CCA Letter to HHS Secretary Sebelius on Incentives for Wellness Programs

January 25, 2013

The Honorable Kathleen Sebelius
Secretary
U.S. Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201
 

RE: CMS–9979–P / RIN 0938–AR48

Dear Madam Secretary,

Care Continuum Alliance (CCA) appreciates this opportunity to comment on the proposed rule regarding Incentives for Nondiscriminatory Wellness Programs in Group Health Plans.

CCA is an association that 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, CCA advances strategies that improve quality in the health care system and achieve cost savings. Our diverse membership includes: physician groups, nurses, other health care professionals, hospital systems, wellness and prevention providers, population health management organizations, health plans, pharmaceutical manufacturers, pharmacies and pharmacy benefit managers, health information technology innovators, employers, researchers, and academics.

Overall, we are pleased with the thoughtful and balanced approach by the Department of Health and Human Services (HHS), the Department of the Treasury, and the Department of Labor in jointly drafting this proposed rule. The rule makes great strides in balancing the need for flexibility in wellness program and incentives design, with appropriate patient protections to access and participate in wellness services.

Recommendation: Maintain flexibility in the core features of a “reasonably designed” wellness program.

CCA and our members would appreciate flexibility in interpreting the language of “reasonably-designed” wellness programs. In determining “reasonable design”, we strongly agree with the notion that wellness programs cannot be ‘one size fits all’. Different patient populations require different health interventions, as clearly indicated in this proposed rule. Also, maintaining a basic framework that permits flexibility in “reasonable design” reflects HHS’s broad goal of delivering the right care, at the right time, in the right setting.

We defined core components of a wellness program in the CCA Outcomes Guidelines Volume 5 Report.[1] This report also provides a framework and relevant factors for evaluating the impact of wellness programs on health outcomes and cost-savings. Noting that wellness programs employ many different behavior change techniques and lifestyle management strategies, core design features should include:

  • Help for individuals to maintain and improve their level of health and well-being by identifying health risks and educating them about ways to mitigate these risks;
  • increasing awareness of factors that can affect health and longevity;
  • enabling individuals to take greater responsibility for their health behaviors;
  • preventing or delaying the onset of disease; and
  • promoting healthful lifestyles and general well-being [2]

These guidelines establish a flexible foundation to build a variety of wellness programs tailored to the specific health needs and preferences of different patient populations. We suggest that HHS maintain the level of flexibility exemplified by these guidelines in the final rule, along with core features outlined in the consensus statement 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.[3]

Recommendation: Key considerations for both wellness program and incentives design.

While CCA supports the use of evidence-based strategies in wellness program design and implementation, the proposed rules must also allow for program innovation to create new evidence on wellness strategies for specific populations. To achieve a balance and provide guidance to fellow healthcare industry stakeholders, CCA’s members assembled the Outcomes Guidelines Steering Committee. The Committee developed the following basic considerations for wellness program design in a consensus report entitled Outcomes Guidelines Report Volume 5: [4]

  • the program is designed to address modifiable health risks;
  • an evidence-based tool is used to assess health risks;
  • a targeted intervention is used to support healthful behavior;
  • individual patient-level information is collected to measure outcomes; and
  • the outcome is measured in a scientifically rigorous manner, using appropriate comparative measures

CCA and a working group of our members also outlined key considerations for designing incentives in a 2012 report entitled Participant Engagement and the Use of Incentives.[5] The considerations include:

  • Incentive-related needs and expectations evolve as patient needs and interests change.
  • Organizations should have an evaluation plan to determine whether incentives are improving health outcomes and/or achieving cost savings in a given population.
  • Intrinsic and extrinsic incentives can have different effects.
  • It is important to encourage active engagement and participation to achieve lasting healthy behavior change, not just enrollment.

The working group distilled these overarching considerations from a current comprehensive literature review and case study analysis. In light of these broad considerations, we recommend that HHS leave ample room for program innovation in wellness program and incentives design.

CCA would be glad to offer additional case studies, share peer-reviewed literature, and field questions as HHS moves forward in the rulemaking process.

Thank you,

Frederic S. Goldstein
Acting Executive Director
Care Continuum Alliance

Vicki Shepard
Chair of the Government Affairs Committee
Care Continuum Alliance

Victoria Shapiro
Director of Government Affairs
Care Continuum Alliance


[1] Care Continuum Alliance, Outcomes Guidelines Report, Vol. 5 (2010) www.carecontinuumalliance.org/OGR5_user_agreement.asp

[2] Id. at 37.

[3] Health Enhancement Research Organization, American College of Occupational and Environmental Medicine, American Cancer Society and American Cancer Society Cancer Action Network, American Diabetes Association, and American Heart Association, Guidance for Reasonable Designed Employer Sponsored Wellness Programs Using Outcomes Based Incentives, Journal of Occupational and Environmental Medicine, vol. 54 (July 2012).

[4] Care Continuum Alliance, Outcomes Guidelines Report, Vol. 5 at 42.

[5] Care Continuum Alliance, Participant Engagement and the Use of Incentives (2012): 16 www.carecontinuumalliance.org/pdf/201301/Incentives-Document.pdf.

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.

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.

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

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