The Medicare Diabetes Prevention Program (MDPP), launched in 2018, is a covered behavior change program for Medicare beneficiaries designed to prevent type two diabetes. Diabetes' prevalence and financial burden are troublesome in the US, as prevalence is expected to grow to almost 18% by 2060 and it cost the country $327B in 2017.
In the 2022 Medicare Physician Fee Schedule final rule, CMS disclosed that only 27% of eligible provider organizations participate in the MDPP. Out of about 16.4M eligible enrollees, there's only about 3,600 patients who participate.
To increase uptake, CMS's new rule stipulates that MDPP will be shortened to one-year, maximum payments to providers will increase to $705, and the previous $599 enrollment fee for providers will be waived. But the rule does not extend reimbursement of providers who deliver the program virtually past the public health emergency.
CMS's choice not to continue to reimburse for virtual delivery of the MDPP indicates that 1) CMS is wary of the effectiveness of delivering this care virtually, and 2) despite efforts, the program will likely continue to experience relatively low adoption rates from providers and result in minimal patient benefit.
The efficacy of a virtual MDPP
CMS has argued there isn't sufficient evidence to suggest that virtually delivered MDPPs improve outcomes and reduce costs. The agency is uncertain of self-reported weight figures, which in a virtual world is a statistic that is much easier to deflate.
Beyond CMS, academics like Kasia Lipska, an Endocrinologist from Yale University, also have concerns with evidence around virtually delivered MDPP programs.
"Marketing has vastly outstripped evidence in terms of proving that these digital diabetes coaching systems improve outcomes. Many people know the right diet and right exercise level, but how do you implement it into a person's busy life and keep them motivated?"
– Kasia Lipska, Endocrinology, Yale School of Medicine
The available evidence from studies shows concerns are legitimate. One study found that the difference between virtual MDPP experiences compared to in-person lacked statistical significance. However, the study's sample was limited to military veterans, hampering the study's generalizability to the broader public.
A qualitative study found that patients experiencing MDPP virtually and in-person found them "similarly-useful." But of course, the study's results are not robust and should not inform critical national policy. Additionally, Omada Health, a virtual health provider lobbying for integration with the MDPP, published a promising study touting the supposed benefits of virtually provided MDPP's; but critics bemoan the fact it hasn't been published in any academic journal.
CMS's wariness of virtual MDPP delivery is in line with the lack of usable evidence that proves its efficacy but may be a factor the MDPP's overall low utilization.
The future adoption of the MDPP
Virtual health providers and advocates have strongly shaped their virtual MDPP strategy around lobbying politicians without resolving the core issue of presenting robust research supporting the benefits of virtual services.
Lucia Savage, a Chief Privacy and Regulatory Officer for Omada Health, is disappointed in CMS's decision. Omada Health and others are supporting the Prevent Diabetes Act which would enforce reimbursement for providers delivering the MDPP virtually. It is a bipartisan bill that was introduced in the Senate in June 2021 having previously failed in 2020.
Additionally, lobbying documents submitted to the Senate from seven organizations (Livongo, Noom, Teladoc, eHealth Initiative, the Healthcare Leadership Council, the American Diabetes Association, and the Association of Diabetes Care & Education Specialists) between 2020 and 2021 reported spending a total of $890,000 on lobbying efforts that include mention of the Prevent Diabetes Act. Dozens of advocacy organizations also penned an open letter in support of the bill.
The new CMS rule and uptick in lobbying efforts reveal that virtual care advocates are at a crossroads between strategies, both informed with incomplete information. It's not currently clear if CMS can authorize reimbursement for virtual MDPP providers beyond the PHE in any rule, and the available evidence from research does not clearly indicate that virtual MDPP delivery leads to improved health outcomes and reduces costs.
Either way, the MDPP likely faces another year of relatively low adoption rates from providers, which may lead to continued access challenges for patients and further stymie actual diabetes prevention efforts.