Prevention is Not Expendable

A core component of the Affordable Care Act is the most comprehensive recognition to date of the value of prevention and health promotion. Numerous provisions in the ACA support wellness and prevention efforts in the workplace and in Medicare and Medicaid. CCA has repeatedly applauded these provisions and actively and aggressively supports their rapid implementation.

Yet, we continually face efforts by Congress and even the administration to target the ACA’s landmark Prevention and Public Health Fund as an extraneous cost – particularly now, in discussions on the fiscal 2013 federal budget. But the Prevention Fund is anything but extraneous or expendable. Rather, it provides a critical catalyst for the surge nationally in health care system innovation and care delivery improvements.

CCA strongly supports allocating monies dedicated to the Prevention Fund to fulfill its intended purpose and to power health care transformation. The Department of Health and Human Services must seize the opportunities made possible by the Prevention Fund through community collaborations and partnerships with health care industry leaders. Congress, rather than looking to the fund for easy cuts, should instead encourage its constructive use legislatively, such as through Sen. Ron Wyden’s “Medicare Better Health Rewards Program,” which would apply Prevention Fund monies toward initiatives that build on programs already established through reform.

States have a stake in the Prevention Fund’s viability, as well. The Fund materially impacts and advances individual state health care initiatives, such as behavioral health screenings, data infrastructures and wellness services. It has contributed more than $121 million toward state projects in Ohio, California, Nevada and Kentucky alone. HealthCare.gov provides a full public accounting of individual state contributions and program descriptions.

The Prevention Fund already has sustained a 10-year, 33 percent cut through February’s Middle Class Tax Relief and Jobs Creation Act. Additional cuts would derail federal and state progress toward prevention and health promotion, stifle health care transformation and undermine significant industry investments in innovation.

Stakeholders are working continuously and at an unprecedented pace to drive the health system toward better care, better health and lower costs. The Prevention Fund must remain available to achieve this important goal.

Love Letter to TEDMED

Wow. That’s all I can say after three unbelievable days attending the inaugural TEDMED DC event. My head is swelling with ideas and inspiration and innovative opportunities for population health. It was unlike any “event” I’ve ever attended and it sets a new standard for education and networking.

What’s it all about? TED stands for “technology,” “entertainment,” “design.” There were performance artist poetry slams about thinking outside the box that literally took my breath away. There were personal vignettes about surviving breast cancer by the President and CEO of the Red Cross. There were discussions about the technology of food, of fitness, of wellness, of illness. So much of this conference had a population health theme that is perfectly aligned with CCA’s goals and the work of our industry leaders. It was all just presented in a way that makes you think harder and better and more collaboratively.

A common thread through nearly every presentation, I found, was the importance of personal wellbeing and responsibility. Obesity was a key theme and presented from various perspectives. A huge takeaway for me: Obesity is directly linked to one-third of all cancers. Encouraging healthful behaviors at a community and social network level was another key issue and was the top choice of TEDMED delegates in the Great Challenges of health and medicine. Kudos to Challenge Advocate Rajiv Kumar, Founder and Chief Medical Officer, ShapeUp, for promoting the “Inventing Wellness Programs that Work” Challenge. Rest assured, you got several of my votes!

Finally, let me state emphatically: TEDMED, don’t change a thing for next year in DC. I ran into a few of my DC colleagues who work in other health industry organizations this week and, in the words of one, they just “didn’t get it.” Yes, it’s different. Yes, it’s all “West Coast-y.” It is NOT your same old, same old conference with a bunch of boring policy wonks and PowerPoints. Not all of the speakers were equally enthralling (although most of the ones I saw were) but there was certainly a nugget or grain of an idea in every single one that spurred a conversation and possibly another innovation down the road. This conference is about IDEAS and PEOPLE and NEW WAYS OF THINKING. It was also a great equalizer in that the vast cross section of delegates attended to meet and explore. There was no hierarchy, just idea sharing. It was, simply, awesome.

—Tracey Moorhead, President & CEO

Incentive-Based Wellness Initiatives for All: Good practices = Good Outcomes

CCA has long supported the use of incentive-based workplace wellness programs. We’ve issued recommendations on core components and the role of incentives, and certainly agree that programs should not “inappropriately punish workers in poor health, [be] overly coercive, or create perverse financial incentives that result in poorer health outcomes.” We further believe that existing federal and state safeguards should be applied to programs that violate existing HIPAA requirements for reasonable design, annual requalification, alternative standards and other benchmarks. In short, there’s a growing body of research that clearly demonstrates the value of wellness programs, including those employing incentives for participation and outcomes, for improving health and reducing preventable health care costs (see here, here, here and here).

Congress, too, recognizes the value of wellness programs for all populations. The Affordable Care Act provided landmark recognition of workplace and community-based wellness and prevention programs. Particularly important, the statute in 2014 will increase from 20 percent to 30 percent of total premiums the allowable value of incentives employers may offer employees to participate in workplace wellness programs. We applaud Sen. Tom Harkin, D-Iowa, for his continued support for workplace wellness initiatives.

Now, another leading Senate Democrat is poised this week to unveil legislation that would offer incentive-based wellness programs to Medicare beneficiaries. This legislation recognizes the importance of wellness initiatives, including smoking cessation and weight management, and the success of incentive-driven wellness initiatives for our nation’s seniors.

I’m delighted to report on these developments and the sustained march toward greater awareness of the value of wellness programs for all populations. These developments stand in direct contrast to the thinly veiled conjecture and anecdotes propagated by policy organizations and advocacy groups that repeatedly ignore the preponderance of evidence on the benefits of workplace wellness programs.

Clearly, there is significant evidence of the positive impact of incentive-based wellness. CCA looks forward to supporting this important new Senate legislation and to promoting the real truth about wellness programs, using evidence and research rather than speculation and fear tactics.

—Tracey Moorhead, President & CEO

Federal Prevention Fund: Two Steps Forward, One Step Back

When President Obama signs payroll tax cut legislation today at a White House ceremony, with him will be working Americans who represent the 160 million taxpayers the bill will benefit. Based on best estimates, a third of the men and women expected to be at Obama’s side are at risk for diabetes and have two or more risk factors for heart disease. Two-thirds will be overweight or obese and a third will have high blood pressure. In that light, the payroll tax cut extension loses much of its luster, as the bill also will cut $5 billion from the Prevention and Public Health Fund to help avert a scheduled 27 percent drop in Medicare physician reimbursements.

It’s a penny wise pound foolish approach to Medicare’s dysfunctional sustainable growth rate (SGR) that kicks the can down the road at the expense of programs to fight the very conditions that drive most health care spending. We fully support fair payment to physicians and understand the magnitude of the threat they face with the scheduled SGR adjustment. But gutting badly needed federal support for wellness and prevention isn’t a solution. It’s an exclamation point on the short-sightedness of this legislation and a disheartening step back just as the federal government appeared to be moving firmly forward toward supporting workplace and community health promotion initiatives.

We wrote recently about the “glaring disconnect” that remains between the strong evidence base for programs targeting diabetes and other chronic conditions and the broader application of those care strategies. Throttling back federal spending on wellness and prevention robs us of a promising opportunity to close that gap. Yes, we must find payment strategies that satisfy providers and promote greater quality, value and accountability in care—and there are lawmakers working toward this sensible goal, such as Rep. Allyson Schwartz, D-Pa. But until we’re there, let us not dig the spending hole deeper with stop-gap solutions that diminish our best chance to climb out: wellness, prevention and care management.

IOM Report Reflects Expanding Role of Population Health Management

Over the past couple weeks, there’s certainly been no shortage of commentary on our industry and its evolution from the early days of siloed, call center-based disease management to today’s integrated, sophisticated population health management (PHM).

Certainly, the recent CBO report was a catalyst for some of these conversations—especially as the Care Continuum Alliance (CCA) and others highlighted the outdated design of the programs detailed in that report. But another catalyst is the increasing interest in PHM strategies from public and community health organizations, as well as primary care groups.

This was reinforced in my mind this week as I read the Institute of Medicine (IOM) report, Living Well with Chronic Illness: A Call for Public Health Action. At the request of the Centers for Disease Control and Prevention (CDC) and the Arthritis Foundation, the IOM developed the report to identify public health strategies that reduce disability and improve the function of and quality of life for people with chronic conditions.

As you’d expect, the report focuses on public health and its authors almost exclusively are public health leaders. The important point here, however, is that the report gives great attention to and identifies significant opportunities for the current and likely future iterations of population health management strategies and services. Specifically, the report includes several recommendations significantly relevant to our industry, including that:

• the CDC increase demonstration programs for chronic disease control that cut across specific diseases or multiple chronic conditions and emphasize mitigating the secondary consequences of various chronic conditions;
• the Department of Health and Human Services and state and local government public health agencies evaluate existing, emerging and new models of chronic disease care that promote cooperation among community-based organizations, the health care delivery system, employers and other stakeholders to support living well with chronic illness; and
• HHS supports states in developing comprehensive, collaborative, population-based strategic plans with resources that focus on the management of chronic illness, including community-based efforts.

A key takeaway from the IOM report: Ultimately, successful health care is local. Current federal and state policy priorities seek to advance this concept through community-based, primary-care led models to improve health and health care quality and to constrain costs. Yet, all stakeholders recognize that this evolution in health care delivery will require the integration and coordination of numerous care providers and services in new ways. We’re seeing this happen throughout the industry in multiple collaborative projects. The IOM cites other challenges, including a lack of incentives for care coordination and the prevalence of fee-for-service payments.

This week’s IOM report asserts the potential for community-based care and collaborative models to improve the lives of people managing chronic conditions and to mitigate the impact of chronic disease. These models will benefit from the very strategies and tools in the wheelhouse of population health management as practiced today. It’s a particularly salient point in a week when so many were overly fixated on old approaches to chronic condition care.

—Tracey Moorhead, President & CEO

Health Care Policy Perspective and Insights

Care Continuum Alliance began hosting policy briefings for its Board of Directors three years ago, with a day we called the “Capitol Caucus.” The day has been a great opportunity for our industry leaders to step outside of their day-to-day corporate areas of expertise and hear the latest on key policy issues influencing the growth and evolution of population health management. Our Board members have commented on the high value of these briefings, with one Board member telling me, “This is the most productive day I’ve ever spent in Washington, D.C.”

Well, CCA staff and Board members want to share this valuable experience with a broader swath of our members and industry leadership. This year, for the first time, we’re opening Capitol Caucus to a small group of non-Board member attendees. Capitol Caucus 2012 is shaping up to be a fabulous opportunity to hear updates and insights on a broad variety of health care policy issues, including Affordable Care Act implementation. Attendees also will hear an election-year forecast from a highly regarded campaign analyst.

We’re working hard to confirm speakers on an invitation list that includes Congress, the Centers for Medicare and Medicaid Services, Office of the National Coordinator for Health Information Technology, the Medicare Payment Advisory Commission, the National Governors Association and other federal and state offices; you can view the tentative agenda here, as well as member and non-member registration pricing and sponsorship opportunities.

This event aligns strongly with our strategic vision for advocacy, education and research: to convene, educate and communicate on behalf of population health management and to promote PHM strategies and tools to improve the quality and value of health care. I hope you’ll be a part of that process by joining us at the Capitol Caucus.

—Tracey Moorhead, President & CEO

Nailing the Coffin Shut?

Lots of buzz this week about disease management. First, Archelle Georgiou, MD, proclaims the “The Death of Disease Management (Finally).” Archelle’s arguments seem reasonable enough if you don’t consider that her post-mortem describes a DM model so outdated that today’s providers likely wouldn’t recognize it. Al Lewis reinforces that point with his excellent rebuttal – one with which I actually agreed. (I will, ahem, set aside for another day my thoughts on his position regarding outcomes methodology.)

Then, today, the Congressional Budget Office weighs in with a report on all the Medicare demonstration projects testing “disease management, care coordination, and value-based payment” models. Guess what? CBO says DM didn’t reduce Medicare spending in any of the Medicare demonstration and pilot programs. Really? This is news? Not at all.

The eight-page CBO Issue Brief released this morning summarizes a 30-page report, and I direct your attention to it: It contains a wealth of information that backs up much of what we, the population health management industry, know and that reflects program models being implemented today, in 2012.

Certainly, news reports will proclaim this yet another nail in DM’s coffin. Yet, the full report contains much about which we should crow – and loudly. The full report details the individual strategies upon which each demo or pilot was built and which of those strategies had more success than others. In addition, the report discusses the potential for success and the weaknesses of the studies due mainly to sample size. News flash: Many of the strategies that were more successful are the exact strategies that form the foundation for today’s programs. Further, (and here’s the really wonky part) the report correctly points out the confidence intervals for each study and suggests that, due to the large size of these CIs, we really don’t know how successful or unsuccessful each of these programs really were.

Bottom line: Today’s CBO report is a clear road map on how to build effective programs for Medicare populations. Remember that we can learn as much from what works as what does not work. This is a great road map for our industry and one, frankly, we’ve followed turn-for-turn in recent years.

A final point: Archelle noted, “At the end of the day, DM that does not achieve a net savings is not successful.” It’s an astonishingly cynical conclusion, especially juxtaposed with her “About Me” commitment to “health care projects, initiatives, and causes I believe are most meaningful to making a difference for people.” So, saving money is the only way to make a meaningful difference? Consider this counterpoint, published in the January 2008 American Journal of Managed Care and penned by former Care Continuum Alliance Chair Gordon K. Norman, MD:

“Let us return to the question of whether the current excess of $1 billion spent annually for DM is a good investment. Let us suppose that it is eventually shown by replicated RCTs that, in aggregate, DM programs consistently improve clinical outcomes, quality of life, functional status, and worker productivity but do not invariably produce cost savings. Might it still be the case that DM is consistently cost-effective? If that were the case – and many DM experts believe that it is plausible – it would be noteworthy because little of what physicians do to patients is ever cost saving (albeit life saving). Medicare is not allowed to consider cost-effectiveness in approving new technology for reimbursement, and the US Food and Drug Administration must approve any new drug shown to be safe and effective regardless of cost or comparative effectiveness. Few would question whether health plans should conduct case management, whether hospitals should provide discharge planning, or whether physicians should educate patients about prevention and healthful lifestyles, but none of these accepted health interventions have been shown by replicated RCT evidence to be consistently cost saving or cost-effective, to my knowledge.”

Bingo. Few health care interventions have been shown to save money, yet no rational person would suggest, for example, an office visit with a physician is “not successful” or bypass surgery is “not successful.” A more responsible measure of success might be whether the intervention creates value – in other words, whether you get your money’s worth. It’s the same yardstick we hold up to most other transactions, from a grocery store purchase to a new home. In that light, the evidence is clear that the right disease management intervention for the right population at the right time improves clinical outcomes (and, despite what disease management’s pallbearers would have you believe, can save money).

Where does that leave us? With a vibrant industry that continues to grow and evolve, as evidenced by the rapid pace of recent acquisitions and investments. There’s clearly value to be derived from current population health management strategies in new care delivery models – we see that in the quality improvement drive in the Medicare Advantage Star Ratings program. While I’m sure we haven’t yet heard the last post-mortem on these outdated demos and pilots, when they do crop up we can’t help but think of that memorable Saturday Night Live Weekend Update line, “Generalissimo Francisco Franco is still dead.”

—Tracey Moorhead, President & CEO

A Voice for Population Health Management in a New Year of Opportunities

Tracey Moorhead, Care Continuum Alliance President & CEO

Welcome! We’re thrilled to launch this blog as another important step in the evolution of Care Continuum Alliance (CCA). Our members, along with other industry leaders and observers, know that CCA has long served as the convening voice for care management strategies, first for disease management and, since 2007, for the full continuum of population health interventions – wellness, prevention and other approaches to improving health, reducing disease risk and raising productivity. Today, we add the industry’s voice to the vibrant online community of social media commentary.

Since early in the debate over health care reform, there’s been much talk about the Triple Aim of better care quality, outcomes and value – and nearly as much head scratching over just how to achieve it. That’s a perplexing sight from the perspective of population health management (PHM), which has long offered tools and resources to reach all three goals (and a growing body of work to support its view). PHM also has an indispensable role in the drive toward greater accountability in care delivery, a point that came through clearly in the comments of industry leaders in a recently published CCA white paper on key industry issues for 2012.

We reached out, through a survey, to high-level thought leaders within and outside our membership to develop the paper and found strong optimism about opportunities in accountable care and other new delivery models; expanding government and societal recognition of the value of wellness and prevention; and increasing consumer acceptance of mobile health and other technology-enabled care common in PHM programs. “Key Issues in Population Health Management – Key Industry Issues for 2012,” available freely as a download from the CCA website (www.carecontinuum.org), illustrates the many avenues available to population health management for making meaningful differences in care quality and value.

There may be those who say the white paper’s resolutely positive tone comes filtered through rose-colored glasses. But the industry isn’t alone in its optimism. From policymakers to patient advocates to employers and others at ground zero of the chronic disease fight, the precepts of population health management – care coordination, patient self-management, physician collaboration, outcomes assessment and others – are increasingly part of the arsenal. Also, population health management isn’t shy about looking in the mirror: Survey respondents tempered their upbeat outlook with admonishments that the industry must do more to build the evidence base for and to promote its work.

We intend to meet that challenge with robust research in 2012, vigorous advocacy in support of PHM strategies and promotion through education, including at our annual meeting, The Forum 12, online learning and new events (more on that soon). CCA members and the broader community of stakeholders in wellness, prevention and health management must do the same to broaden the reach of these essential programs.

— Tracey Moorhead, President & CEO