajan, founder and CEO of HabitNu, a supplier of both in-person and online diabetes prevention classes, based in Chicago, Illinois. “Why aren’t health plans promoting it?”
The level of participation—just a few thousand Medicare beneficiaries—has been tiny compared with the massive size of the prediabetes problem in the US. CMS has estimated that 16.4 million beneficiaries meet the program’s eligibility standards.5
Low participation also represents a profound missed opportunity to confront disparities in health outcomes for lower-income and minority groups, who are disproportionately at risk for diabetes. African American, Hispanic, and Asian American people are significantly more likely than White people to develop the disease, according to the CDC.15
Researchers and people who run diabetes prevention efforts say that participation in the MDPP is low because of the way CMS has set up the program. It pays program providers too little—a maximum of $704 per participant, and usually much less, depending on each beneficiary’s attendance and weight loss—for dozens of classes over two years.5 It also imposes cumbersome billing rules, doesn’t adequately publicize the program, and requires in-person classes with no online options except during the pandemic emergency period, researchers and providers say.
In addition, most MA plans haven’t promoted the program to their members. Program providers say they’ve had a hard time signing up with the plans to become in-network providers so that enrollees can be referred to them. “Not all MA plans in the area have contracted with us, and if they don’t contract with us, we’re an out-of-network provider and they may only pay us $13 per session for a person,” said Kita, the Tampa Metropolitan Area YMCA’s Healthy Living director.
The RTI International evaluation of the MDPP in 2021 found that the number of enrollees is too small to even determine whether participation improves health outcomes or lowers Medicare costs.6
With only about 200 organizations providing MDPP classes at 762 sites around the country, CMS needs to prioritize signing up more providers, RTI International said. Nationwide, about 1,900 organizations are certified by the CDC to offer diabetes prevention classes, but only a small percentage have chosen to participate in Medicare. Seven states—including Alabama, New Mexico, and Nevada—and a number of major metropolitan areas have no MDPP providers at all.6
The diabetes prevention initiative is just one of several programs that have been found to be effective in reducing or treating chronic medical conditions but have been underused because of the US health care system’s lack of focus on disease prevention.
For instance, Medicare’s coverage of personal nutrition counseling for people with diabetes or kidney disease is used by fewer than 1 percent of the fifteen million beneficiaries with those conditions.16 Under the prevailing fee-for-service payment system, insurers, hospitals and physicians lack strong financial incentives to offer preventive services, experts say.
‘Growing Concerns’
Acknowledging that enrollment has fallen far short of projections, CMS on July 13, 2021, proposed addressing some, but not all, of the problems limiting participation in the MDPP.5 The proposal included shortening the program to one year, starting in 2022. Too few beneficiaries were completing the second year, providers reported. Other changes proposed by CMS would slightly raise reimbursement to providers, potentially paying them $61 more per beneficiary than they previously received for one year of the program but somewhat less than the full two-year fee. As of October 2021 CMS was also planning to waive a $599 fee that groups offering the classes must pay to be part of its program.
The agency hopes that these changes will lower the barrier to entry and make Medicare beneficiaries more enticing to providers such as YMCAs and other local community organizations. Increasing enrollment in the program, in turn, would reduce the incidence of diabetes in the Medicare population and potentially cut federal spending to treat diabetes-related conditions, CMS anticipates.
A key factor limiting providers’ participation up to now, however, is that CMS has tied higher payment to beneficiaries’ losing at least 5 percent of their body weight, which only a minority of participants may achieve. It’s a difficult target that some experts call unreasonable, especially given evidence that more modest weight loss also can reduce HbA1c levels and the associated risk of developing diabetes, said Heather Hodge, senior director of community health for YMCA of the USA.
In contrast, the CDC recently updated its certification standards for diabetes prevention programs to include two alternative measures for successful completion of the program: a 0.2 percent decrease in HbA1c levels or a 4 percent weight loss combined with at least 150 minutes a week of physical activity.3
A 2017 study found that just 35.5 percent of about 15,000 participants in CDC-certified programs over the first four years lost 5 percent of their body weight, with an average reduction of 4.2 percent. Those who attended more sessions, including maintenance classes in the second six months, did better, with a median weight loss of 6 percent.17
Under its new proposed rule, however, CMS would maintain its 5 percent weight loss requirement. MDPP providers would receive up to $635 per beneficiary if the person hit the 5 percent weight loss target and attended thirteen sessions over the course of one year, or $661 if the person lost 9 percent of their body weight. In contrast, per beneficiary payment would be capped at just $338 if the person did not hit the 5 percent weight loss goal.5
Researchers and providers say that this payment model hurts organizations that serve low-income and minority groups, whose members are less likely to attend all of the sessions and achieve 5 percent weight loss but whose health can still improve through the program.
“Low-income people have more barriers—they can’t attend the same amount of lessons, so they achieve lower results,” said Maria Alva, an assistant research professor at Georgetown University, in Washington, D.C., who has studied the MDPP. “This weird, value-based payment model ends up punishing providers for providing services to low-income populations.”
“Five percent is not very attainable, and CMS should know that from their data,” said Amanda Parsons, who previously headed the MDPP at Montefiore Health System, in New York City, which serves mostly low-income Black and Hispanic beneficiaries. She noted that the original program model included one-to-one nutritional counseling, free transportation and gym access, and cash incentives for enrollees—none of which are part of the current program.
Even without the de facto penalty for not hitting the 5 percent target, Medicare’s payment rate doesn’t come close to covering the cost of running in-person classes, experts say.
In a 2018 study of Montefiore’s experience with the MDPP, Parsons and her colleagues found that Medicare payments would cover only about 20 percent of the costs of running the in-person program, based on the attendance and weight loss performance of her program’s participants.18
“You have to very much want to be a [diabetes prevention program] provider, beyond its [financial] value, to participate,” she said.
But not everyone wants it that much. Indeed, some hospital system leaders are reconsidering their participation in MDPP because of the payment and administrative hassles. That was the takeaway from a listening session last fall conducted by Comagine Health, which has contracted with the CDC to help expand MDPP enrollment to 30,000 by March 2023. The session hosted five large hospital systems from the West Coast and Rocky Mountain regions that were early MDPP adopters.
“All of them have growing concerns about retaining leadership buy-in to continue and grow their MDPP programs due to claims rejection and low reimbursement,” Comagine reported in an unpublished summary.
For instance, because of the claims hassles, Intermountain Healthcare, in Salt Lake City, Utah, is covering the cost of Medicare beneficiaries’ participation in its certified version of diabetes prevention, called Weigh to Health, through its community benefit foundation. For the system, it’s just not worth it to seek Medicare reimbursement.
“MDPP has 15 G codes you have to bill through the two years of the program,” explained Karlee Adams, Intermountain’s Weigh to Health coordinator, referring the Medicare billing codes and the conditions each participant has to meet for a provider to receive payment. “No one at CMS could walk us through the process.”
Asked to comment, a CMS spokesperson said that the agency “continues to work to enroll providers into the MDPP and thus increase beneficiary access. CMS cannot speak to the reasons why an organization chooses to enroll or not enroll in Medicare.”
On the issue of the 5 percent weight loss benchmark for payment, the spokesperson said that CDC standards require providers to meet performance targets but did not explain why CMS didn’t adopt the CDC’s alternative success measures.
‘A Person’s Busy Life’
Although providers have welcomed the proposed CMS rule changes as improvements, some providers and researchers say that the changes don’t go nearly far enough to recruit more providers and patients. “It’s an improvement, but this will result in a marginal increase in participation,” Georgetown’s Alva said.
Providers also sharply criticize CMS’s continued refusal to cover classes and counseling delivered to Medicare beneficiaries through online methods including phone apps, videoconference, and texting. During the pandemic emergency period, CMS has allowed payment for online classes. But when the emergency period ends, so will coverage for online programming—including the Zoom classes that have worked so well for Vlamis.
Asked why CMS didn’t propose allowing online classes after the pandemic emergency period ends, the CMS spokesperson said that the MDPP was originally intended to provide primarily in-person services. He added that organizations providing the program must remain prepared to return to in-person classes when the pandemic emergency policy ends.
That stands in contrast to the CDC, which first started certifying online providers in 2015, according to Miriam Bell, the CDC’s team lead for the National Diabetes Prevention Program. About 300 organizations now are certified to offer some form of online delivery, she said. But those providers can’t receive Medicare payment because of CMS’s refusal to recognize that mode of delivery.19 State Medicaid programs generally have followed CMS’s policy of paying solely for in-person delivery, with just a few states, including California20 and Maryland,21 paying for online delivery.
Some CDC-certified online programs, such as that from Omada Health, feature fully automated lessons available through phone apps or the internet.3 Participants log in at a time of their own convenience, but they must complete lessons on time and show progress toward meeting weight loss and physical activity targets. These “asynchronous” programs also must provide a personal health coach for each participant, who offers two-way communication through texting, email, or phone calls, giving guidance and feedback.
Omada’s coaches review participants’ food choices and exercise activities, track their weight changes, and offer guidance to help them meet their goals, said Chris Rogers, an Omada account executive who demonstrated the program. The exercise goal is taking 7,500 steps per day, as measured by a pedometer provided by Omada. Most discussions with the Omada coaches take place via text message, although participants can schedule time to talk by phone. Participants are placed in peer groups, but discussion is entirely online.
A second type of CDC-certified online program, similar to those provided by the YMCA, is called distance learning, featuring live delivery of classes through videoconference or call-in. A third type combines the asynchronous and distance learning modes.
“Some people may not have the ability to commit to going to one location in person for a year,” Bell said. “Virtual programs open up options for people to participate on a schedule that meets their needs.”
Many health insurers covering people younger than age sixty-five pay for online diabetes prevention programs, which claim success rates comparable to those of in-person classes.
Omada cites a randomized controlled trial completed last year that found that participants in its online diabetes prevention program achieved an average weight loss of 5.4 percent after one year compared with 2 percent for the control group. The trial also found that 58 percent of Omada participants lowered their HbA1c level to the normal range after one year versus 48 percent in the comparison group.22
A Blue Cross Blue Shield of Michigan spokesperson said that its diabetes prevention program, delivered by Omada, has produced a 5 percent weight reduction for about 30 percent of its MA enrollees since CMS’s pandemic emergency rule went into effect in March 2020. The insurer’s commercial, non-Medicare enrollees have achieved an average weight reduction of 3.7 percent through Omada’s program.
But Kasia Lipska, a diabetes outcomes researcher at Yale University, in New Haven, Connecticut, said that she hasn’t seen any solid studies proving that online delivery matches the effectiveness of in-person programs. The study cited by Omada hasn’t yet been published in any journal, she noted.
“Marketing has vastly outstripped evidence in terms of proving that these digital diabetes coaching systems improve outcomes,” Lipska said. “Many people know the right diet and right exercise level, but how do you implement it into a person’s busy life and keep them motivated? That’s hard to do just on a web-based platform.”
Intermountain Healthcare offered in-person diabetes prevention classes at many of its hospitals but switched to online classes during the pandemic. It also has tested using Omada to deliver online classes to non-Medicare participants, including its own employees.
Liz Joy, Intermountain’s senior medical director for wellness and nutrition, said that Omada’s program has been successful and that Intermountain and its health plan, SelectHealth, are considering expanding that partnership.
“Virtual access would improve access and reduce disparities for people who have barriers such as transportation and distance,” Joy said, noting that a significant percentage of the people Intermountain serves live in remote rural areas.
Omada has been lobbying CMS for four years to allow Medicare coverage of online providers, without success.
“CMS tells us they don’t believe they have legal authority to expand modalities that weren’t tested, but we don’t think that’s true,” said Lucia Savage, Omada’s chief privacy and regulatory officer. “We’re told there are fraud concerns, but we’ll put our audit trails in competition with any in-person [diabetes prevention program].”
Republicans and Democrats in the House and Senate are cosponsoring a bill, the Prevent Diabetes Act, to let CDC-certified virtual providers participate in the Medicare Diabetes Prevention Program. The sponsors say that virtual programs will expand access to lower-income, minority, and rural Americans who can’t get access to in-person programs.23
‘I Helped Them, Too’
In 2019 Damon Diessner’s physician told him that if he didn’t bring his weight down significantly, he was at high risk of following his grandfather and father in developing type 2 diabetes. At more than 400 pounds, Diessner, an environmental consultant who lives in Redmond, Washington, had long struggled unsuccessfully to change his lifestyle. As his HbA1c neared the 6.5 percent level—above which someone is typically diagnosed as diabetic—his physician suggested that he get into the Diabetes Prevention Program at his local YMCA in Bellevue, Washington.
Now sixty-eight, Diessner said he was inspired to get into program by watching his young grandson’s brave efforts to cope with type 1 diabetes. He started the program through Medicare in May 2019. The group classes, at first held in person and later via Zoom during the pandemic, were led by YMCA health coach Anne McDowell, who he said was “really great.” She facilitated online discussions among the dozen or so participants, during which people shared what worked for each of them. As of early July 2021 Diessner was still logging into monthly meetings through Microsoft Teams.
“Online is working great,” he said. “I’m not a big online guy, but the sharing of information between the participants was key in my success. The information they gave me was invaluable, and I’d like to think I helped them, too.”
Over the course of the program, he dropped from 435 pounds to 205. His HbA1c level is now 4.8 percent, which is in the normal range. “My experience with this program is just amazing,” he said.
Diessner was shocked when he was told that only 3,600 Medicare beneficiaries have participated in the MDPP nationally during the three years of its existence.
Back in Florida, Vlamis fears that even if Medicare did a better job getting the word out about the MDPP and recruiting more providers, many people who need the program wouldn’t necessarily sign up. “I’ve been talking it up to people, but so far I haven’t gotten any nibbles,” he said. “It’s kind of hard to change your ways.”
NOTES
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