New Medicare Diabetes Prevention Coverage May Limit Beneficiary Access and Widen Health Disparities
Abstract
Background: The Centers for Medicare and Medicaid Services recently issued final rules for the Medicare Diabetes Prevention Program (MDPP), offering an unprecedented opportunity to provide lifestyle intervention to Medicare beneficiaries with prediabetes via a pay-for-performance model. The MDPP is based on the widely disseminated, yearlong National Diabetes Prevention Program (NDPP), which has lesser but still beneficial risk-reduction outcomes among minority and low-income participants. Objectives: We compare projected payments based on outcomes of a diverse sample of Medicare beneficiaries to service delivery costs, and explore resulting implications for MDPP access and sustainability. Methods: We delivered NDPP in a safety-net health care system from 2013 to 2017 and conducted an analysis of service cost, beneficiary performance, and projected MDPP reimbursement. Results: Among 1165 total participants, 213 (18.3%) were Medicare beneficiaries. Participating beneficiaries were 40.6% Hispanic, 31.6% non-Hispanic black, and 26.9% non-Hispanic white and 69.5% low-income. Overall beneficiary performance would result in an average reimbursement of $138.52 (interquartile range=162.50). Program delivery costs were $800 per participant, leaving an average gap of $661 per beneficiary. Conclusions: Findings from delivering the NDPP to diverse and undeserved patients show a large gap between service costs and projected reimbursement. Although many MDPP suppliers are needed to reach all Medicare beneficiaries with prediabetes, insufficient reimbursement may be a deterrent. Health disparities may also widen as suppliers serving diverse and low-income populations will likely receive especially low payments, threatening access. Higher payments are supported by strong return-on-investment findings and seem needed to reduce diabetes prevalence and related disparities.
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Suppliers may be dissuaded from entering markets with especially high-risk populations who are less likely to achieve performance payment milestones.
“Another concern is that suppliers may be dissuaded from entering markets with especially high-risk populations who are less likely to achieve performance payment milestones.69,75”
From <p>Current Perspectives on the Impact of the National Diabetes Prevention Program: Building on Successes and Overcoming Challenges</p> (2020) · cites this paper as [69]
With Medicare, reported delivery costs (for first-year, in-person services) were 553-800 USD with average reimbursement of only 108-190 per participant, resulting in a gap of 363-792 USD.
“With Medicare, reported delivery costs (for first-year, in-person services) were 553–800 USD with average reimbursement of only 108–190 per participant,69,70 resulting in a gap of 363–792 USD.”
From <p>Current Perspectives on the Impact of the National Diabetes Prevention Program: Building on Successes and Overcoming Challenges</p> (2020) · cites this paper as [69]
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- Authors
- Ritchie, N. D., & Gritz, R. M.
- Affiliations
- Denver Health Medical Center (US)
- University of Colorado Anschutz (US)
- Corresponding author
- Ritchie, Natalie D.
- Venue
- Medical Care
- Published
- 2018-11
- Volume
- 56
- Issue
- 11
- Pages
- 908-911
- ISSN
- 0025-7079 (ISSN-L)
- OpenAlex
- W2897708337
- Cited by
- 35
- References
- 7
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 7 · 2023: 5 · 2022: 3 · 2021: 4 · 2020: 8 · 2019: 1
- FWCI
- 4.95
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Medical Care (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Center for Chronic Disease Prevention and Health Promotion (U58 DP004157)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Keywords
- prediabetes, lifestyle intervention, performance-based pay, reimbursement, health disparities, health care access, National Diabetes Prevention Program, safety net health care, low-income populations, program sustainability, service delivery costs
- MeSH terms
- Healthy Lifestyle, Aged, Cost-Benefit Analysis, Diabetes Mellitus, Health Expenditures, Female, Medicare, Health Promotion, Humans, Male, Middle Aged, Minority Groups, Poverty, Prediabetic State, Reimbursement, Incentive, United States, Centers for Medicare and Medicaid Services, U.S., Health Status Disparities, Weight Reduction Programs, Safety-net Providers
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