By Zach Bredl

What is MDPP?

Diabetes is a condition that affects more than 1 in 4 Americans age 65 and older.1 Centers for Medicare and Medicaid Services (CMS) estimated that Medicare spent $42 billion more on beneficiaries that have diabetes than it would have spent if those beneficiaries did not have diabetes. Let’s take a look at PMPY (Per Member Per Year) spend breakouts in 2018 for beneficiaries with and without diabetes. To calculate these PMPYs, CareJourney utilized the CMS Virtual Research Data Center (VRDC) through the Innovator License program. This dataset allows us to access 100% of Medicare claims and link beneficiaries across all parts to create a longitudinal view of their care.

Table 1: Average PMPY by Spend Category

Spend Category Patients with Diabetes Patients without Diabetes
Professional $3,419.89 $2,678.87
Inpatient $4,515.10 $3,845.77
Outpatient $2,523.07 $1,767.88
Skilled Nursing Facility $899.23 $853.55
Home Health $701.16 $506.19
Hospice $164.77 $602.49
DME $364.41 $219.94
Total $12,587.64 $10,474.70

Note: This table considers all Fee-For-Service beneficiaries. Calculations are normalized based on Part A & Part B enrollment (member months).

You can see that diabetes patients spend roughly 20% more per beneficiary per year than non-diabetes patients. Diabetes patients are spending more across the board (besides hospice) including 43% more in outpatient services and 28% more in professional services. For a deeper dive on the diabetic population in Medicare, see our previous blog on Exploring Variation in Healthcare Services in the Medicare Diabetic Population. In addition to the expenditure gap shown above, prevalence of diabetes among the Medicare population is projected to double for all U.S. adults (ages 18-79) by 2050. Recognizing this, the Center for Medicare and Medicaid Services (CMS) has expanded the Medicare Diabetes Prevention Program (MDPP) with the goal of preventing beneficiaries with certain pre-diabetes indicators from becoming diabetic. The program consists of at least 16 sessions over six months. Curriculum is designed to encourage dietary change, physical activity, and overall healthier behavior – with a primary goal of five percent weight loss. A study by the National Institutes of Health found that the lifestyle changes that resulted in a small weight loss led to a large reduction in risk for becoming diabetic.

Not a CareJourney member?

Request a demo

POLITICO Summary

In October of 2019, POLITICO contacted CareJourney for assistance in pulling utilization data on MDPP and published an article that states that the program has fallen well short of its mission. POLITICO cites evidence that had projected MDPP to be utilized by 50,000 to 110,000 annually, however through CareJourney’s access to 100% of Medicare claims through CMS’ Innovator License we see that only 202 patients took advantage of this service in 2018.

The article explains that one reason MDPP is so extremely underutilized may be because there are only 600 authorized MDPP providers. It is difficult for patients to utilize a service if there are no options within 100 miles. The Medicare claims dataset allowed CareJourney to pull a list of top providers that are performing this service in the first half of 2019.

Table 2: MDPP Participation Breakdown

NPI Provider Name Q1-Q2 2019 Claims Provider Zip Code Provider State
1205381332 YMCA of Delaware 382 19801 DE
1689815383 Hockomock YMCA 234 02706 MA
1326463779 Sun Health Services 185 85374 AZ
1215431697 Providence Health and Services 154 98503 WA
1184185803 Board of Regents Univ. of Oklahoma 116 73117 OK
1962526046 YMCA of Greater Seattle 110 98104 WA
1194272518 YMCA of the Suncoast 87 34685 FL
1295278901 Harrisburg Area YMCA 75 17102 PA

Note: This table considers only Fee-For-Service claims.

Notice something in common? The article confirms that 20 YMCA locations have gone through this process of becoming an authorized provider and they are by far dominating the early market for this service. What else jumps out from this data? MDPP claims have sharply increased in the first two quarters of 2019. In fact there have been 2,090 claims billed in the first two quarters of 2019 which over four times the 522 claims billed throughout the entirety of 2018.

MDPP Return On Investment

So what is the expected return on investment for this program? A study done on the 10-year effectiveness of this program shows that patients who adhere to the lifestyle changes and meet the modest weight loss goal reduce their relative risk for Type 2 Diabetes by 49.4%.2 Along with the risk reduction we see a cost savings per beneficiary of $4,250 to $6,300 per participant of the 10 year time period. Insurers like UnitedHealth Group and their employer partners have also seen savings from the implementation of MDPP. A Director of Risk and Benefits Management for the School District of Palm Beach County stated that they saw a nine percent reduction in total net costs in the first year of the program – a savings of $2.9 million.3

Explore With CareJourney

Want to see if the participants in the Medicare program have seen any benefits thus far? At CareJourney, we can identify the patients that participated in the program and follow their care journey longitudinally. We can explore their utilization across all Medicare parts and all places of service before, during, and after the interventions. CareJourney specializes in codifying leading care models and obtaining insights to help our members make data-driven participation decisions. From Million Hearts Risk Reduction to the Oncology Care Model to Primary Care First, we have the tools to help organizations to determine what care models are valuable to them. Please contact us for more information or to request a meeting.

  1. https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985133/
  3. Study: UnitedHealthcare’s Diabetes Health Plan Can Lead to Improved Health, More Effective Disease Management, Better Cost Control. 2013. UnitedHealthGroup.