Expanded Medicare coverage of preventive services for type 2 diabetes may mean providers will need to add staff or connect with community resources as early as next year.
Results from the pilot National Diabetes Prevention Program were persuasive enough for the independent Office of the Actuary in the Centers for Medicare & Medicaid Services to certify that the expansion would result in reduced net spending and better patient outcomes.
It’s the first preventive model to be developed in the CMS Innovation Center , which itself was created as part of the Affordable Care Act.
“This program has been shown to reduce health care costs and help prevent diabetes, and is one that Medicare, employers, and private insurers can use to help 86 million Americans live healthier,” Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued on the ACA’s sixth anniversary. “The Affordable Care Act gave Medicare the tools to support this groundbreaking effort and to expand this program more broadly.”
The Centers for Disease Control and Prevention estimates that as many as one in three adult Americans has prediabetes , which with weight loss and exercise can be prevented from progressing to type 2 diabetes.
According to the CMS, the evidence-based diabetes prevention program resulted in savings of $2,650 per enrollee over 15 months, compared with costs associated with nonprogram beneficiaries – enough to cover the cost of the program. Program participants also were shown to lose about 5% of their body weight.
But who will deliver these preventive services and how they will be paid for are still questions to be answered.
“While the government supports expansion of the diabetes prevention program, it must now go through a period of rule making and public comment beginning this summer,” American Medical Association President-Elect Andrew W. Gurman said in an interview.
The AMA supports the expansion, having already helped to develop and pilot a similar community-based prevention program nationally in partnership with the YMCA. Based on that experience, the AMA has created a resource base for physicians and other providers to screen, test, and refer patients for their prediabetes, available online .
“This is an important step in advancing more enlightened health policy and recognizing the important role of prevention in stemming the tide of chronic disease in our country,” Dr. Gurman said.
The joint pilot AMA-YMCA diabetes prevention program relied mainly upon trained lifestyle coaches rather than physicians for service delivery.
When introduced this summer, the proposed 2017 Medicare Physician Fee Schedule will likely have more on the prediabetes program expansion, according to CMS officials.
The American College of Physicians suggests members consider adopting the patient-centered medical home model of care, which emphasizes team-based care and helping patients gain access to lifestyle change programs.
That is particularly helpful in anticipation of the 2019 merit-based reimbursement schedules featured in the Medicare Access and CHIP Reauthorization Act (MACRA), according to Shari Erickson, the ACP’s vice president for governmental affairs and medical practice. Such an approach is already gaining traction nationally and is used across the country by a number of payers, both public and private, she added.
“The ACP also has been seeking the development of a code bundle for diabetic care management to emphasize better care coordination, communication, and integration of the care team aimed at a better overall outcome and cost of care for the Medicare beneficiary,” Ms. Erickson said in an interview.
Leveraging the ACA for better diabetes care
Endocrinologists are calling for more integrated approaches to diabetes care and prevention.
A trifecta of concerns – cost saving, improved patient outcomes, and potential workforce shortages – are cited in a white paper published online outlining ways the health care system can leverage the Affordable Care Act to create multidisciplinary modes of diabetes care.
“Coordinated care is necessary to ensure the best possible outcomes for people with diabetes. An effective team-based approach must provide comprehensive, continuous, and timely care without duplicating any tests or services,” Dr. Alvin C. Powers , the report’s lead author and an endocrinologist at Vanderbilt University, Nashville, Tenn., said in a statement released by the Endocrine Society on the ACA’s sixth anniversary.
Currently, more than 29 million Americans have diabetes, according to the society . Without public health interventions, that number is expected to roughly double over the next 5 years, at an estimated cost to the U.S. health care system of $512 billion.
Passage of the ACA has helped increase the number of insured people able to receive a clinical diabetes diagnosis, creating the need for a broader and deeper range of diabetes-related services, according to the society.
People with diabetes often require care from a range of specialists, such as nephrologists, podiatrists, and ophthalmologists, as well as endocrinologists and primary care physicians who are skilled in managing diabetes.
The society supports programs such as the one announced by HHS Secretary Burwell, along with evidence-based community and employer-sponsored care, and incentives to providers to integrate diabetes care in practice.
The society is also calling for additional federally funded research, faster medication approvals from the Food and Drug Administration, and incorporation of the drugs into CMS beneficiary packages.
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