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

https://www.washingtonpost.com/video/postlive/wplive/content-from-blue-cross-blue-shield-association-improving-health-through-personal-touch-technology/2018/06/20/788646c2-74cb-11e8-bda1-18e53a448a14_video.html?utm_term=.2d8d9a46cc08

 

New Medicare Advantage rules hold big potential for pop health

June 14, 2018 / in News / by admin

HealthcareDIVE

The push toward valued-based care and population health management has raised visibility around nonmedical conditions that impact health outcomes.

Improving health outcomes using population health strategies could get a major boost with a new Medicare Advantage rule taking effect this week.

Payers will now be able to work with companies like Uber or Lyft to provide transportation, for example, as part of a more complete set of benefits for the quickly growing MA population.

CMS issued a final rule in May giving MA plans more flexibility in determining the types of supplemental benefits they can offer chronically ill enrollees, including nonmedical benefits. The new policy, part of a broad 2019 Medicare payment rule, means plans like UnitedHealthcare and Humana aren’t harnessed to a set palette of supplemental benefits for members with chronic conditions, but can tailor them to the specific needs of individuals.

The rule could see an array of new benefits aimed at improving health outcomes by addressing issues such as housing and food insecurity, transportation and social isolation. Potential benefits include ride-hailing services, home visits, nutritional support, air conditioners for people with asthma, home renovations like grab bars and other accommodations to prevent falls, and home health aides.

Providers have praised the expansion of benefits. “We now have a funding stream effectively within Medicare Advantage around social services,” Don Crane, president and CEO of America’s Physician Groups (APG), told Healthcare Dive in an interview. He called the change a “necessary and appropriate step” in managing chronic diseases.

The focus on social determinants of health and population health management is part of the broader shift to value-based care and reimbursement. Some providers, payers and employers already offer wellness and prevention programs or free rides to cut down on patient no-shows.

Whether the CMS rule leads to wider adoption of population health programs generally remains to be seen, but as a fast-growing segment of the Medicare market, insurers and providers are likely to be watching for any impact on access to care, outcomes and cost.

Currently, about 21 million Americans are enrolled in MA plans — or a little more than a third of Medicare beneficiaries. However, L.E.K Consulting predicts enrollment will jump to 38 million, or 50% of market penetration, by 2025.

‘Reasonable expectation of improving health’

Under the bipartisan budget deal signed by the president in February, Congress expanded supplemental benefits for the chronically ill to include ones that “have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and may not be limited to being primarily health related benefits.” The law also authorizes CMS to waive uniformity requirements, but only with respect to supplemental benefits for enrollees with chronic conditions.

Uber and Lyft, both with active partnerships in healthcare, say the new policy will help them expand their footprint.

“This guidance demonstrates how serious CMS is in giving health plans the tools they need to address the social determinants of health — of which transportation is foundational,” Lauren Belive, director of federal government relations at Lyft, told Healthcare Dive via email. “This new flexibility will allow us to partner even more dynamically with MA plans to not just help seniors suffering from chronic health conditions get to their health appointments, but to more broadly leverage our platform to remove transportation barriers and encourage healthy and active living.”

Katherine Hempstead, senior adviser to the EVP at the Robert Wood Johnson Foundation, agrees. “It fits into the overall trend toward paying for value and thinking about the broader array of things in our living conditions that affect our health,” she told Healthcare Dive. “There can definitely be sort of an ROI in covering some of these things.”

Tackling social determinants of health

Following CMS’ release of the rule, APG announced a partnership with the nonprofit Partners in Care Foundation to offer their patients new benefits enabled by the rule. With the new regulations, practices with MA members will likely want to avail themselves of the opportunity to expand benefits. The issue is whether to build the infrastructure for these services in-house or contract them out. “Our agreement with Partners in Care creates ready resources for members to use,” Crane said.

Integrated benefit network Solera Health also sees an opportunity in CMS’ expansion of benefits. “We think it’s extremely significant because it validates the realization that healthcare-related social determinants of health can have an impact on peoples’ ability to maintain and improve their health between doctor visits,” Brenda Schmidt, founder and CEO of the Phoenix-based company, told Healthcare Dive.

Solera, which is helping administer the Medicare Diabetes Prevention Program, recently announced a partnership with nonprofit Feeding America to address food insecurity. Among those who will benefit are Solera’s 37 MA plans, representing about 13 million covered lives. The company also serves about 6 million Medicaid beneficiaries and 40 million commercial lives.

Solera has a similar partnership with the Food as Medicine Coalition in California, which received a $64 million grant from MediCal to document the impact from providing medically tailored meals for 3,000 people in California.

Food and other social services for the needy and elderly have been around for a long time. Meals on Wheels, for example, brings healthy food to homes and addresses social isolation and inability to get around. What changed with the budget bill and the CHRONIC Care Act included in it is that industry now has the opportunity to operationalize and monetize these healthcare-related social supports so that there is a sustainable revenue model for organizations that typically have been philanthropically funded or grant-supported, Schmidt says.

At the same time, it increases visibility at the member level around who is receiving services so plans can document quality and cost.

This, in turn, provides a big opportunity for a new model in healthcare, Schmidt says. “These highly disparate, highly fragmented nonmedical social services really have never been integrated into healthcare and require a business model that’s going to help health plans feel comfortable with the quality and regulatory compliance of this class of providers,” she says.

Insurers that Healthcare Dive reached out to did not say whether or what new benefits they may offer next year. However, Sarah Bearce, spokeswoman for UnitedHealthcare, said via email that “Medicare benefits should not be one-size-fits-all, and continued rate stability and greater benefit design flexibility enable health plans to provide a more personalized healthcare experience for the millions of people who choose Medicare Advantage.”

While the new flexibility provides a lot of room for innovation, it could also be a slippery slope. “You have to think about what’s the limit to this,” Hempstead says. “On the one hand, you can reduce healthcare costs by making sure people have all these other things covered. On the other hand, you might think, wow, everything in the healthcare system is so expensive. To what extent do we want to bring all these things into the healthcare system?”

Plans need to carefully think about how they price these new benefits and how much the system is paying for them so patients get benefits without making everything cost more, she added. “I think there will be a lot to learn about what is a good investment and what is not.”

An unintended victim?

One potential victim of expanding MA benefits is the long-term care insurance market. The number of people purchasing LTC plans dropped nearly 14% from 2015 to 2016 — an eight-fold decline from the market’s peak in 2002. Earlier this year, a major carrier went belly up, forcing other carriers to pay into its guaranty fund. Carriers have complained that they are underpriced and that people are staying in policies longer than expected, with fewer lapses and higher claims than expected.

With an average annual premium of $3,490 for a 60-year-old couple, many seniors may choose to switch to MA plans now that they can provide some of the same benefits around daily living and home health aides.

“It will be interesting to see to what extent this partially solves the long-term care problem, because right now Medicare doesn’t cover that stuff, so people either buy long-term care insurance, they use their private savings or they end up kind of spending down and using Medicare,” Hempstead says.

June 6, 2018 / in News / by admin

Solera Health Founder and CEO Brenda Schmidt Named “Best MedTech CEO”
2018 MedTech Breakthrough Awards Program Recognizes Solera Leader for Innovation and Vision

Phoenix, AZ – June 6, 2018Solera Health, a leading integrated benefit network, today announced that Founder and CEO Brenda Schmidt has been recognized as the “Best MedTech CEO” by MedTech Breakthrough, an independent organization that recognizes the top companies, technologies, and products in the global health and medical technology market.

“It’s an honor to receive this award from MedTech Breakthrough,” said Schmidt. “When I founded Solera Health less than three years ago, I saw the need for a transformative network model to tackle chronic health issues at their roots by connecting patients, payers, and providers to proven non-medical health interventions – like medical nutrition therapy and diabetes prevention programs. We believe that getting these critical interventions paid through medical claims by payers like any other medical service is an important step in preventing and better managing chronic health conditions and lowering our national healthcare costs. This award is a validation of our work to-date, and I am excited about our plans for the future.”

The mission of the MedTech Breakthrough Awards is to honor excellence and recognize the innovation, hard work, and success across a range of health and medical technology categories. This year’s program attracted over 3,000 nominations from more than 12 different countries.

“We are thrilled to name Brenda Schmidt as our 2018 MedTech Breakthrough Award winner for “Best MedTech CEO” in recognition of her dedication to supporting and scaling evidence-based programs,” said James Johnson, managing director, MedTech Breakthrough. “It’s exciting to see the initiatives Solera Health is driving, from food insecurity to diabetes prevention. Brenda is not only a visionary healthcare entrepreneur and industry leader, she also contributes to several important organizations such as the Council for Diabetes Prevention and the Population Health Alliance. We congratulate Brenda and the Solera Health team on their successes and we look forward to seeing their future contributions to the health and medical technology field.”

Solera Health recently announced partnerships with Feeding America and the California Food is Medicine Coalition to address food insecurity, and on April 1 launched MedicareDPP.org, a national referral and selection website for the new Medicare Diabetes Prevention Program.

About Solera Health

Solera Health is an integrated benefit network that connects patients, payers, and physicians with community organizations and digital therapeutics providers, simply and securely. Solera helps consolidate highly fragmented programs and services into one integrated network, allowing health plans and medical providers to increase consumer participation while lowering associated costs. Solera proactively identifies the “best fit” program provider based on each individual’s unique needs and preferences, which has proven to have a significant impact on improved patient outcomes at a fraction of the cost of traditional medical care. For more information, visit Solera Health at www.soleranetwork.com, call 800-858-1714 or follow us on Twitter @SoleraNetwork or LinkedIn.

About MedTech Breakthrough
The MedTech Breakthrough Awards program, part of the Tech Breakthrough Awards organization, is devoted to honoring excellence in medical and health related technology companies, products and people. The MedTech Breakthrough Awards provide a platform for public recognition around the achievements of breakthrough MedTech companies and products in categories including Patient Engagement, mHealth, Health & Fitness, Clinical Administration, Healthcare IoT, Genomics, Medical Data, Healthcare Cybersecurity and more. For more information visit www.MedTechBreakthrough.com.

 

 

Solera Health and EVA Health Announce Partnership

May 30, 2018 / in News / by admin

Phoenix, AZ – May 30, 2018 – Solera Health, a leading integrated benefit network, today announced that Covina, CA-based EVA Health has joined its national network of diabetes prevention program (DPP) providers.

EVA Health is a local pharmacy provider that is certified to hold classes for people at risk of developing diabetes who are registered for a DPP, like the Medicare Diabetes Prevention Program (MDPP), which was effective as of April 1 as a covered benefit for eligible Medicare beneficiaries.

The MDPP’s goal is to reduce the risk for type 2 diabetes through a year-long program. The small group classes will use a standardized curriculum and will be led by a trained lifestyle coach. The program aims to improve nutrition and increased physical activity with the goal of losing a minimum of 5% body weight; this has been correlated with a 70% reduction in the risk of type 2 diabetes for people over age 60.  Individuals who are successful in meeting the CDC-established weight loss and attendance goals in the first 12 months of the program can continue with ongoing maintenance in the MDPP for up to an additional year.

“We’re very excited to be part of the Solera network and have the expanded access to participants, and the administrative support, that comes with that,” said Chad Nour, CEO, EVA Health. “I’m hoping that our organization taking this step will be a catalyst for other independent pharmacies in the area to start offering the DPP as well. Pre-diabetes is a critical health inflection point. I’m passionate about helping ensure that people’s pre-diabetes doesn’t progress to a diabetes diagnosis.”

“Nearly all of Los Angeles county’s health plans now cover the diabetes prevention program – even more so when Medi-Cal adds DPP as covered service on January 1, 2019,” said Brenda Schmidt, CEO, Solera Health. “We’re thrilled that residents within San Gabriel Valley can now go to a trusted, local community site for their DPP classes.”

About Solera Health

Solera Health is an integrated benefit network that connects patients, payers, and physicians with community organizations and digital therapeutics providers, simply and securely. Solera helps consolidate highly fragmented programs and services into one integrated network, allowing health plans and medical providers to increase consumer participation while lowering associated costs. Solera proactively identifies the “best fit” program provider based on each individual’s unique needs and preferences, which has proven to have a significant impact on improved patient outcomes at a fraction of the cost of traditional medical care. For more information, visit Solera Health at www.soleranetwork.com, call 800-858-1714 or follow us on Twitter @SoleraNetwork or LinkedIn.

California Food is Medicine Coalition Selects Solera Health to Help Drive a $6M Program for the Chronically Ill

May 23, 2018 / in News / by admin

Partnership will enable medically-tailored meal interventions to be billed as health care benefits

PHOENIX, May 23, 2018 /PRNewswire/ — Solera Health, a leading integrated benefit network, today announced a partnership with the California Food is Medicine Coalition (CalFIMC). The news comes on the heels of Solera’s recently announced national partnership with Feeding America to address food insecurity. In this new partnership, Solera will work with CalFIMC to strengthen, accelerate, and scale their comprehensive medically-tailored meal and medical nutrition therapy interventions (CMTM) with the goal of improving outcomes for patients with complex chronic conditions.

CalFIMC is a coalition of nonprofit, medically-tailored food and nutrition services providers. Last year, the providers came together under a $6 million California pilot program to evaluate the delivery of CMTMs to eligible chronically ill Medi-Cal (California Medicaid) members. The pilot program is testing the impact of daily, nutritious medically tailored meals and medical nutrition therapy to 1,000 Medi-Cal members with congestive heart failure or type 2 diabetes. Researchers from the University of California San Francisco and Stanford will compare their results with 4,000 matched Medi-Cal beneficiaries who are not receiving the intervention.

“The pilot’s goal is to evaluate how a CMTM intervention impacts individual health outcomes and the cost of their care, by providing medical nutrition therapy combined with twelve weeks of meals tailored to the client’s chronic conditions after a hospital discharge,” said Mark Ryle, CEO of Project Open Hand in San Francisco, one of the California organizations that makes up the CalFIMC. “Preliminary studies indicate enormous potential to improve people’s health in the long-term and save money across the state.”

“We recognize that for CMTM to be a scalable solution for health insurers we need to ensure the highest standards of client privacy, data security, and auditable tracking of services and meal provision,” continued Ryle. “Our clients deserve an infrastructure and technology platform that allows for their CMTM services to be handled like any other health care service, billed as a covered benefit. Solera Health has demonstrated its ability to meet our needs for community-delivered, non-medical services through its experience scaling the National Diabetes Prevention Program.”

“There is now industry-wide recognition of the importance of social determinants of health, but it is a challenge to scale these interventions unless they can be integrated into the healthcare ecosystem like any other clinical service,” said Sandeep Wadhwa, MD, Chief Health Officer of Solera Health. “These new  interventions must meet the rigorous program integrity, quality assurance and audit requirements for health plans to pay for healthcare-related social supports in the same way as other healthcare services.”

“On April 4, 2018 CMS finalized guidance allowing Medicare Advantage plans to expand supplemental benefits to include items and services that address social determinants of health,” continued Wadhwa.  “We’re excited to work with CalFIMC to operationalize comprehensive medically-tailored meal interventions not only to prepare for eventual state-wide coverage by Medi-Cal, but to drive adoption by Medicare Advantage plans under this new CMS guidance. We believe commercial, marketplace and Medi-Cal managed care plans will now want to offer CMTMs, knowing they can ensure these items and services are flowing through as medical claims.”

The CalFIMC initiative is modeled off an earlier study conducted in Philadelphia by Metropolitan Area Neighborhood Nutrition Alliance. The organization retroactively looked at health insurance claims for 65 chronically ill Medicaid patients who received three medically-tailored meals each day for six months. Their medical claims were compared to a control group. The study showed that the health care costs for those 65 meal recipients were on average, $12,000 less than the control group.

About the California Food is Medicine Coalition
The California Food is Medicine Coalition (CalFIMC), the leading Nutrition Services providers in the state that serve thousands of clients annually with coverage across seven counties, offers a unique, cost-effective, high-quality managed-care solution for improving health outcomes for critically-ill clients. Members include Project Open Hand, Ceres Community Project, Project Angel Food, Mama’s Kitchen, Food For Thought and Health Trust represent a California contingency of the Food Is Medicine Coalition. For more information, visit www.calfimc.org or follow us on Twitter @CalFIMC.

About Solera Health
Solera Health is an integrated benefit network that connects patients, payers, and physicians with community organizations and digital therapeutics providers, simply and securely. Solera helps consolidate highly fragmented programs and services into one integrated network, allowing health plans and medical providers to increase consumer participation while lowering associated costs. Solera proactively identifies the “best fit” program provider based on each individual’s unique needs and preferences, which has proven to have a significant impact on improved patient outcomes at a fraction of the cost of traditional medical care. For more information, visit Solera Health at www.soleranetwork.com, call 800-858-1714 or follow us on Twitter @SoleraNetwork.

SOURCE Solera Health

Related Links

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Solera Health Named one of Modern Healthcare’s Best Places to Work in Healthcare

May 17, 2018 / in News / by admin

Phoenix, AZ – May 18, 2018 – Solera Health, a leading integrated benefit network, has been selected by Modern Healthcare as one of the 2018 Best Places to Work in Healthcare. The complete list of this year’s winners, in alphabetical order, is available here. Modern Healthcare will publish a special supplement featuring ranked lists of all the winners along with the October 1 issue.

Modern Healthcare’s Best Places to Work in Healthcare award identifies and recognizes outstanding employers who foster positive work environments. The program uses employee surveys to gather feedback and evaluate organizations across a range of different areas, including culture, leadership, working environment, role satisfaction, pay and benefits, and overall satisfaction.

Now in its eleventh year, the Best Places to Work program recognizes 150 U.S. healthcare companies and organizations for their supportive, dynamic workplaces and for empowering their employees to provide patients and clients with outstanding care, products and services.

“We’re very honored to be named a Best Place to Work,” said Brenda Schmidt, CEO of Solera Health. “Winning this award is a validation that we’re not only working hard to serve our clients and partners, but that we’re also committed to creating a great corporate culture that supports and empowers our employees to achieve our mission of helping people maintain or improve their health.”

About Solera Health

Solera Health is an integrated benefit network that connects patients, payers, and physicians with community organizations and digital therapeutics providers, simply and securely. Solera helps consolidate highly fragmented programs and services into one integrated network, allowing health plans and medical providers to increase consumer participation while lowering associated costs. Solera proactively identifies the “best fit” program provider based on each individual’s unique needs and preferences, which has proven to have a significant impact on improved patient outcomes at a fraction of the cost of traditional medical care. For more information, visit Solera Health at www.soleranetwork.com, call 800-858-1714 or follow us on Twitter @SoleraNetwork or LinkedIn.

 

 

Solera Health Introduces MedicareDPP.org to Match Medicare Beneficiaries with Diabetes Prevention Programs

April 2, 2018 / in News / by admin

The website offers millions of at-risk older adults a simple way to access the new Medicare Diabetes Prevention Program services

Phoenix, AZ – March 27, 2018 Solera Health, a leading integrated benefit network, today announced the launch of MedicareDPP.org, a national referral and selection website for the new Medicare Diabetes Prevention Program (MDPP). The site’s goal is to increase awareness of and participation in diabetes prevention programs by making it easy for Medicare beneficiaries to learn their risk for type 2 diabetes, and if eligible, find and participate in a local diabetes prevention program that fits their needs and preferences.

Effective as of April 1, the MDPP is a milestone in the history of Medicare. For the first time, an estimated 22 million Medicare beneficiaries at high risk of developing type 2 diabetes have access to evidence-based, diabetes prevention services at no cost. The MDPP, which aims to reduce the risk for type 2 diabetes through a two-year program, is the culmination of years of work across government agencies to scale the National Diabetes Prevention Program. This has included research from the National Institutes of Health, the translation of that research into community-based programming by the Centers for Disease Control and Prevention (CDC), the completion of the MDPP expanded model pilot and actuarial analysis by the Centers for Medicare and Medicaid Innovation (CMMI), and now the addition of MDPP as a covered preventive service by the Centers for Medicare & Medicaid Services (CMS).

MedicareDPP.org is a user-friendly portal that encourages individuals to learn more about the MDPP and verify that they meet the program qualification criteria. Once eligibility is verified, the site connects the beneficiary to Solera’s national network of non-medical, community-based MDPP suppliers that meet CDC and CMS requirements. Solera is contracted to administer the MDPP for more than 32 Medicare Advantage plans, however, the website is designed to verify eligibility and match all eligible Medicare beneficiaries with MDPP suppliers.

“The National Diabetes Prevention program can reduce the risk for type 2 diabetes and provide a positive financial return in 12 to 14 months,” said Brenda Schmidt, CEO of Solera Health. “Through MedicareDPP.org, we act like Match.com to find the best diabetes prevention program for Medicare members to help them live healthier lives. We are excited to work with our MDPP network partners to achieve this goal.”

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About Solera Health

Solera Health is an integrated benefit network that connects patients, payers, and physicians with community organizations and digital therapeutics providers, simply and securely. Solera helps consolidate highly fragmented non-medical programs and services into one integrated network, allowing health plans and medical providers to increase consumer participation while lowering associated costs. Solera proactively identifies the “best fit” program provider based on each individual’s unique needs and preferences, which has proven to have a significant impact on improved patient outcomes at a fraction of the cost of traditional medical care. For more information, visit Solera Health at www.soleranetwork.com, call 800-858-1714 or follow us on Twitter @SoleraNetwork or LinkedIn.

 

Media Contact
Vanessa Ulrich
(410) 534.1161
vulrich@sage-growth.com

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

/ 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 MedicareDPP.org, 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 Match.com 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, MedicareDPP.org, 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 https://tinyurl.com/ycm346zm.