Tucked within bipartisan telehealth legislation that passed out of a House committee in September is the Prevent Diabetes Act, a bill that would expand Medicare coverage for virtual diabetes prevention programs.
A cadre of groups under the banner of the Diabetes Advocacy Alliance (DAA) support the legislation. Members include the American Medical Association, the Diabetes Patient Advocacy Coalition and providers like Noom, Omada Health, Teladoc, WeightWatchers and the YMCA of the USA.
The bill makes changes to the Medicare Diabetes Prevention Program (MDPP). This is separate from the Center for Disease Control and Prevention's (CDC’s) National Prevention Program, which includes all types of providers.
Advocates spoke with Fierce Healthcare to explain how the bill would change the virtual diabetes care landscape.
What does the bill do?
Some providers are recognized by the CDC through its National Prevention Program but do not hold Medicare supplier status through the MDPP.
Right now, Medicare does not include fully virtual programs, drastically limiting the number of program participants.
“The exclusion of innovative virtual suppliers from the MDPP expanded model has impeded the program’s reach and created substantial access gaps, particularly for older Americans living in rural and underserved urban communities,” said Sen. Tim Scott, R-South Carolina, a supporter of the bill.
There were just 301 MDDP approved suppliers (PDF) as of May 2024, according to the proposed 2025 physician fee schedule. Fewer than 5,000 beneficiaries have been enrolled in these programs through Medicare since 2018.
“On the Medicare side, about one out of two beneficiaries has prediabetes,” said Diana Catron Gallo, a diabetes prevention program director at Noom. “There are millions of people who could be taking advantage of this program and making real impacts on their lifestyle.”
MDDP is a Center for Medicare and Medicaid Innovation model and has been celebrated as a success at improving clinical outcomes and lowering costs. A MDPP program includes at least 16 classroom-style educational sessions over six months. The goal is to for the participants with prediabetes to achieve 5% weight loss.
The CMS Office of the Actuary found the model resulted in gross savings of $2,650 per person (PDF) across 15 months and a statistically significant reduction in hospitalizations and emergency department visits, wrote the Health Care Transformation Task Force.
The Prevent Diabetes Act would allow Medicare to cover in-person, fully virtual and all hybrid offerings in between.
Not only could the bill be more convenient for beneficiaries, it could have positive financial ramifications for Medicare Advantage (MA) plans.
If an MA plan contracts with a virtual diabetes prevention provider today, the program is treated as a supplemental benefit. If they contract with an approved Medicare supplier, however, the program can be counted toward the organization’s star ratings.
A national payer is therefore not incentivized to contract with virtual-based suppliers as of now, said Lucia Savage, chief privacy and regulatory officer at Omada Health and the former chief privacy officer at the Office of the National Coordinator for Health IT.
“There aren’t many organizations that operate nationwide with an in-building program because that’s not how healthcare works,” she explained. “Healthcare is all local.”
Direct-to-consumer providers could then bill Medicare directly under fee-for-service.
The bill also eliminates a once-in a-lifetime cap that restricts Medicare beneficiaries from enrolling in a program repeatedly due to financial strain.
“Right now, once a Medicare beneficiary begins that program, they have to keep going because Medicare will only pay for it one time,” said Heather Hodge, vice president of emerging opportunities for YMCA of the USA. “That can be really challenging. Seniors may get sick or injured, or other life events might happen.”
“Additionally, beneficiaries may spend several decades on Medicare, especially if they enter the program well before 65 (e.g., via a permanent disability), and the strategies they learned at a younger age may no longer align with their life circumstances in later years,” the DAA said in a letter to CMS in September.
CMS does not enforce similar lifetime caps on smoking cessation or intense behavioral therapy programs.
Government advocacy
Organizations in the DAA have long supported core aspects of this bill and are repeatedly speaking with CMS to include friendly provisions in the yearly physician fee schedule.
In the CY 2018 physician fee schedule rule, CMS expanded the MDPP program but limited it to in-person services, after hinting the previous year it would include all types of offerings, said Savage.
“We did a lot of work, starting in 2017 and ongoing to this day, with many other industry collaborators to really change the thinking about what CMMI had changed in the first place,” she said.
The bill on the table today would give a five-year extension. This gives providers more time to prove MDPP results in cost savings justifying permanency.
Already passed out of House Committee on Energy and Commerce, the bill must still get past the House Ways and Means Committee and the Senate. If it doesn’t pass by year-end, it must get reintroduced, for a fourth time now, in the new Congress.
“I definitely think it’s been advantageous to be seen as part of a larger telehealth package,” said Savage. “We’re very, very hopeful. We’re making progress every year.”