Increasing Coverage of the National DPP Lifestyle Change Program

September 15, 2021

In 2017, the Centers for Disease Control and Prevention (CDC) awarded ADCES a five-year cooperative agreement to ensure that all communities have equitable access to the National Diabetes Prevention Program (DPP). To fulfill its cooperative agreement, ADCES is working to scale and sustain this program for specific priority populations.

The Opportunity

ADCES decided to use the CDC cooperative agreement as an opportunity to increase its focus on supporting providers in communities with little or no access to CDC-recognized programs with implementing the National DPP lifestyle change program. ADCES actively recruited community health centers into the program to achieve this goal.

The Community Health Center (CHC) Program, including Federally Qualified Health Centers and FQHC Look-Alikes, works to bring community-based and patient-directed care to underserved and vulnerable populations. Nationally, CHCs serve an increasing number of patients with prediabetes, at risk of developing type 2 diabetes, or with type 2 diabetes. The high prevalence of prediabetes and type 2 diabetes risk among CHC patients make FQHCs and LALs ideal partners for implementing the National DPP lifestyle change program.

However, CHCs are a unique provider type that must adhere to multiple federal regulations, operate myriad federal health programs, and ensure no patient is turned away from receiving care. CHCs must also follow strict guidelines on using some of their financial resources. These factors pose challenges for CHCs in effectively and sustainably implementing the National DPP lifestyle change program.

Recognizing the CHCs they work with needed additional support with integrating the National DPP into their operations, including understanding how to leverage their reimbursement schedule to sustain the infrastructure necessary to sustain the program, ADCES sought a reimbursement consultant with expertise in billing for CHCs. Specifically, they were seeking a consultant with experience in potential revenue streams for diabetes prevention programming such as Medicare Diabetes Prevention Program (MDPP) services, as well as related prevention and self-management services that, together, could develop a sustainable funding stream for CHCs.

Goals

The outcome of the engagement with a reimbursement consultant would help ADCES in achieving the following key strategic goal for their cooperative agreement with the CDC: Increase coverage of the National DPP lifestyle change program.

ADCES looked to achieve this strategic goal by producing collateral to support CHCs with:

• Understanding how the National DPP can fit into the full array of primary care services offered within the CHC setting;
• Looking at opportunities to fully leverage the National DPP Lifestyle Coach position to ensure comprehensive services are made available to participants; and
• Linking diabetes-related services to opportunities for incentive and shared savings dollars under payer contracts.

During Year 4 of their cooperative agreement (2020-2021), ADCES sought to engage Atrómitos and our Advisor, Lavondia Alexander of Evolve Health Strategists, for this work given our extensive familiarity with CHC operations, background in principles of change management, and capability to synthesize and directly apply policy and regulatory guidance. Our proposal demonstrated an understanding of standard CHC billing practices (including common codes billed within a CHC setting).

It also included a strategy to assist CHCs in leveraging their National DPP staff within their larger infrastructure to ensure participants received all relevant and medically-appropriate primary care services while engaged in the National DPP lifestyle change program. We committed to supporting ADCES by developing collateral specific to integrating the National DPP within a CHC setting and conducting training with CHCs participating in ADCES’ cooperative agreement.

The engagement would require us to review policy and regulations controlling both the National DPP and CHC billing practices, apply principles of change management to help CHCs consider how to redesign their workflows and service delivery to optimize care for their National DPP participants, and successfully convey this information through a virtual training to CHC staff.

Approach

Market Analysis
The first part of our engagement involved completing semi-structured key informant interviews with the CHCs participating in the National DPP lifestyle change program under ADCES’ cooperative agreement with the CDC. The purpose of the interviews was to conduct a deep dive into each CHC and better understand: (1) their current clinical, operational, and financial workflows related to caring for patients with prediabetes or with or at risk of type 2 diabetes; (2) what value-based payment arrangements they had experience being reimbursed under; and (3) what infrastructure support(s) they had in place (e.g., population health management platforms, participation in Accountable Care Organizations, etc.).

Legislative and Regulatory Analysis
These interviews informed how we progressed with the project’s next phase: research on billing, clinical quality measures, and reimbursement guidelines for services provided to patients with prediabetes or at risk of type 2 diabetes. We reviewed guidelines from Fee-For-Service Medicare, Medicare Shared Savings Programs, and state Medicaid programs to identify how they reimburse CHCs for diabetes-related services and which programs offered incentive payments for diabetes-related clinical measures. We also reviewed state and federal billing regulations to determine what, if any, credentials were required to perform the identified diabetes-related services.

Brief and Whitepaper Development & Change Management
Once we completed our research, we developed a series of collateral that outlined key considerations for CHCs when they are looking to sustain their National DPP:

• identifying billing codes for relevant primary care services
• workforce considerations to optimize service delivery
• the relationship between diabetes-related services and incentive payment opportunities through payer contracts.

The purpose of this collateral is to provide CHCs a starting point in understanding their options in redesigning how they are caring for participants of the National DPP, and what those changes may mean for clinical services and financial opportunities.

Meeting Facilitation
The final stage of our engagement involved conducting a virtual training for all CHCs participating in the National DPP under ADCES’ cooperative agreement. We delivered all finished collateral to CHC staff registered for the training and facilitated a sixty-minute review of the collateral. During the training, we also conducted surveys and poll questions to assess the CHC’s knowledge gain based on their review of the collateral, and their readiness to engage in change management practices related to sustaining their National DPP.

Conclusion

We produced four collateral items for ADCES and the CHCs they support:

1. Community Health Centers & the National Diabetes Prevention Program highlights the importance of the National DPP and how it benefits CHCs and their patients;
2. Operational Considerations for the National Diabetes Prevention Program discusses the concept of developing a comprehensive Diabetes program within a CHC centered on the National DPP;
3. Diabetes-related Codes & Services lists out the suite of services patients could receive, and reimbursements CHCs were eligible for, across the diabetes spectrum; and
4. The National DPP and Quality Measures: Connections to Payer Payments outlines a strategy CHCs could consider when looking to use the National DPP to increase the number of billable services they provide and their performance on payer-related quality metrics.