Community-Based Wellness and Prevention Programs Could Reduce Health Costs

Pursuant to the directives under provisions of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), CMS released a report compiling its work towards an evidence review and evaluation of existing community-based wellness and prevention programs to date. Once complete, these evaluations will serve as the basis of recommendations to Congress regarding the promotion of healthy lifestyles and improved chronic diseases self-management measures for Medicaid beneficiaries. The report is a part of a three phase process CMS is conducting pursuant to certain provisions of the new health reform legislation.

PPACA Directives

Section 4202 of the PPACA, which is entitled “Evaluation and Plan for Community-based Prevention and Wellness Programs for Medicare Beneficiaries,” directs the Secretary of HHS to conduct the evaluation of existing programs with a focus on programs emphasizing the following: (1) increasing physical activity; (2) reducing obesity; (3) improving diet and nutrition; (4) reducing falls; (5) promoting chronic disease management; and (6) improving the management of mental health issues. The overall goal of this provision of the PPACA is to provide a basis for recommendations regarding how best to promote healthy lifestyles and chronic disease management for Medicaid recipients and, in turn, improve beneficiary health outcomes and reduce health care costs;

Phases and Findings

The CMS report makes conclusions with respect to the first two phases of its three phase plan. In the first phase CMS employed the Altarum Institute to conduct a review of existing literature surrounding community-based wellness and prevention programs and an environmental scan of all the potential programs that could be evaluated under the PPACA provision. Through the literature review, Altarum identified 75 programs that were eligible for evaluation pursuant to the six areas of focus outlined in the PPACA. The environmental scan consisted of in-depth examinations of selected wellness and prevention programs, including site visits to 34 locations. These surveys revealed a diversity in the range of programs offered and methods of operation and implementation, yet the consistency of federal funding was identified as a key factor for the future of sustainability for the evaluated programs.

In the second phase, CMS employed Acumen, LLC to assist in retrospectively linking up data for participants in certain health intervention programs in order to analyze the changes in health care utilization and cost before the program to the use and costs of health care after the participation in the program. For the purpose of this phase, CMS evaluated participation in ten programs which were separated into three intervention areas: chronic disease self-management, falls prevention, and physical activity. Four of the programs investigated revealed total cost savings and two other programs exhibited evidence of inpatient cost savings due to participation. However, with respect to this data, CMS noted certain limitations including differences in baseline demographics, small sample sizes, and limited evaluation time frames.

Future Plans

With respect to the final stage, CMS’s work is ongoing. To enact and complete the third stage, which is projected to analyze the overall interest in Medicare beneficiaries in community-based wellness and prevention programs and to more fully assess the impact of participation on health care utilization and cost, CMS has once again contracted with Acumen to provide evaluation services. CMS expects these efforts to continue through the next four years.