Content from Blue Cross Blue Shield Association: Improving health through personal touch, technology

June 21, 2018 / in Coverage / by admin

President and CEO of Blue Cross Blue Shield Association Scott P. Serota moderates a conversation about how technology combined with a personal touch is uncovering community solutions and improving health for patients fighting chronic disease.
June 20, 2018 | 1:28 PM EDT


April 1 Brings Day One of the Medicare Diabetes Prevention Program, and Challenges for Health Plans

April 2, 2018 / in Coverage / by admin

by Mary Caffrey

“Some Medicare Advantage plans may not be fully ready for the requirements of this history-making preventive service.”

Sixteen years after a National Institutes of Health study showed it worked, and 2 years after the CMS actuary said it could save millions of dollars, the Medicare Diabetes Prevention Program (DPP) launches today, making history in the way CMS fights a disease that accounts for $1 in every $3 spent in Medicare.

Medicare DPP achieves 2 key milestones:

  • First, an evidence-based preventive service will be expanded to all beneficiaries at no cost, which means every Medicare Advantage plan must have a way to offer it to members under CMS’ rules.
  • Second, community groups with nonclinical providers, such as the Y-USA, can be paid to offer the plan through medical claims instead of grants.

The American Journal of Managed Care® spoke on Friday with Brenda Schmidt, founder and CEO of Solera Health, a company that serves as an integrator—the only one of its kind—to provide technology, regulatory, and support services that will allow community programs, health systems, and Medicare Advantage plans meet CMS requirements. At the same time, Solera touches the consumer, connecting those interested in the DPP with a program best suited to their needs. The company adds Medicare DPP to its network after years of working with commercial plans, community groups, digital providers, and other network participants.

It’s been a busy time leading up to April 1. “We’ve been doing a lot of testing,” Schmidt said. “There are so many new administrative requirements, and new CPT [Current Procedural Terminology] codes.”

And there were still Medicare Advantage plans calling over the past week, unsure if their steps to meet CMS requirements would meet demand. “A lot of Medicare Advantage plans thought the launch would be delayed,” Schmidt said. Unique features of the program—such as those to accommodate seniors with 2 residences—are catching some health plans off guard, she said.

This morning, Solera launched, which directs users to a short questionnaire to help gauge eligibility; those who meet baseline criteria are instructed how to learn more.

Read more…

As MDPP Launch Looms, Solera Builds ‘Flex Model’ of Suppliers

March 21, 2018 / in Coverage / by admin

Reprinted with AIS Health permission from the March 15, 2018 issue of Radar on Medicare Advantage.

As the April 1 launch date of the expanded Medicare Diabetes Prevention Program approaches, Medicare Advantage organizations are busily working to ensure that their own benefits and provider networks are sufficient to offer MDPP services. Designed with the goal of preventing the onset of type 2 diabetes among Medicare beneficiaries diagnosed with pre-diabetes, MDPP services that were tested through the Center for Medicare and Medicaid Innovation’s Health Care Innovation Awards must now be covered by all MAOs. But setting up adequate networks of MDPP “suppliers” in what many plans viewed as a short implementation timeframe has proven to be a challenge, contends Brenda Schmidt, founder and CEO of Solera Health.

“Any new benefit that’s covering all of their beneficiaries is a big lift for a health plan because it touches so many parts of their organization. And the expanded MDPP is creating a unique set of issues for MA plans for a variety of reasons,” observes Schmidt in an interview with AIS Health. Namely, a “highly fragmented” supplier market that is traditionally made up of community-based organizations delivering the services through non-credentialed or licensed Lifestyle Coaches. Moreover, MDPP services are categorized as high-risk (similar to home care) due to the opportunity for fraud, creating an additional burden for MA plans in terms of the reporting and audit requirements, she explains.

The MDPP expanded model includes an evidence-based set of services that will be available to beneficiaries meeting certain criteria with no cost sharing through Medicare-enrolled MDPP suppliers. The services are delivered through “structured sessions” using a curriculum that is approved by the U.S. Centers for Disease Control and Prevention (CDC) and trains enrollees in long-term dietary change, increased physical activity and behavioral change. Participants must attend a minimum of 16 core sessions in a group-based, classroom-style setting over a period of six months, followed by less-intensive monthly follow-up meetings to help maintain healthy behaviors. The primary goal of the program is at least 5% weight loss by participants.

Given the high cost and prevalence of obesity and diabetes in the U.S., CMS with the November 2016 publication of the 2017 Physician Fee Schedule (PFS) established MDPP services as a Part B service, meaning all Medicare health plans — including MAOs, cost plans and Programs of All-Inclusive Care for the Elderly — are required to cover MDPP services for eligible beneficiaries. A year later, CMS in the 2018 PFS established policies related to the set of MDPP services, including supplier enrollment requirements. CMS had originally proposed a Jan. 1, 2018, start date for Medicare coverage of MDPP services, but in the 2018 PFS pushed it back three months after hearing from concerned stakeholders about not having enough time to contract with suppliers.

Solera Health, a Phoenix-based company that integrates payers and providers in chronic disease prevention, has been working on behalf of MA clients across the country to create an “integrated benefit network model.” Solera handles the “credentialing” and auditing of MDPP suppliers and assumes the responsibility for meeting CMS requirements as the delegated entity of the health plan. Solera has about 60% of MA lives under contract already and as of earlier this month was still receiving calls from prospective clients, according to Schmidt.

“What we’ve done is found organizations that are interested in scaling the DPP who meet [the requirements] and then we’re scaling those in independent pharmacies, grocery, retail, area agencies on aging, etc., creating a flex model,” she explains. Solera works with many of the Blues insurers as well as larger insurers such as Aetna Inc., Cigna Corp. and Kaiser Permanente to determine where to set up classes based on their members’ ZIP codes, she adds.

Program Must Be Delivered In-Person

Despite requests from stakeholders to include telehealth and digital forms of coaching, the program can only be offered in-person, thus limiting it further. Moreover, only about 400 out of about 1,600 MDPP suppliers nationwide meet the CMS criteria, and many have chosen not to apply because of what it takes for them to be a Medicare supplier from a compliance perspective, adds Schmidt. And other experienced organizations simply don’t qualify because they haven’t delivered the program for a full year, “so that pool of suppliers ended up to be pretty small,” she remarks.

The company also performs all the beneficiary outreach and determines enrollee qualification for the program. “Then, we act like to find the best DPP program providers for the individuals. And if the members switch [plans] or move out of state, we have the ability to move the data with them because all of these community DPP providers use our technology to document the engagement and weight of participants in our programs,” explains Schmidt. “The technology piece of it is what makes this work.” Solera is also launching a website,, on April 1 aimed at simplifying clinician referrals and consumer enrollment in the MDPP.

Although the CMS Office of the Actuary certified that the MDPP pilot program created an estimated $2,650 return on investment (ROI) per person over a 14-month timeline, many plans are interested in doing their own analysis before they aggressively enroll members, adds Schmidt. Moreover, the services provided by MDPP suppliers are submitted as medical claims, and plans were not able to submit any additional costs associated with the MDPP in their bids to CMS, “so a risk-adjusted MA plan perceives the costs associated with the program as an expense until they see an ROI,” she explains.

For more information, contact Brenda Schmidt or visit

U.S. Preventive Medicine, Solera Health Partner to Deliver Comprehensive Health Coaching

February 21, 2018 / in Coverage / by admin

HIT Consultant covers Solera’s new partnership with U.S. Preventive Medicine to deliver comprehensive health coaching and nurse based chronic condition care management services for Solera clients.

Click here to read.

Purpose-Driven Healthcare Innovation

January 25, 2018 / in Coverage / by admin

Solera Health’s CEO talks with the Business of Healthcare on purpose-driven innovation and how it aligns problem, purpose, and business model.

Click here to watch her interview.

The Integrator Role in Expanding Medicare Beneficiary Access to Diabetes Prevention Programs

/ in Coverage / by admin

Solera’s CEO, Brenda Schmidt, on the integrator role in expanding the Medicare Diabetes Prevention Program benefit, which for the first time ever, creates a preventive service for seniors delivered by a diverse range of non-clinical MDPP providers.

Click here to read.

Solera Health and WellDoc Announce Partnership

January 22, 2018 / in Coverage / by admin

Solera Health and WellDoc, a leading digital therapeutic company, announced that WellDoc’s BlueStar digital therapeutic will join the Solera network as a diabetes management solution of choice.

Click to read the article.

Solera Health to Offer WellDoc’s BlueStar Diabetes Management Platform

/ in Coverage / by admin

Solera Health and digital health provider Welldoc announced that they had partnered to offer WellDoc’s BlueStar, an FDA-approved diabetes management program, through Solera’s marketplace.

Click here to read.

Solera Health, WellDoc Partnership a “Natural Evolution” That Will Address Diabetes Prevention, Management

January 19, 2018 / in Coverage / by admin

Brenda Schmidt, CEO of Solera Health, and Kevin McRaith, CEO of WellDoc, announced a partnership that will make BlueStar available across Solera’s network, giving Solera the ability to offer a what Schmidt calls a “holistic” approach to diabetes prevention and management.

Click here to read. 

Blue Mesa Health Unveils Spanish Language Digital Diabetes Program on Solera Health Network: 3 Things to Know

/ in Coverage / by admin

Digital therapeutics company Blue Mesa Health recently launched “Transformemos,” its Spanish language diabetes prevention program, on the Solera Health network.

Click here to learn more.