The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule on July 7 to update payment policies and rates, as well as quality provisions, for services provided under the Medicare Physician Fee Schedule (PFS). 

One principal proposed change is the expansion of the CMS Innovation Center’s Diabetes Prevention Program—a structured intervention that targets individuals with prediabetes—into Medicare starting Jan. 1, 2018, to give more beneficiaries access to the program. CMS is seeking comments on several aspects of this expansion, such as whether to permit entities recognized by the Centers for Disease Control and Prevention that participate in the program to enroll in Medicare starting Jan. 1, 2017, so they can submit claims as soon as possible once the program is integrated into Medicare. Other factors of the proposed expansion that are open for comment pertain to payment structure, beneficiary eligibility, IT requirements and capabilities, quality measurement and reporting, whether services must be provided in person or could be delivered virtually, and whether the expansion should be undertaken all at once or phased in, either by geographic regions or subpopulations of providers/suppliers. 

The rest of the proposed changes would begin Jan. 1, 2017. Among them are revisions to payments for chronic care management to compensate practitioners for providing extra care management after the initial visit for patients with multiple chronic conditions. Other proposals include payment for certain behavioral health services provided under the Collaborative Care Model; a new payment code for assessment and care planning for patients with cognitive impairment (e.g., those with Alzheimer’s disease); improved payment for care provided to beneficiaries with mobility-related impairments; new codes to be added to the list of services eligible for telehealth, including services for dialysis related to end-stage renal disease, advanced care planning services, and critical care consultations via telehealth; and new payment policies regarding the use of a new place-of-service code for reporting telehealth services.

To promote greater transparency and help beneficiaries make enrollment decisions, CMS is proposing the release of bid pricing data that organizations submit to participate in Medicare Advantage and the Part D prescription drug program, as well as data on Medicare health and drug plan medical loss ratios for Medicare Advantage organizations and Part D plan sponsors. 

The agency is also proposing revisions to the methodology used to calculate geographic practice cost indices. These updates, which would be phased in during 2017 and 2018, would “significantly” increase overall PFS payments in Puerto Rico and address legal requirement to use new locality definitions in California.

CMS is accepting comments on these and other changes proposed under the rule until Sept. 6, 2016. The rule will appear in the July 15 Federal Register.

Our Take: In 2011, the CMS Innovation Center awarded the National YMCA Council $11.8 million to enroll eligible Medicare beneficiaries who were at high risk for developing diabetes in a program designed to reduce that risk. Participants met with a lifestyle coach weekly for the first month to learn about strategies for dietary change and increased physical activity. After the initial training, participants could attend monthly followup meetings.

In March, HHS Secretary Burwell called the results “striking,” and indeed they were. Beneficiaries enrolled in the program lost about 5 percent of their body weight, which according to HHS, is enough to reduce the risk of diabetes. Over 90 percent of participants attended at lease four weekly sessions. And CMS estimated $2,650 per enrollee in savings over a 15 month period, “…more than enough to cover the cost of the program.”

The program was evaluated by the independent Office of the Actuary for CMS, who certified that expanding the Diabetes Prevention Program would reduce net Medicare spending. 

All too often we focus on what CMS does wrong, or bemoan CMS actions that we disagree with. This time, CMS got it right. The Diabetes Prevention Program is a roadmap for creating a healthier aging population—and for reducing the burden on the Medicare Trust Fund. 

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