Medicare wants to prevent you from having to ever use this.
Photograph by Bally Scanlon--Getty Images
By Laura Lorenzetti
March 23, 2016

Medicare unveiled a new initiative Wednesday that would allow reimbursement for diabetes prevention programs to all seniors covered by the program, underlining the agency’s commitment to chronic disease pArevention.

Secretary of Health and Human Services Sylvia Matthews Burwell detailed the new plan to reimburse recognized providers of diabetes prevention programs to eligible beneficiaries. These “lifestyle change programs,” where trained counselors help pre-diabetic patients adopt healthier lifestyles to prevent full-blown Type 2 diabetes, are meant to decrease the number of diabetic Medicare recipients by intervening before their blood sugar levels become a major and more costly health risk.

The move, which falls on the sixth anniversary of the Affordable Care Act, has been part of an overarching push by the Obama administration to extend value-based care models that are able to help patients while keeping costs under control.

Until now, there was no reimbursable way for pre-diabetic patients to receive care, said Mike Payne, head of medical affairs at Omada Health, the nation’s largest federally recognized provider of diabetes prevention programs in the U.S. Medicare has always reimbursed providers to screen for diabetes and to treat those who have the disease, but there wasn’t a way for providers to be reimbursed to stop that progression all together.

“Medicare is slowly but surely turning its efforts to prevention at a much bigger scale,” said Payne. “Overall, the U.S. health system only spends 3% on prevention versus 97% on treatment. The move by Medicare is a big deal, signaling a shift towards preventing illness instead of waiting for patients to become sick enough for more costly care.”

There are nearly 86 million pre-diabetic adults in the U.S., and at least 22 million of them are over the age of 65. Pre-diabetic patients are at an increased risk of heart disease, stroke, and adult-onset diabetes. However, progression of the condition can be properly controlled with interventions like those provided by Omada and the YMCA, which worked with the Centers for Medicare and Medicaid Innovation on the trial program.

The formal evaluation by HHS found that diabetes prevention programs “reduce health care costs and help prevent diabetes,” said Burwell. The total saved per beneficiary was $2,650 over 15 months, and participants lost about 5% of their body weight, enough to help change their health trajectories and reduce their diabetic risk.

Expanded access to diabetes prevention programs could result in substantial savings for Medicare over time. Without intervention, nearly a third of pre-diabetic patients will progress to type 2 diabetes over the next three years, according to Omada. Medicare spent more than $15,700 per beneficiary with diabetes in 2014, but effective intervention strategies could decrease federal spending on diabetes treatment by $1.3 billion in the first decade, according to analysis by Avalere Health.

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