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CMS readies a bold new demonstration aimed at putting the focus on prevention

Sometime this summer CMS will announce which five vendors it has selected to participate in its Senior Risk Reduction Demonstration (SRRD), an entirely new program-and a new direction for CMS-that targets a relatively young and healthy population of Medicare beneficiaries. The program's purpose, according to CMS, is to see whether lower-level preventive interventions deployed early on will ultimately deliver clinical and financial dividends by preventing or delaying the onset of chronic disease and disease-related complications.

CMS, noting that the approach is focused on health promotion and disease prevention as opposed to DM, says it wants to determine whether health-risk-reduction programs that have been effective in the private sector can be tailored to produce results in Medicare populations as well. Although the official start date of the three-year demonstration appears to be still a year or more away, the approach is generating interest, especially among advocates of early intervention and prevention. Further, if the approach bears fruit, it could not only affect the health of a huge portion of the population but also give Medicare an appealing weapon for controlling long-term costs.

Evidence supports a risk-reduction focus

CMS has good reason to believe that this new direction has merit. A report commissioned by CMS from the RAND Corporation, the Santa Monica, CA-based think tank, concluded that risk-reduction programs that begin with the administration of a health-risk assessment (HRA) and include tailored follow-up interventions can beneficially affect behavioral, physiological, and general health-status outcomes.

"There has been a growing base of literature supporting [the contention that] multicomponent health-promotion programs that engage participants in self-care and increase their involvement in healthcare decision-making, can achieve long-term behavior change and health-risk reduction in large populations," says Pauline Lapin, MHS, a technical advisor in the Division of Health Promotion and Disease Prevention Demonstrations at CMS.

Ultimately, CMS plans to invite as many as 85,000 Medicare beneficiaries between the ages of 67 and 74 to participate in the demonstration. CMS says it hopes to attract a broad spectrum of participants, but in a departure from the approach of the Medicare Health Support program- another large CMS program targeting chronically ill beneficiaries-administrators emphasize that they are not specifically looking for seniors with chronic disease.

"This is not a DM demonstration. It is more of a health management demonstration," Lapin says. "There is some overlap, but the whole point is that CMS has provided services on one end of the health spectrum, and we are now trying to explore ways to provide services to people on the other end of the spectrum."

In fact, plans for the SRRD were developed even before the Medicare Health Support program began enrolling patients, notes Sidney Trieger, director of the Division of Health Promotion and Disease Prevention Demonstrations. "We view this as a very different program than Medicare Health Support," he says. For example, vendors will not be put at full risk the way they are under the earlier program.

Model takes a broad approach

Already tapped to design and implement the SRRD are the Cornell University Institute for Policy and Research in Ithaca, NY, and Washington, DC-based Thomson Healthcare, partnering organizations that won the assignment with a proposed model that initially targets 17 health risks, ranging from obesity and tobacco use to lack of transportation and high stress.

"It is not a specific category of risks . . . but it is any and all of the above risk factors and a kind of multicomponent, comprehensive risk-reduction program," says Ron Goetzel, PhD, a vice president at Thomson Healthcare and director of the Institute for Health and Productivity Studies at Cornell. "There are a lot of reasons why we [adopted a] broad rather than a narrow [approach], one of which is that peoples' risks travel together. People who have one risk often have other risks as well."

The model is designed to take some of the lessons learned from 20-30 years of experience in providing healthpromotion programs to employees and health plan members, and see whether at least some of those lessons can be applied to the Medicare population, Goetzel explains.

"Medicare traditionally has not really done very much with prevention and health promotion other than paying for screenings and certain procedures," he says, noting that statistics suggest that the potential for such a health-promotion program is huge. "A very small minority of the Medicare population has a lot of illnesses and [accounts for] close to half of total Medicare expenditures. But on the flip side of that, about half of all Medicare beneficiaries consume very [few medical resources], so there is a fairly large segment of the population . . . that is relatively healthy, and the idea is to keep these people healthy to begin with."

Interventions based on behavioral theory

The first step for participants who agree to participate in the demonstration will be to complete an HRA. At least initially, the goal of the HRA is to serve as an awareness- building tool to heighten the participants' knowledge of their risks and health status, Goetzel says.

However, vendors will also use the tool to triage people toward risk-specific interventions. Once a participant gets triaged into a higher or lower risk category and gets targeted for specific types of intervention, the vendor will send educational materials and information over the telephone, through the mail, or via the Internet. Depending on an individual's needs, the intervention may take the form of regular health coaching or counseling offered by phone or a series of educational mailings about a particular health issue of concern to that person.

"The idea is to provide as much or as little of this as is needed for the individual and to do it using behavioral theory," says Goetzel, noting that health coaches will rely on such techniques as motivational interviewing, assessing readiness to change, goal setting, and other approaches proven effective in producing lifestyle change.

In addition to providing counseling and education, the intervention also includes a mechanism for referring participants to community-based resources that can assist them in working on the health-related risks and issues that have been identified. To accomplish this, communities involved with the demonstration will receive funds to set up Information, Referral, and Assistance (IR&A) programs. Goetzel emphasizes that the funding will not go toward paying for external resources such as health club memberships, for example. Instead, the IR&As will help direct people to senior centers, local YMCAs, and other organizations that can help them work toward their goals.

Physicians may be involved-or at least apprised of the SRRD activities-but their involvement is left up to the beneficiaries themselves, according to CMS. "The way it works is if the beneficiaries would like their feedback report, which is based on their responses to the HRA, to be shared with their physician, they will be offered that opportunity," says Lapin, explaining that in these cases the vendor organization will mail the reports to the physicians. However, Lapin adds that even when the physicians do not receive the reports, the intervention supports their work with patients by providing counseling and support that physicians may not have much time to deliver during their encounters with patients.

Results could be powerful

The demonstration is set up so that participants will be randomized into one of three study arms or a control group. Consequently, some participants will receive standard interventions, some will receive enhanced interventions- which include more frequent contact with a health coach-and some will receive an HRA and generic feedback.

"The demonstration is designed to be as true an experimental study as you can get it to be," Goetzel says. "The intent is to engage five vendors in this intervention. And the way the study is powered is that even if only one vendor shows significant findings, we will have enough of a sample size to see that. If all five vendors [show significant results], then obviously it is going to be quite powerful."

As it stands now, CMS anticipates that a one-year pilot of the approach will begin within three to four months after it selects the participating vendors this summer. CMS will use the pilot phase to iron out any problems and make sure that all of the processes involved with the demonstration run smoothly.

Then, about six months following initiation of the pilot, enrollment in the three-year demonstration will begin.

CMS says it is interested in comparing outcomes related to behavior change and medical expenditures in the various arms of the demonstration and how these results stack up against those from a group that will not receive any intervention.

If the intervention delivers positive results, CMS could go forward with further demonstrations, perhaps on a larger scale, or it could ask Congress to consider making the intervention a full benefit of Medicare. Putting the focus on prevention should pay off in the long run, according to Goetzel.

"Eventually, you are going to save more money if you prevent people from getting sick than if you try to get sick people to all of a sudden become healthy, so there is merit to getting people at whatever age . . . to begin to adopt healthy lifestyle habits because it will make a difference," he says.