Diabetes

Medicare’s diabetes prevention benefit: What doctors should know

Half of American seniors have prediabetes, but evidence-based lifestyle change programs can prevent or delay the progression to type 2 diabetes, and the AMA has resources to help physicians connect their patients with the services they need. 

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The AMA is working with the Centers for Disease Control and Prevention (CDC) and other partners through the National Diabetes Prevention Program (National DPP) to link high-risk patients with lifestyle-change interventions that help them achieve and maintain the moderate weight loss needed to halt diabetes from taking hold. 

An educational video offered via the AMA Ed Hub™ discusses what a diagnosis of diabetes will mean for most patients who develop the condition in their 60s or 70s. 

“There will be treatment options to describe, medications to prescribe, specialists to consult, lab tests to order—a level of care that will repeat every three to six months for the rest [of a patient’s] life, in the best case,” the video says. 

The AMA Ed Hub is an online platform with top-quality CME and education that supports the professional development needs of physicians and other health professionals. With topics relevant to you, it also offers an easy, streamlined way to find, take, track and report educational activities. 

The free online CME module “Preventing Diabetes in Your Medicare Population” is enduring material and designated by the AMA for a maximum of 0.25 AMA PRA Category 1 Credit™.  

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While noting how many older adults are at risk for the chronic condition, the video notes that “type 2 diabetes is not inevitable for all of them.” 

This is especially true now as Medicare offers beneficiaries free access to diabetes prevention programs (DPPs) that follow a CDC-approved curriculum, are led by a trained lifestyle coach, and provide evidence-based services that help people improve their diet, become more physically active and make other lifestyle changes that are important in the fight against diabetes. 

The video and “Preventing Type 2 Diabetes,” an AMA guide to referring patients to an evidence-based prevention program, offer instructions on how to incorporate DPP referral into a practice workflow. 

Screening and referral can be used to boost a practice’s score in the Medicare Quality Payment Program’s Merit-based Incentive Payment System (MIPS). 

This includes following the U.S. Preventive Services Task Force’s recommendation to screen patients who are between 40 and 70 years old and overweight or obese for prediabetes and refer them to a qualified DPP. 

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To be eligible for a Medicare DPP, patients must: 

  • Have Medicare Part B or Medicare Advantage coverage. 
  • Have a body mass index of 25 or greater (or 23 for patients who identify as Asian). 
  • Have no history of type 1 or type 2 diabetes (except for gestational diabetes). 
  • Not have end stage renal disease. 
  • Have either a hemoglobin A1c test with a value between 5.7 percent and 6.4 percent, a fasting plasma glucose between 110–125 mg/dL, or a two-hour plasma glucose between 140–199 mg/dL. 

Qualified Medicare DPPs offer 16 sessions over six months followed by six monthly maintenance sessions led by a trained lifestyle coach. Patients who meet attendance requirements and a 5% weight loss are eligible to continue with the program for up to another year. 

Physicians who implement systematic prediabetes and diabetes screening through their certified electronic health record and achieve and document systematic improvement in the quality of care they deliver can earn credit for a medium-weight MIPS “population management” improvement activity (IA): Glycemic Screening Services. 

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Similarly, they can also earn population management medium-weight IA credit for Glycemic Referring Services by attesting to the implementation of systematic referral of eligible patients to CDC-recognized DPPs. 

In addition to the health benefits, halting the progression of prediabetes to type 2 diabetes could have tremendous economic benefits. A recent study published in the American Diabetes Association journal Diabetes Care calculated that the economic burden associated with diagnosed diabetes, undiagnosed diabetes and prediabetes, and gestational diabetes mellitus reached nearly $404 billion in 2017. 

The Centers for Medicare & Medicaid Services (CMS) estimated that Medicare spent $42 billion more on beneficiaries with diabetes in 2016 than it would have spent if those patients did not have diabetes.