What MDPP Benefits Mean to You

As your patients age, their health needs change as well, which can increase their risk for chronic disease. In fact, of U.S. adults ages 65 and older, 23.1 million, or 48.3 percent, have prediabetes, according to the National Institutes of Diabetes and Digestive and Kidney Diseases. This condition, in which blood glucose levels are higher than normal but not high enough to be diabetes, puts them at increased risk for developing type 2 diabetes and cardiovascular disease, which can lead to heart attack and stroke.   

In an effort to prevent patients with prediabetes from progressing to type 2 diabetes, the Centers for Medicare & Medicaid Services (CMS) has expanded a successful model test by the Centers for Medicare and Medicaid Innovation so that all eligible Medicare patients will receive the Medicare Diabetes Prevention Program (MDPP) as a covered benefit starting April 1, 2018. The MDPP program builds on the foundation of the National Diabetes Prevention Program, developed by the Centers for Disease Control and Prevention (CDC). 

Here’s what you need to know about the new MDPP benefit. 

Who qualifies for the MDPP benefit?

Patients enrolled in Medicare Part B are eligible for the MDPP benefit if they meet the following requirements:

      Body mass index (BMI) of greater than or equal to 25, or if Asian, greater than or equal to 23

     Lab value in the prediabetes range determined by one of the following:

     HbA1C: 5.7-6.4 percent

     Fasting glucose: 110-125 mg/dL

     Two-hour plasma glucose tolerance test of 140-199 mg/dL

     No previous type 1 or type 2 diabetes diagnosis (other than gestational diabetes)

     No current diagnosis of end-stage renal disease 

Eligible MDPP participants can attend weekly meetings for coaching and education on long-term dietary changes, increased physical activity and weight control strategies over six months. This is then followed up with six months of monthly check-ins to make sure they’re maintaining healthy habits. The goal is for participants to achieve 5 percent weight loss. Participants who are able to maintain the targeted 5 percent weight loss will also be eligible to receive up to one additional year of monthly maintenance sessions.  

How do patients access the MDPP benefit?

Only 14 percent of adults aged 65 and older with prediabetes know they have the condition. By screening patients and recommending that that they participate in MDPP services, you can help patients learn their risk and understand their treatment options.  While patients can enroll in the MDPP without a physician referral, you can increase the likelihood that your patient will participate if you refer your patients to the program.  CMS will be publishing a list of Medicare DPP programs after the benefit starts in April. 

What do physicians stand to gain from the MDPP benefit?

The CMS has ruled that reimbursements will not be given for virtual DPPs, only in-person. For those with an on-site DPP, the MDPP is an opportunity to bring a low-cost initiative to your patient community. It also offers a cost-savings in terms of clinical services that also improves patient outcomes.  

For physicians who participate in the CMS’s Merit-based Incentive Payment System (MIPS), systematically screening patients for prediabetes and referring patients to a DPP can garner rewards as well. CMS has approved two Improvement Activities that offer an incentive for diabetes prevention: glycemic screening services and glycemic referring services.  By ensuring quality care to your Medicare patients who have prediabetes through one or both of these Improvement Activities, and backing it up with evidence-based and practice-specific data, you could be eligible for a performance-based payment adjustment to your Medicare reimbursement. AMA’s MIPS Action Plan can show you how. 

*As part of ongoing work to reduce the incidence of type 2 diabetes nationwide, the American Medical Association (AMA) has commenced a multi-state effort to reach more of the estimated 84 million Americans who unknowingly live with prediabetes.  MSSNY has proudly partnered with the AMA to launch this proactive initiative to educate New York State physicians on how to initiate clinical practice change and prevent diabetes in patient population. In addition, MSSNY is working to identify health systems, private and/or group practices who are interested in implementing the Center for Disease Control’s (CDC) National Diabetes Prevention Program.