PHA is featured in Partnership for the Future of Medicare’s 2014 Partner Perspectives

The Population Health Alliance (PHA) is featured in the latest issue of the Partnership for the Future of Medicare’s Partners Perspectives. This year’s publication compiles examples of the work that many organizations are doing to improve and innovate within the Medicare program.

PHA is proud to collaborate with the Partnership for the Future of Medicare to ensure the long-term security of the program. PHA supports the goal of strengthening beneficiary protections and encouraging coordinated, efficient, high quality care in the Medicare populations. PHA has long pursued research and policy initiatives that define and accurately measure outcomes of successful health and health care programs. We have also provided evidence-based advocacy regarding Medicare proposals.

PHA shares CMS’ goals of improving the quality of care for Medicare beneficiaries, and fully supports the agency’s quality measurement objectives. An objective Star Ratings methodology will drive better care delivery and empower beneficiaries to make informed decisions about their health care. PHA advocates administratively feasible solutions, such as embedding self-improvement into every measure and rewarding plans for outcomes.

In 2014, PHA convened a Medicare Action Coalition to protect Medicare Advantage beneficiaries from rate cuts in the 2015 rate-setting process. Our position focused on the value that 15 million beneficiaries receive through evidence-based services such as care coordination and wellness benefits that are not available under traditional fee-for-service Medicare. We provided research that demonstrated the program has proven results in better health outcomes and well-being, while reducing emergency room visits, hospital admissions and other acute health episodes. This was a broad-based stakeholder group representing consumer and advocacy groups, industry and trade associations, physicians and health systems and employers.

PHA members play a strong role in leading the industry in Medicare innovation as well as other programs that improve individual well-being and reduce health care costs. Our population health approach includes several case studies as examples of these innovations and successes.

The publication showcases several case studies that reflect PHA’s work in improving Medicare.

Read the 2014 Partner Perspectives

PHA applauds CMS’ efforts in favor of payment for non-face-to-face care coordination services


As part of its advocacy efforts on behalf of its members, on September 2, the Population Health Alliance (PHA) wrote to Ms. Marilyn Tavenner, CMS Administrator, to applaud the Centers for Medicare and Medicaid Services’ (CMS) efforts to improve care for beneficiaries with multiple chronic conditions by facilitating payment for non-face-to-face care coordination services.

Read the letter Re: CMS 2015 Medicare Physician Fee Schedule


If you are interested in the Population Health Alliance (PHA)’ advocacy and government affairs work, please, come on board and work with us:

Medicare Advantage Action Coalition is disappointed, concerned with CMS 2015 Advanced Notice

As part of its advocacy efforts on behalf of its members, the Population Health Alliance (PHA) has been an integral part of the Medicare Advantage Action Coalition. On March 4, the Coalition wrote to Ms. Marilyn Tavenner, CMS Administrator, to express its disappointment and concern over the Centers for Medicare and Medicaid Services (CMS) February 21st Advanced Notice.

The  Medicare Advantage Action Coalition represents several thousand stakeholders across the health care spectrum, including but not limited to, physicians, health care professionals, health plans, aging and disability groups, industry and trade associations and employers.

Read the letter Re: CMS 2015 Advanced Notice and Call Letter

If you are interested in the Population Health Alliance (PHA)’ advocacy and government affairs work, please, come on board and work with us:


PHA Letter to CMS about Proposed Rulemaking (NPRM) Medicare Program




As part of its advocacy efforts on behalf of its members, the Population Health Alliance (PHA) submitted comments to the Centers for Medicare & Medicaid Services regarding the January 10, 2014 Notice of Proposed Rulemaking entitled: Medicare Program: Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Program. We are very concerned that CMS’ proposed requirements around preferred pharmacy networks and eligibility for Medication Therapy Management (MTM) will result in increased out-of-pocket costs, clinically inappropriate care, and reduced access to high-quality pharmacy networks for the 37 Million seniors enrolled in the Medicare Prescription Drug Program (Part D).

Read the letter: Re: Notice of Proposed Rulemaking (NPRM) Medicare Program: Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Program


Get Involved! Medicare Advantage Call to Action

As follow-up to the December 17th CCA and National Association of Manufacturers (NAM) Medicare Advantage Roundtable, please join us for a meeting on February 5th from 9am – 10am EST to discuss next steps in response to the forecasted 6.5% cut to 2015 Medicare Advantage rates and other political updates!  Special thanks to our co-host Healthcare Leadership Council.

Date:         Wednesday, February 5th, 2014 

Time:       9:00 – 10:00 am EST                                

Location:  Healthcare Leadership Council 750 9th St NW Suite 500 Washington, D.C. 20001

Call in number: 877.394.9920 Conference code: 7488204719

Please RSVP for security: Vicki Shepard, or Isabel Estrada-Portales

Given the diverse multi-stakeholder nature of our group, we are uniquely positioned to communicate the value of Medicare Advantage in advocacy efforts with policymakers in CMS and on Capitol Hill. It will be important to discuss the following next steps:

  • Individual and group efforts around Medicare Advantage
    • Draft sign-on letter and timing (attached) – If you are not able to attend, and are ready to sign or have questions, please let us know.
    • Generating individual organizational letters – See the material from our last meeting and sample letters. WELCOME TO SEND NOW AND BRING TO MEETING!
    • Potential Capitol Hill visits
  • Strategy to reach out to additional stakeholders
    • Coalition Info Sheet (attached)
    • Other stakeholder groups who should be involved


Medicare Advantage Action Coalition

Sign On Letter to CMS Administrator Marilyn Tavenner

Protecting Medicare Advantage (MA) Roundtable Discussion & Call to Action

Due to the number of inquiries we received at our last meeting for a call-in number, please use the following if you cannot join us in person:

Dial-in number(s): 877.394.9920 Conference code: 7488204719

CCA and National Coalition on Health Care Joint Letter on CMS “Two Midnights” Requirement

October 31, 2013
Jonathan Blum
Deputy Administrator, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, D.C. 20201

RE: FY2014 Medicare Inpatient Prospective Payment System (IPPS) Final Rule – Anticipated CMS Guidance on “Two Midnights”

Dear Deputy Administrator Blum:

On September 26th, the Centers for Medicare & Medicaid Services (CMS) held a Special Open Door Forum during which CMS stated that the Agency was planning to issue detailed subregulatory guidance to clarify the FY2014 Medicare Inpatient Prospective Payment System (IPPS) Final Rule’s “Two Midnights” requirement. CMS specifically stated that such guidance would address that hospital utilization review programs and conditions of participation are not changing with implementation of the Final Rule. CMS also confirmed that the IPPS Final Rule, “should not be used as a reason for hospitals to abandon their use of critical medical necessity and coverage assessments,” in public statements made by the CMS Philadelphia Regional Office. We agree that the “Two Midnights” requirement should not be interpreted as a substitute for sound clinical judgment based on objective, evidence-based medicine.

To assist CMS in issuing needed clarifying language, attached please find proposed language for inclusion in the forthcoming subregulatory guidance that CMS is currently preparing. We appreciate your continued efforts to clarify these important details regarding “Two Midnights” in order to minimize confusion and ensure beneficiaries are receiving appropriate care at the appropriate time. Thank you.


John Rother, President & CEO, National Coalition on Health Care

Frederic S. Goldstein, Executive Director, Care Continuum Alliance

Read the Letter

CCA Letter to Congressman Ryan on behalf of Medicare Advantage Beneficiaries

October 4, 2013

The Honorable Paul Ryan

Chair, Committee on Budget

United States House of Representatives

1233 Longworth House Office Building

Washington DC 20515

Dear Representative Ryan:

As the Congressional discussion of budget priorities continues, we are writing on behalf of the Care Continuum Alliance (CCA) to seek your support in assuring that the more than 14 million Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan will not experience any additional cuts to the MA program, and will continue to have access to the quality care delivery, care coordination and wellness and prevention services offered by MA plans.

CCA convenes a broad range of stakeholders dedicated to enhancing the health of populations. Through advocacy, research, and education, CCA advances evidence-based population health management strategies. The CCA aims to improve care quality and health outcomes while reducing preventable costs for the healthy and those at risk of or suffering from chronic conditions. Our diverse membership of more than 200 organizations and individuals includes physician groups, nurses, other health care professionals, hospital systems, wellness and prevention providers, population health management organizations, pharmaceutical manufacturers, pharmacies and pharmacy benefit managers, health information technology innovators, employers, researchers, and academics.

Our member organizations serve Medicare beneficiaries across the country, including a large majority of beneficiaries enrolled in MA plans across the country. MA enrollees receive high quality care and enhanced services at lower costs. Of particular importance, MA enrollees often receive enhanced, evidence-based wellness and prevention services and chronic care management. These programs directly benefit America’s seniors and help reduce health care spending overall.

For example:

Medicare seniors with diabetes in a MA Special Needs Plan had 7% more primary care physician office visits and 19% fewer days in the hospital compared to seniors in Medicare fee for- service (FFS). [i]

Seniors in an MA plan had a 14.5% 30-day readmission rate from 2006-2008, which was 22% lower than FFS readmission rates.[ii]

Seniors in MA plans are less likely to report trouble in receiving care, more likely to have a usual source of care, and more likely to receive necessary preventive services compared to seniors in FFS.[iii]

Despite the measurable success of MA, the program faces challenges in 2014, 2015 and beyond. The Patient Protection and Affordable Care Act (PPACA) mandated $200 Billion in cuts to the MA program. In addition, the 2012 Fiscal Cliff deal cut $2.5 Billion from Medicare Advantage through a coding intensity provision. The Congressional Budget Office has outlined projected cuts to these programs in the coming years:

Even though only a small portion of PPACA cuts have taken effect so far (only ten percent of the cuts will have gone into effect by the end of 2013), the reduction in beneficiary choices has begun.[iv]  The number of MA plans is projected to drop in 2014.[v] Although we understand that Congress faces many difficult choices in the budget debate, we are concerned that any further cuts to the MA program will undermine the ability of the program to sustain its impressive track record in improving care and reducing costs for Medicare beneficiaries.

We would be pleased to provide additional information on the program, highlight examples of the program’s success, and further detail the positive impact it is having on the lives of America’s seniors.  If we can be of assistance, please feel free to contact Vicki Shepard at 202-525-9588



Fred Goldstein

Acting Executive Director

Care Continuum Alliance

Vicki Shepard

Chair, Government Affairs Committee

Care Continuum Alliance

[i] “Medicare Advantage Chronic Special Needs Plan Boosted Primary Care, Reduced Hospital Use Among Diabetes Patients.” Health Affairs 31.1 (2012).

[ii] Lemieux, J., Sennett, C., Wang, R., et al., “Hospital Readmission Rates in Medicare Advantage Plans.” American Journal of Managed Care 18(2):96-104 (2012).

[iii] Centers for Medicare and Medicaid Services, Medicare Advantage, Hill Notification Document, 11 (2007).

[iv] Congressional Budget Office, Letter to the Honorable Nancy Pelosi (March 20, 2010).

[v]Avalere Health analysis of CMS Landscape File, September 23, 2013 accessed at


Incentives For Nondiscriminatory Wellness Programs In Group Health Plans: Highlights From The Final Rule

General Information About The Final Rule …

On May 29, 2013, HHS, the Department of Treasury and the Department of Labor issued a Final Rule on Incentives For Nondiscriminatory Wellness Programs In Group Health Plans. The final rule clarifies the scope of HIPAA and Affordable Care Act rules governing wellness programs and incentives. It outlines criteria that a wellness program must satisfy for an affirmative defense in response to a claim that the health plan or issuer discriminated under HIPAA provisions.

Read the Wellness Incentives Final Rule Expanded Summary

HIPAA Nondiscrimination Requirements For Wellness Programs By Program Type …

Wellness programs can be either Participatory or Health-Contingent.

Participatory programs either (1) do not offer rewards or (2) offer rewards that are not based on health factors. These programs must be made available to all similarly situated individuals, regardless of health status. No other restrictions or requirements are imposed.

Health-Contingent programs require an individual to satisfy a standard related to a health factor in order to obtain a reward. Health Contingent Programs can be Outcomes-Based or Activity-Only.

Activity-Only programs require an individual to perform or complete an activity, but not achieve a specific health outcome in order to obtain a reward. *A reasonable alternative standard for obtaining the incentive must be provided to any individual who has a medical condition or restriction that makes it unreasonably difficult or inadvisable to attempt the activity.

Outcomes-Based programs require an individual to attain or maintain a specific health outcome in order to obtain a reward. *A reasonable alternative standard or waiver must be provided to all individuals who do not meet the initial standard.

5 HIPAA Nondiscrimination Criteria For Health-Contingent Programs …

Health-Contingent wellness programs must: (1) Provide individuals with the opportunity to qualify for the reward at least once per year; (2) Keep the total reward offered to an individual or any class of dependents within 30% of the premium or 50% for tobacco-related programs; (3) Be reasonably designed to promote health or prevent disease without being overly burdensome or a subterfuge for discrimination based on a health factor; (4) Make The Full Reward Available To All Similarly Situated Individuals; (5) Provide notice of a reasonable alternative standard.

Additional Rules and Considerations For “Reasonable Alternative Standards” …

Health-Contingent programs must offer a “reasonable alternative standard”. The same full reward must be available to those who satisfy the reasonable alternative as provided to those who satisfy the otherwise initial standard. In lieu of providing a reasonable alternative, a plan or issuer may always waive the applicable standard and simply provide the reward. Plans and issuers do not have to establish a particular reasonable alternative standard in advance of an individual’s specific request for one. An individual can involve a personal physician at any time and must be given the opportunity to comply with a physician’s recommendations as a 2nd reasonable alternative standard.

Verification Rules In Health-Contingent Programs …

“Verification” is when a plan or issuer requires an individual obtain verification from a personal physician that a health factor prevents the individual from meeting the otherwise applicable standard for receiving a reward/ incentive.

Outcomes-Based programs: plans and issuers cannot condition their obligation to provide a reasonable alternative standard on verification by an individual’s personal physician.

Activity-Only programs: plans and issuers may require verification as a condition of providing a reasonable alternative standard when it is reasonable to determine that medical judgment is required to evaluate the validity of the request for an alternative.

Room For Innovations …

The final regulations provide the flexibility to encourage innovation. Nothing prevents a plan or issuer from establishing more favorable eligibility rules, premium rates, or rewards for individuals with adverse health factors compared to individuals without adverse health factors.

Future Considerations …

HHS, Treasury and DOL anticipate issuing future sub-regulatory guidance to provide additional clarity and potentially proposing modifications to this final rule as necessary. Also, compliance with the HIPAA nondiscrimination and wellness provisions is not determinative of compliance with any other applicable Federal or State law, which may impose additional accessibility standards for wellness programs.

Wellness Incentives Final Rule Expanded Summary

For Questions, Please Contact:

Victoria L. Shapiro

Director of Government Affairs 

office: 202.737.1107

cell: 202.870.2166

Just Released: Final Rule on Incentives for Nondiscriminatory Wellness Programs in Group Health Plans

After a long wait, on May 29, the agencies released the final rule on Incentives for Nondiscriminatory Wellness Programs in Group Health Plans is a must read and essential for all population health and wellness industry stakeholders.

The rule was issued by the Internal Revenue Service, Department of the Treasury; Employee Benefits Security Administration, Department of Labor; Centers for Medicare & Medicaid Services, Department of Health and Human Services.

Victoria Shapiro, Care Continuum Alliance Government Affairs Director wanted to share our initial impression review of the rule´s impact for CCA members and the industry as a whole.

In its formal comments on the proposed version of this rule, CCA asked HHS to:

  • Maintain flexibility in the core features of a “reasonably designed” wellness program.
  • Allow for program innovation to create new evidence on wellness strategies for specific populations.

The final rule expressly used this language and granted both of these requests. CCA is also cited in the language of the final rule:

“Currently, insufficient broad-based evidence makes it difficult to definitively assess the impact of workplace wellness on health outcomes and cost; however, available evidence suggests that wellness programs may have some effect on improving health outcomes. The RAND Corporation’s analysis of the Care Continuum Alliance (CCA) database found statistically significant and clinically meaningful improvements in exercise frequency, smoking behavior, and weight control between wellness program participants and non-participants.”

The Departments anticipate that future sub-regulatory guidance may be needed to further clarify portions of this final rule, and will issue such guidance as necessary.

Some Key Points about the Final Rule

  • Clarifies the scope of HIPAA and the Affordable Care Act rules governing wellness programs.
  • Outlines criteria for “an affirmative defense that can be used by plans and issuers” in a claim regarding compliance with HIPAA provisions.
  • Offers detailed steps a plan or issuer can take to ensure wellness programs are reasonably designed and also what constitutes a “reasonable alternative standard”.

Last Thought

The language of the rule reads:

“These final regulations continue to provide plans and issuers flexibility and encourage innovation.”

Final rule on Incentives for Nondiscriminatory Wellness Programs in Group Health Plans

CCA Comments and Recommendations to EEOC on Wellness Programs and Incentives

May 23, 2013

The Honorable Jacqueline Berrien, Chair

The Honorable Constance Barker, Commissioner

The Honorable Chai Feldblum, Commissioner

The Honorable Victoria Lipnic, Commissioner

The Honorable Jenny Yang, Commissioner

The Honorable P. David Lopez, General Counsel

U.S. Equal Employment Opportunity Commission

Re: Wellness Programs and Incentives

Dear Sir or Madam,

The Care Continuum Alliance (CCA) welcomes this opportunity to comment on the discussion at the May 8th EEOC public meeting on “Wellness Programs Under Federal EEOC Laws” in Washington, D.C. We are a non-profit association of almost 200 companies. CCA convenes all stakeholders in the population health management industry. Our members design and provide services, programs and tools to better coordinate care for all patients along the continuum, from the healthy to those with chronic conditions. Through advocacy, research and education, we advance strategies that increase quality in the health care system while reducing costs.

CCA appreciates your thoughtful consideration and careful attention to the value of worksite wellness programs and incentives. We observed in your meeting that a significant portion of the discussion revolved around the “voluntary” aspect of workplace wellness programs. Jointly-issued 2006 final regulations on Nondiscrimination and Wellness Programs by the Department of Labor, Department of the Treasury and Department of Health and Human Services expressly identify the five-prong Health Information Portability and Accountability Act (HIPAA) standard as the appropriate metric for evaluating the “voluntary” aspect of worksite wellness programs.[1] The EEOC also referenced this standard in its 2008 final rule, acknowledging that Title II of the Genetic Information Nondiscrimination Act allows covered entities to offer incentives for participating in wellness programs.[2] 

The HIPAA five-prong test states that wellness programs offering rewards based on achieving a particular health status are voluntary if: (1) the reward does not exceed 30 percent of the cost of the individual’s health coverage or 50 percent in relation to tobacco; (2) the program is reasonably designed to promote health or prevent disease; (3) individuals have the opportunity to qualify for the reward at least once annually; (4) the reward is available to all similarly situated individuals; and (5) disclosure of a reasonable alternative standard if the terms of the program are described.[3],[4] Please also note the useful Wellness Program Analysis and Checklist provided by the Department of Labor to clarify application of the existing HIPAA standard.[5]

CCA supports this HIPAA standard as the appropriate metric. We encourage the EEOC to adopt this standard and issue such guidance to employers. This will alleviate confusion and concern regarding the possibility of additional regulatory hurdles for worksite wellness programs.[6] Confusion often leads employers to simply withdraw or abstain from offering even well-designed evidence-based wellness and incentive programs. The HIPAA standard aligns with CCA’s and the EEOC’s shared goal of promoting and improving health, while prohibiting discrimination in an employee’s eligibility or ability to participate in wellness programs.[7] Furthermore, applying the standard to worksite wellness programs offers compelling advantages over forging new compliance requirements. Using this standard in the context of worksite wellness programs would be a natural extension from its current application with group health plans, ensuring consistent and streamlined regulatory requirements around wellness programs in the health industry. Also, many employers with well-received and successfully implemented wellness programs currently use the five-prong HIPAA standard. This indicates that the standard operates as a strong functional basis for future EEOC guidance.

We are providing you with a current literature review and case studies that demonstrate advancements in worksite wellness programs. The literature shows that incentives can facilitate behavior change to increase patient engagement in wellness programs. It also positively indicates that appropriate incentive and wellness program design can produce cost savings for employers. Finally, the literature reinforces that the value of incentives in wellness programs extends beyond direct healthcare cost savings. As one component of an organizational culture of health, incentives in wellness programs can produce additional positive outcomes such as workforce productivity. 

We are also including a joint consensus paper by the Health Enhancement Research Organization, the American College of Occupational and Environmental Medicine, the American Cancer Society and American Cancer Society Cancer Action Network, the American Diabetes Association, and the American Heart Association entitled, “Guidance for a Reasonably Designed, Employer-Sponsored Wellness Program Using Outcomes-Based incentives”. This paper offers valuable insights on wellness program and incentives design for your consideration. It outlines elements of a reasonably designed wellness program and provides guidance on devising reasonable alternative standards.[8] The paper notes that incentives in wellness programs should be designed with flexibility to incent meaningful progress toward health goals and not just ideal targets.[9] It also advises employers to incorporate options that allow employees to earn any given incentive in multiple ways, promoting behavior change through individual choice.[10]

CCA looks forward to continuing this dialogue and would be glad to serve as a resource. Please feel free to contact us with thoughts or questions.

Thank you,

Frederic S. Goldstein

Interim Executive Director

Care continuum Alliance

Victoria Shapiro

Director of Government Affairs

Care Continuum Alliance

Read CCA Submitted Comments to EEOC on Wellness Programs under Federal EEOC Laws, May 23, 2013

Read JOEM Joint Consensus Statement article on Workplace Wellness Programs and use of Incentives

[1] 45 CFR Part 146 §146.121(f)(2)(i)-(v), Department of the Treasury, Department of Labor, Department of Health and Human Services, Nondiscrimination and Wellness Programs in Health Coverage in the Group Market, Federal Register vol. 71 No. 239 (Dec. 2006): 75052.

[2] 29 CFR Part 1635, Equal Employment Opportunity Commission, Regulations Under the Genetic Information Nondiscrimination Act of 2008, Federal Register vol. 75 No. 216 (Nov. 2010):68923 n.13.

[3] 45 CFR Part 146 §146.121(f)(2)(i)-(v) at 75052.

[4] §1201, Patient Protection and Affordable Care Act, H.R. 3590 (2010).

[5] Employee Benefits Security Administration, U.S. Department of Labor, Wellness Program Analysis, Field Assistance Bulletin No. 2008-02 (Feb. 2008) 1-5.

[6] 45 CFR Part 146 §146.121(f)(2)(i)-(v) at 75052.

[7] Id.

[8] Health Enhancement Research Organization, the American College of Occupational and Environmental Medicine, the American Cancer Society and American Cancer Society Cancer Action Network, the American Diabetes Association, and the American Heart Association, Guidance for a Reasonably Designed, Employer-Sponsored Wellness Program Using Outcomes-Based Incentives, Journal of Occupational and Environmental Medicine, Vol. 54 (July 2012).

[9] Id. at 894

[10] Id.


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