March 21, 2018 / in Coverage / by Neha Purohit
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.
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.