March 17, 2020
By Julie Gould
Oftentimes, National Diabetes Prevention Program (DPP) providers are community-based organizations and they are not equipped to bill Medicare and Medicaid directly for services, according to a recent study. Because of this, researchers suggest that National DPP providers require increased reimbursement options.
In order to better understand the study findings, which were published online in The Journal of Public Health Management & Practice, and why billing and reimbursement approaches play a critical role in the types of programs that can be administered and delivered by a clinical practice, we spoke with Jennifer Torres Mosst, PhD, program manager of Diabetes Strategies at the Division of Chronic Disease and Injury Prevention.
Please introduce yourself, including your name, title, and affiliation. Please feel free to include details about your research background, too.
I am Jennifer Torres Mosst, PhD, and I serve as program manager of Diabetes Strategies at the Division of Chronic Disease and Injury Prevention (CDIP) in the Los Angeles County Department of Public Health. In my role as program manager I lead division efforts to scale up and increase access and availability to diabetes prevention and management programs in the region. This work has been made possible by two Centers for Disease Control and Prevention (CDC) funding programs (1422 and 1817) focused on creating strategies for preventing and managing diabetes, heart disease and stroke. Through these initiatives, our Division has been able to work with regional organizations to build capacity and infrastructure for scaling and sustaining evidence-based lifestyle change programs designed to prevent and mange diabetes.
Research Background: Testing innovative approaches to scale up and sustain diabetes prevention and management programs among high need, high risk population in large jurisdictions.
The diabetes team at CDIP works with organizations in the region that have an interest in implementing prevention and management programs and provides technical support to guide them through the program implementation process. As part of our efforts we have developed a tailored technical support program that links new/early implementers of the diabetes prevention and management programs with CDIP subject matter experts who can guide them through the process of program development and implementation. The process includes helping these implementers to become nationally recognized and/or accredited by the CDC, developing an infrastructure to better collect and manage data, and increasing program referrals through networking opportunities and/or via building of health systems referral pathways. Simultaneously, the diabetes team has been working with local, state and national leaders to actively engage in key efforts to increase billing and reimbursement options for diabetes prevention and management services.
What existing data led you and your co-investigators to conduct this research?
At the time we started this work, few, if any, comparable approaches or models existed for billing and reimbursement of the National Diabetes Prevention Program (National DPP). Just bringing partners to the table and discussing the issue was a significant step forward. However, despite the lack of information on this, there were significant investments made at the national level to scale up the program and identify opportunities to develop policies to make the National DPP a covered benefit among public and private payers.
At the national level there was movement by the Centers for Medicare and Medicaid Services (CMS) to make this a covered benefit especially for seniors who showed significant improvements in A1Cs and weight control after completing the program. In 2017 the National DPP became a covered benefit under Medicare (Medicare DPP or MDPP). Following the implementation of the MDPP, the CDC, in partnership with the National Association of Chronic Disease Directors (NACDD), launched the Medicaid Coverage Learning Collaborative where state and local leaders considered various payment approaches to test for potential Medicaid coverage. During this time, we launched our pilot project while our state partners explored options for making the National DPP a covered benefit. In 2017, the National DPP became a covered benefit under California’s Medi-Cal program. Results from our pilot project, along with those from other efforts at the state level, subsequently helped inform the implementation of the Medi-Cal Diabetes Prevention Program in California.
Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?
The objective of the case study was to highlight how a local public health department worked with a large Medicaid Managed Care Organization and a local community-based service provider to identify a reimbursement approach that could be used to cover the cost of delivering the National DPP to a safety net population. Reimbursement approaches explored as part of the project were fee for service, contracting (e.g., request for proposal, memorandum of understanding, and/or invoicing arrangements), and the use of a third-party payer/integrator (private company that specializes in serving as administrative go-between payers and service provider). Identifying and establishing key partnerships and selecting a reimbursement approach that fit the intended goal of the case study were key considerations that guided the work. In regard to partnerships, the project was guided by the funder’s goal of reaching the safety net population, which helped focus partner selection and engagement and facilitated critical reflections around associated benefits and challenges (e.g., working with CBOs with deeper reach among underserved groups but often with underdeveloped administrative infrastructure). In regard to reimbursement options, the importance of flexibility in setting terms that would mutually benefit both the payer and the provider (e.g., mutually agreed upon reporting/quality assurance standards, service benchmarks, and fee schedules for reimbursement) was key to ensuring the pilot’s success. After engaging in collaborative learning and planning for several years the partners in Los Angeles ultimately determined that the administrative burdens of partnering directly were too great and that the use of a third-party payer integrator was the most feasible and sustainable approach, although it resulted in less revenue for the providers (due to administrative fees charged by third-party payer).
Project outcomes that were particularly surprising were the administrative challenges faced by providers looking to partner directly with payers. Which often included lack of contracting experience and lack of data system/infrastructure to handle billing and reimbursement procedures. This outcome was particularly surprising given that scale up efforts have focused on expanding this program among community-based organizations that may particularly struggle when it comes to navigating administrative processes set forth by payers.
What are the possible real-world applications of these findings in clinical practice?
Billing and reimbursement approaches play a critical role in the types of programs that can be administered and delivered by a clinical practice. Although this study did not focus on direct clinical applications for billing and reimbursement practices, the types of payment models payers decide to implement could directly impact how and where clinics refer patients for diabetes prevention services. This study did identify some lessons learned that a clinic could use to enhance their billing and reimbursement. They include:
- engaging health administrators and physicians to develop/enhance partnerships with payers;
- enhancing data infrastructure to more efficiently track and manage services output/activities;
- increasing partnerships with community-based providers to supply services that fill gaps; and
- enhancing sharing of data that could improve clinical practice quality.
Do you and your co-investigators intend to expand upon this research?
Our goal is to continue to expand upon this research. As a next step we hope to explore how these new reimbursement policies impact service providers. We would like to learn more about the type of support that is required to build the infrastructure for billing among program providers in the region. Areas we will explore will include type and level of support programs that will be needed to navigate different stages of the billing process; what capacity or infrastructure is required; and how do different types of organizations compare in terms of readiness.
Is there anything else pertaining to your research and findings that you would like to add?
One of the most important lessons learned through this process was that there is not a one size fits all approach to expanding and implementing billing and reimbursement policies. Although, we did identify some key elements to establishing a reimbursement model for Los Angeles County. These included: (1) identifying the right partners; (2) selecting a reimbursement approach that match the needs of the partners and the region; and (3) prototyping reimbursement options, paying particular attention to fit and sustainability. Results suggest that as practice landscapes vary across jurisdictions (different organizational players, different populations, different regulatory environments) other jurisdictions may encounter different or unique challenges. Despite growth in reimbursement approaches there is still a need for federal agencies to provide more in-depth guidance on how state and local jurisdictions can work with program providers to navigate the ever changing landscape of reimbursement policies for public and private payers and to address the challenges a typical service providers (eg, health systems, community based, digital, telehealth) face (eg, data infrastructure, organizational capacity) when billing for diabetes prevention and other related services.
Mosst JT, DeFosset A, Sivashanmugam M, Kuo T. Exploring Reimbursement Options for the National Diabetes Prevention Program: Lessons Learned From a Pilot Project in Los Angeles, 2014-2018 [published online ahead of print, 2020 Jan 30]. J Public Health Manag Pract. 2020;10.1097/PHH.0000000000001136. doi:10.1097/PHH.0000000000001136