Medicare underpayment for Diabetes Prevention Program: implications for DPP suppliers.

OBJECTIVES: To examine if Medicare reimbursements for the Diabetes Prevention Program (DPP) cover program costs.

STUDY DESIGN: A retrospective modeling study.

METHODS: A microcosting approach was used to calculate the costs of delivering DPP in 2016 to more than 300 patients from Montefiore Health System (MHS), a large healthcare system headquartered in Bronx, New York. Attendance and weight loss outcomes were used to estimate Medicare reimbursement. We also modeled revenue assuming that our program outcomes had been similar to those observed in national data.

RESULTS: The 1-year cost of delivering DPP to 322 participants in 2016 was $177,976, or $553 per participant. The costliest components of delivery were direct instruction (28% of total cost) and patient outreach, enrollment, and eligibility confirmation (24%). Based on our program outcomes (14.3% lost ≥5% of their initial weight and 50% attended ≥4 sessions), MHS would be reimbursed $34,625 ($108/patient). If outcomes were in line with national CDC reports (eg, better attendance and weight loss outcomes), MHS would have been reimbursed $61,270 ($190/patient).

CONCLUSIONS: In a large urban health system serving a diverse population, the costs of delivering DPP far outweighed Medicare reimbursement amounts. Analyzing and documenting the costs associated with delivering the evidence-based DPP may inform prospective suppliers and payers and aid in advocacy for adequate reimbursement.