The integrator role in expanding Medicare beneficiary access to Diabetes prevention programs

The Centers for Medicaid and Medicare Services and the Center for Medicare and Medicaid Innovation have been working diligently on establishing the Medicare Diabetes Prevention Program benefit, which for the first time ever, establishes a preventive service for seniors delivered by a diverse range of non-clinical MDPP providers.

The program which will begin on April 1, 2018, is expected to enable millions of Medicare members at risk for type 2 diabetes to significantly reduce their odds of developing the disease.

This initiative is certainly a sentinel event in Medicare’s history as to date we haven’t seen a coverage determination that in theory can be accessed as a preventive benefit by so many eligible individuals. It is expected that once this benefit is implemented, Medicare beneficiaries will be able to choose from a diverse range of more than 1,500 CDC-recognized national or community-based DPP providers.

It’s worth noting however, that there are formidable challenges to effectively implementing the Medicare DPP. Connecting DPP providers with at-risk Medicare beneficiaries while meeting the program administrative requirements, ensuring program integrity and compliance with CMS supplier regulations, and handling the intricacies of Medicare billing by non-clinical providers will be unchartered territory, which could limit the availability and impact of this important new benefit. For example, a large percentage of DPP providers currently recognized by the CDC do not have the technical expertise or resources to meet the regulatory requirements proposed in the administration of the Medicare DPP benefit. This is due, in part, to their varying business structures and unfamiliarity with the complex regulatory requirements that apply to the Medicare program. Many DPPs are small community non-profits or small companies with fewer than five employees. Even the larger, older and more sophisticated DPP providers would be seriously challenged to meet the supplier requirements and other programmatic CMS requirements.

It is for these reasons that a Medicare DPP Integrator should be integral to administering the Medicare DPP benefit. An Integrator could help solve the challenges of scaling the Medicare DPP by handling all the back-office functions – due diligence, compliance, program integrity, data validation, quality oversight, reporting, billing, etc. – that could overwhelm those high-quality DPP providers that lack the infrastructure and compliance and technical experience to meet Medicare regulatory requirements on their own. By managing these responsibilities, an Integrator could enable DPP providers to do what they do best – delivering the Medicare DPP to drive sustained healthy lifestyle changes for Medicare beneficiaries.

In order for the Medicare DPP to be successful, we believe the Integrator role will be critical to expanding beneficiary access to a broad and diverse DPP provider network across the entire country and providing real-time program integrity oversight in support of CMS’ efforts to prevent fraud, waste or abuse. For CMS, the benefits of such a role are numerous: a DPP Integrator could reduce the CMS’ administrative costs by providing a single point of contact; reduce the cost to administer the Medicare DPP benefit; more rapidly expand beneficiary access geographically across the country; enhance patient choice; provide real-time data and claims review and quality assurance; and ensure compliance, among others.

It's not every day that a new preventive benefit is eligible for Medicare coverage. As such, we as an industry should be doing everything in our power to allow the DPP to scale and ultimately improve the maximum number of lives as possible. To make this attainable, selecting an Integrator that could solve many of the potential administrative challenges with effectively implementing the Medicare DPP should be an important first step.

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