When the hangover of New Year’s Eve wears off — no, not on January 1, 2017 — but the first day of the year twelve months later, health plans that have planned ahead will be better poised than those that haven’t.
That’s because on January 1, 2018, a major change will affect how all U.S. health plans—public and private—will have to respond to the epidemic of type 2 diabetes.
On that day all eligible Medicare and Medicare Advantage (MA) beneficiaries will have covered access to Medicare-recognized Diabetes Prevention Programs (DPPs). Even if your health plan doesn’t have an MA line of business, you’ll feel the impact of this major development.
Here’s why:
- First: As the largest single payer in the U.S., Medicare wields significant influence over the industry. Forward-thinking health plans will be at the leading edge of this change, not rushing to try to catch up to it. Some, including Humana, Kaiser Permanente, and BCBS of Minnesota are already there.
- Second: Smart health plans with MA offerings aren’t going to stop at offering DPP to their MA members. If it’s saving them billions of dollars with that group, it’s going to save them billions more with their entire population. So to stay competitive, you’ll need to offer DPP to your members too.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
- Third: Per ACA rules, all health plans must provide, at no cost to eligible members, any treatment which receives a Grade A or B recommendation from the US Preventive Services Task Force (USPSTF). The USPSTF recently gave a Grade B recommendation for referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors, such as prediabetes, to “intensive behavioral counseling interventions.” The USPSTF specifically cites DPP as an evidence-based intensive behavioral counseling intervention.
Now’s the time to jump on this swiftly-moving locomotive. Your goal is to implement a DPP benefit that complies with government requirements, cuts your costs, and actually works for your at-risk members. There are a couple of ways to go about this.
DIY DPP
You could develop your own DPP benefit from scratch. This would entail creating or tapping your own innovation center, and dedicating a team to develop and integrate the program—and the technology necessary to scale the program to meet the needs of your population. To do this right, figure budgeting at least three years and several million dollars for development, optimization, and CDC approval.
DPP for Hire
Here you would contract with an existing DPP provider, and offer their program as a covered benefit. This is both the path of least resistance and the path of best outcomes. As long as the provider you choose is meeting ICER’s key recommendations. Let’s unpack them.
Rigorous Standards
Medicare will only cover Medicare-recognized DPPs. These programs use a CDC-approved curriculum that meets the duration, intensity, and reporting requirements described in the Diabetes Prevention Recognition Program (DPRP) Standards. To further ensure clinical rigor, look for providers that can demonstrate sustained results at 12 and 24 months in published, peer- reviewed manuscripts.
Screening
Eligible patients should be screened for prediabetes according to established recommendations. When prediabetes is identified, clinicians should refer patients for diet and activity counseling. Between screenings, there are many occasions when coordinated intervention can improve a participant’s outcome. Clinics can refer eligible patients to digital DPP and work together to achieve behavior change.
Variety of Formats
The DPP can be delivered three different ways.
- In-person programs with group coaching
- Digital programs with human coaching
- Digital programs with automated coaching
ICER compared the three formats and determined that only the first two—in person and digital + human coaching—offer a “net health benefit superior to that of usual care.” To engage the most people, the report encourages offering both of the recommended formats across all plans, with no co-pay.
Tailored to individual needs
ICER recommends that DPP providers tailor their programs to include culturally appropriate curricula for diverse populations. These could include seniors, the working poor, safety-net, and non-English speaking populations. The digital format is especially adept at personalizing and optimizing interventions. DPP providers that collect and analyze robust data sets are privy to a constant feedback loop from which they can draw actionable insights.
Pay for Performance
Payers should establish pay-for-performance contracts with DPP providers based on three metrics:
Patient Participation: Insist that programs address and engage your plan’s entire at-risk population, including low-income, low health literacy, and non- English speaking populations.
Retention in Program: The more of your members who complete the program, the greater the engagement, and the more you pay. You’ll want the measurement interval to be 52 weeks to be clinically meaningful.
Achievement of Weight-loss Goals: t makes sense to tie payment to weight loss. But the participant needs to keep the weight off to keep their risk low. So you want to look for a DPP that ties payment to 52-week measurements.
Getting the Party Started
Health plans have some plans to hash out between now and January 1, 2018.
While Medicare hasn’t yet released a list of approved vendors, historically they have looked to independent research organizations like ICER to help formulate their thinking and strategy. So if you make sure the DPP providers on your short list check all of ICER’s boxes, you should be in good shape to pull the trigger once the approved list is available.
One place to start your research is this exhaustive list of CDC-recognized DPP providers, both in-person and digital. It’s a lot to wade through. But the sooner you start, the sooner you’ll see the financial benefits of reducing your members’ risk for debilitating but utterly preventable chronic disease.
And that’s something worth raising a glass of bubbly to.
Photo: : filipefrazao, Getty Images
