Pharmacy Practice

Medicare Poised to Cover Diabetes Prevention Services

Kate Traynor
Kate Traynor Senior Writer, ASHP News Center Published: January 24, 2018

Clinicians who know how to help their patients lead a healthy lifestyle have a new opportunity this year to be reimbursed for preventive services for Medicare enrollees who are at high risk for diabetes.

The recently launched Medicare Diabetes Prevention Program (DPP) grew from a Centers for Disease Control and Prevention (CDC)–led initiative that now involves more than 1,500 sites nationwide.

The DPP model relies on a standard curriculum adopted by health coaches who encourage groups of patients to make lifestyle changes that have been shown to delay or prevent the onset of diabetes.

The Centers for Medicare and Medicaid Services (CMS) in late 2016 announced its support for the DPP model and stated that the agency planned to cover DPP services for Medicare beneficiaries.

Final details on the Medicare DPP program and its funding structure were published as part of the 2018 physician fee schedule in the November 15, 2017, Federal Register. The enrollment period for new Medicare DPP suppliers started on January 1.

The Medicare DPP model is a 12-month program that includes at least 16 weekly 1-hour group coaching sessions delivered during the first 6 months and 6 or more sessions during months 7–12. The sessions focus on lifestyle interventions to help participants improve their diet, exercise more, manage stress, and lose weight.

To receive reimbursement for Medicare DPP services, an organization must apply to be a supplier of the services and receive full or preliminary recognition from CDC. Staff members who coach patients must obtain a National Provider Identifier number and include it on all claims for the services.

Medicare DPP services may be offered to Medicare Part B enrollees who have a body mass index of at least 25 kg/m2 (23 kg/m2 if the patient self-identifies as Asian); a glycosylated hemoglobin value of 5.7–6.4%, a fasting plasma glucose level of 110–125 mg/dL, or 2-hour glucose tolerance test result of 140–199 mg/dL; no previous diagnosis of diabetes other than gestational diabetes; and no diagnosis of end-stage renal disease.

For each patient who attends the requisite number of coaching sessions during the first 12 months, loses at least 5% of their initial weight, and maintains that weight loss, the supplier is eligible for a Medicare payment of $445—or $470 for a maintained weight loss of at least 9%. An additional $200 can be billed to Medicare during the next year if the patient attends 8 ongoing maintenance sessions and keeps the weight off. Medicare’s maximum payment for patients who don’t reach their weight loss goal is $195.

The start date for providing Medicare DPP services is April 1, or 3 months later than CMS initially planned [see June 15, 2017, AJHP News].

Jasmine D. Gonzalvo, clinical pharmacy specialist in primary care for Eskenazi Health in Indianapolis, Indiana, said she doesn’t know if the clinic will opt to participate in Medicare’s DPP. But Eskenazi Health is already a DPP site, and Gonzalvo said it was a logical decision to earn that designation from CDC.

Gonzalvo, a certified diabetes educator, said DPP meshes well with the health system’s already-established lifestyle management program, Healthy Me. The program’s services are available at no cost to patients and employees of the health system.


Although Gonzalvo led her clinic’s push to become a DPP site, she said she knew that for reasons of cost, pharmacists would have minimal involvement in the program.

“We decided right off the bat that a pharmacist wasn’t the ideal person to be immersed in the DPP,” she said. “The people on the ground running the program are health coaches that really focus on lifestyle management.”

Gonzalvo said community pharmacies are likely to be great candidates to offer Medicare DPP services. But within health systems, she said, a pharmacist’s value is usually better realized by caring for patients who already have diabetes and need medication therapy in addition to lifestyle counseling.

Eva Vivian, professor at the University of Wisconsin School of Pharmacy in Madison, said there’s a great need for diabetes prevention in the underserved communities that are the focus of her population health research.

Vivian called DPP “a very good program,” albeit one that she’s not using in her work, primarily because it can be difficult for her target population to travel to the required coaching sessions.

Instead, she’s using a related curriculum, also developed by CDC, as the basis for a peer-to-peer support program that she hopes will take root in the local community.

Through late December, Vivian had identified 10 mothers or grandmothers who are at risk for or have diabetes and trained them to lead healthier lives.

Vivian said some participants were unaware of local resources for low-income community members, such as food pantries, pharmacies that supply medications at no cost, and free bus passes.

As with DPP, she said, having pharmacists heavily involved in her community-focused project may not be a cost-effective practice over the long term. For that reason, Vivian designed her program with the goal of becoming self-sustaining.

“Over time, what I’m hoping is that the mothers and grandmothers will be able to continue this program, and I can serve as more of a consultant,” she said.

[This news story appears in the February 15, 2018, issue of AJHP.]

Posted January 24, 2018

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