Healthcare finance: principles, systems, and management

Medicare Diabetes Prevention Act of 2013

Healthcare Finance

Senator Franken (D-MN) introduced a bill (S. 452) into the Senate on March 5, 2013 that provides a mechanism through which Medicare and Medicaid recipients, who are at risk for developing diabetes, can receive preventive care services (Medicare Diabetes Prevention Act, 2013; Civic Impulse, 2013). The Senate version of the Medicare Diabetes Prevention Act of 2013 (MDPA) has 14 cosponsors, all Democrats, while the House version has 17 Democrat sponsors. This bill is quite detailed and lengthier than previous bills intended to state a policy position, which suggests there may be considerable interest in moving this bill through the respective committees for a floor vote.

MDPA Details

The main provision in the MDPA gives authority to the Secretary of Health and Human Services to establish public and private diabetes prevention services providers for individuals who qualify for Medicare and Medicaid coverage (Medicare Diabetes Prevention Act, 2013). The main target of the bill is Medicaid recipients, because these individuals tend to be underserved. The rationale behind the bill is provided at the end, which predicts that13 million diabetes and 9 million pre-diabetes patients will qualify for coverage under Medicaid by 2021. The healthcare cost of servicing this patient population is an estimated $83 billion annually. The justification for this bill is based on a Centers for Disease Control and Prevention (CDC) study suggesting diabetes prevention programs (DPPs) can lower diabetes care costs by 58% (DPPRG, 2003), which would amount to a predicted savings of over $48 billion annually by 2021.

Disparities in Access to Diabetes Care

Minority populations in the United States disproportionately suffer from lower socioeconomic status and access to health care (reviewed by Rhee et al., 2005). Minorities also suffer disproportionately from diabetes and comorbid conditions, therefore improving care access should lower both the risk and prevalence of diabetes among this demographic. When researchers surveyed 605 primarily African-American adults (89%) about their efforts to control hyperglycemia, 47% reported trouble getting medical care (Rhee et al., 2005). When HbA1c levels were examined, levels were higher for survey respondents without insurance coverage (p = 0.08) and significantly higher for those getting care through acute care facilities (30%) or not getting care (13%) (p < 0.001 for both). All patients in this study were low income, with 86% having incomes below $15,000 per year. These findings reveal community-based DPPs could have a significant positive impact on the health of underserved populations.

Administrative Impact

If this bill were to be enacted, the administrative impact would be significant (Green, Brancati, Albright, and PPDWG, 2012). Diabetes prevention training programs would have to be implemented or expanded, prevention teams assembled, support personnel recruited (dieticians and trainers), and technical resources allocated to support DPP activities. Legal and regulatory issues would be moot, since the Medicaid infrastructure already exists. What this bill does is expand DPP access to the underserved through state-funded Medicaid programs. The primary obstacle to DPP implementation under Medicaid will therefore be whether any providers will be willing to accept low reimbursement payments in exchange for services provided (Pear, 2011).

Impact on Nursing

Nurse practitioners (NPs) will be affected the most should the bill be made into law. NPs play a major role in providing primary care services to the underserved and many of their patients are covered under state-run Medicaid programs (reviewed by Kaplan, 2012). However, given the massive expansion if the Medicaid program under the Patient Protection and Affordable Care Act of 2010 (ACA), which emphasizes expanding preventive services to Medicaid enrollees (Medicaid.gov, n.d.), the impact of implementing a DPP or referral service should be relatively minor. Probably the most significant change would be the need for additional training in diabetes prevention services.

In Support of S. 452 Passage

There are a number of programs already in existence that can provide diabetes preventive care to at risk individuals. Under ACA provisions, services for obesity prevention, screening, and treatment are mandated for Medicaid enrollees (Medicaid.gov, n.d.). Under this program, many patients at risk for developing diabetes could qualify for care, but the overlap would not be complete. Another prevention program implemented under the ACA offers incentives to Medicaid recipients for their participation in programs designed to reduce the incidence of chronic disease, including diabetes. However, this program is being administered under a limited 5-year grant program in 10 states to test its efficacy. The CDC has provided almost $7 million in funding to establish DPPs for research purposes, which means the number of pre-diabetes individuals helped by these programs will be very limited (CDC, 2012). While these programs will probably provide free or nearly-free diabetes preventive services to a large number of individuals, most underserved patients will not benefit from these programs.

S. 452 is worded in such a way that establishing DPPs under Medicaid will be optional for states (Sebelius, 2010). As of 2010, 43 states covered the expense of screening Medicaid patients for diabetes, but only 13 states provided reimbursement for obesity preventive services. This suggests that states are willing to pay for screening, but not preventive services like lifestyle interventions; however, if only a few states implement DPPs for Medicaid recipients, this will provide a proof-of-principle experiment in a real-world setting and establish the overall healthcare savings such programs can provide.

In an effort to promote preventive services, ACA provision 4106 offers state-run Medicaid programs enhanced federal matching dollars if they eliminate requirements for preventive services cost-sharing (Sebelius, 2010). However, the preventive services that qualify for an enhanced federal match must meet certain evidence-based criteria determined by the U.S. Preventive Services Task Force. The National Institute of Diabetes and Digestive and Kidney Diseases (NDIC, 2012), and the CDC (2012), have stated that DPPs have the potential to reduce the incidence of type 2 diabetes by up to 58%, thus the empirical evidence for implementing preventive care for persons who are at risk for developing diabetes already exists. The U.S. Preventive Services Task Force issued a recommendation that individuals with blood pressure above 135/80 should be screened for diabetes (Norris, Kansagara, Bougatsos, and Fu, 2008).