By Sean Duffy
August 14, 2017 at 5:00 am ET
The scourge of type 2 diabetes across the United States costs American taxpayers billions of dollars every single year. Diabetes and diabetes-related treatment is one of the biggest drivers of rising health care costs for every payer — with Medicare spending more on treating those with the disease every year. This is particularly true in rural America, as the prevalence of diabetes and coronary heart disease is approximately 17 and 39 percent higher in rural areas than urban areas.
Policymakers from both sides of the aisle recognize this reality, and have embraced the challenge of confronting a preventable, but devastating, epidemic. Last month, for the first time in the agency’s history, the Centers for Medicare and Medicaid Services laid out proposed rules to reimburse providers to proactively prevent chronic disease by paying for the evidence-based Diabetes Prevention Program for eligible beneficiaries. Last year, the CMS Actuary certified that this program both improved quality of care and reduced costs for Medicare.
But unfortunately, the proposed rule missed a huge opportunity to extend access to this benefit to the area most in need: rural America.
In the July 13 rule, CMS proposed only making in-person DPP providers eligible for reimbursement, despite enormous evidence that virtual providers can achieve equal, or even better, results with senior populations. In addition, CMS’ sister agency, the Centers for Disease Control and Prevention, has been recognizing digital programs for more than two years while also collecting data demonstrating these programs’ effectiveness.
By excluding virtual DPP from Medicare, CMS has tilted the scales in favor of seniors that reside in urban areas with easy access to brick and mortar programs; even urban and suburban seniors with transportation issues may not be able to access this critical benefit if the proposed rule goes unchanged. Seniors in rural areas may have no reasonable option to access a qualified DPP.
The disparity of access becomes abundantly clear when examining the list of in-person programs registered with the CDC.
In Texas, there are many in-person options for seniors in Dallas, San Antonio and Houston. A senior living in Abilene, however, would need to drive or find transportation to Fort Worth or Lubbock to participate in an in-person program, requiring at least four hours of driving for per week. Seniors in rural areas of states like Georgia, Nevada, New Mexico, South Dakota, Wyoming, Utah and Kansas will be in similar situations, many with a minimum of two hours of driving on a weekly basis to access an in-person location — if they can drive at all.
This formulation sets up unnecessary and prohibitive barriers to millions of Medicare beneficiaries who could benefit from DPP programs.
The distinction between in-person and virtual programs is not supported by the findings of the CMS Actuary. To determine whether DPP should be offered to all eligible Medicare patients, the CMS Actuary evaluated the ability of the DPP curriculum to reduce seniors’ risk of type 2 diabetes, not the setting in which the curriculum was offered. Medicare Advantage plans and dozens of commercial insurers have specifically examined the virtual delivery of DPP and found cost savings, reduced incidence of diabetes and very satisfied program participants. Even if the Actuary was unmoved by these facts, the office now has access to CDC data that would confirm virtual programs’ efficacy with seniors. The Actuary can and should consider this data when preparing the updated program certification needed prior to implementation of the expanded benefit.
There is still an opportunity for CMS to embrace tech-forward, patient-centered solutions to this problem.
In its final rule, CMS should include virtual DPP providers as eligible for reimbursement, to ensure that all eligible seniors have access to qualified programs.
Seniors in rural areas should not be required to travel long distances to participate in an in-person DPP, or forgo the service altogether. Instead, they should be empowered to access preventive care where they live, as long as that virtual DPP provider has met CDC and CMS standards. These seniors should be encouraged to remain active parts of the communities in which they reside, supplemented by online communities. From a system perspective, including these seniors via virtual programs will be necessary to achieve the scale necessary for the potential cost savings.
CMS has an opportunity to embrace technology, empower patient choice and expand access to preventive care for millions of American seniors. The agency should seize it.
Sean Duffy is the co-founder and CEO of Omada Health, a digital behavioral medicine company that is one of the country’s largest CDC-recognized providers of the National Diabetes Prevention Program. Sean holds a BS in neuroscience from Columbia University, was an MD/MBA candidate at Harvard, and worked at Google and IDEO before founding Omada Health.
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