Community-Based Wellness and Prevention Programs: The Role of Medicare

Community-based wellness and prevention programs have long served to address the needs of an aging population with multiple chronic diseases. Title IIID of the Older Americans Act, passed in 1987, called for the Administration on Aging (AoA) to fund “education and implementation activities that support healthy lifestyles and promote healthy behaviors (1).” AoA, now a part of the Administration for Community Living (ACL), has continued to review the evidence base for wellness and prevention programs and launched the EvidenceBased Prevention Program in 2003 to increase access to such programs for older adults (1, 2). The National Council on Aging, in conjunction with AoA, operates a clearing house of evidence supporting wellness interventions and provides technical assistance to organizations implementing the interventions (3). Unfortunately, community-based wellness and prevention programs have yet to be incorporated into the continuum of care for Medicare recipients. At the Centers for Medicare and Medicaid Innovation (CMMI), we have embraced a broader view of addressing prevention and wellness in our beneficiaries. We now have several efforts underway to bridge the gap between clinical and community-based care. In this article, we discuss the results of research to date, describe current efforts to evaluate and engage with community-based wellness and prevention programs, and outline some challenges that we have recognized in fully integrating these interventions into the Medicare system. Recognizing the potential of community-based wellness and prevention programs to improve health and reduce medical costs among Medicare beneficiaries, Congress called upon the Secretary of Health and Human Services to evaluate these programs under Section 4202(b) of the Affordable Care Act. To address this statute, CMMI first directed an evidence review and environmental scan of existing wellness programs, which Altarum Institute completed in 2011. Altarum rated the strength of peer-reviewed literature surrounding a variety of wellness and prevention programs and found several with the potential to benefit older adults (4). The results of this first phase of research informed the selection of promising programs for the second phase of research, a retrospective analysis of claims-based outcomes for Medicare recipients who participated in select wellness interventions from 1999 to 2012. Acumen LLC completed the retrospective study in January 2013, and their findings along with those of Altarum formed the basis for a Report to Congress delivered In November 2013 (5). As described in the Report to Congress, Acumen found statistically significant total medical cost savings for four established wellness programs: EnhanceFitness (EF), Arthritis Foundation Exercise Program (AFEP),Arthritis Foundation Tai Chi Program (AFTCP), and Matter of Balance (MOB). Two additional programs, the widely disseminated Chronic Disease Self-Management Program (CDSMP) and the Arthritis Foundation Aquatic Program (AFAP), demonstrated reductions in inpatient hospital costs, which indicate a potential for future long-term savings. One common element of the programs that were associated with total cost savings is that they all included consistent physical activity to prevent and manage chronic conditions. These findings suggest that physical fitness may be a critical mechanism through which to achieve benefits in health, utilization, and cost outcomes. The next phase of research under the 4202(b) legislation is currently underway: a prospective evaluation of new participants in wellness programs. Acumen LLC, in partnership with Westat, is conducting this study, with initial results expected in 2016. While the retrospective study showed some promising results, it was limited by the inherent selection bias in beneficiaries who voluntarily enrolled in wellness programs. Although Acumen matched program participants to non-participants based on clinical and sociodemographic factors as well as cost and utilization patterns, there still may be an unobservable difference in people who seek out community-based wellness and prevention programs. The prospective study will attempt to address selection bias through a population survey to measure Medicare beneficiaries’ readiness to engage in wellness interventions, which will allow for more precise matching between participants and controls based on personal motivation factors. The survey will also gauge knowledge of and interest in wellness programs, which will inform efforts to scale interventions. Along with the 4202(b) evaluation, CMMI is considering proposing an innovative new community-based service delivery model, the Accountable Health Community (AHC), aimed at achieving better care and lower health care costs for beneficiaries with highly prevalent chronic diseases within a defined geographic area. AHCs would utilize funds from CMMI as well as from other public and private