Four Ways Health Reform Could Spark Wellness Programs

Nearly everyone agrees that prevention and healthy living can help slow the nation's healthcare cost spiral, but actually getting people interested in fitness has always been the problem.

Wellness advocates and population health management officials say Congress took a small step toward a healthier nation by approving health reform.

Here are four ways that health reform could increase and improve wellness programs:

32 million more insured

The legislation will provide health insurance for an estimated 32 million more Americans, which in theory should help improve the health of the currently uninsured. Insurance companies with wellness and disease management programs will enroll the previously uninsured into these programs, which are often run by population health management companies, such as Healthways, Health Dialog, and Alere.

Whether the newly insured can find a primary care physician who can spend time helping them improve their health is in question though.

There are also the issues of how the federal government will implement the broad legislation. Does it invest more in community health centers? Does it invest in demonstration projects and pilots that involve health plans and population health management companies? Or does it fund educational programs?

Though population health leaders are pleased that the legislation could lead to better health and more business, there are still a lot of issues that the feds will have to work out before regulations are implemented.

"This can't be bad, but how will it be shaped in the next round of the process?" says Bob Stone, vice president and co-founder of Healthways. "I would expect people in the [population health management] industry to be fairly active in determining how that gets shaped as it is turned into regulation."

Help for employer wellness programs

The legislation promotes wellness and health promotion activities, including requiring federally qualified health plans to create programs like health risk assessments and allows employers to use more incentives to spark greater employee participation in wellness programs.

Jaan Sidorov, MD, MSHA, FACP, an independent consultant for Sidorov Health Solutions, says reform allows employers to link a higher dollar amount to fitness program participation. Prevention advocates say using that monetary approach can lead to improved fitness participation.

Though he's pleased that many large employers will be able to create more wellness options, Sidorov says he's disappointed that Congress couldn't find ways to help small businesses improve their prevention programs.

Innovation Center

Population health management leaders are especially excited about is the proposed CMS Innovation Center. The program will research and develop care delivery and payment models, which Tracey Moorhead, president and CEO of DMAA: The Care Continuum Alliance, says is an opportunity for the industry to take what has been learned in the commercial and Medicaid markets and replicate in the Medicare setting.

The fee-for-service payment model is often a barrier for wellness programs because their preventive services are not reimbursable. Moorhead says a "more closely aligned care delivery model" would allow wellness companies to have a more active member in the care team through such programs as health coaches and disease management.

Moorhead points to successes, such as the medical home Medicaid programs that have focused on care coordination in areas such as maternity, chronic disease management, and obesity management. These programs feature collaboration between health plans, physicians, and population health management companies to develop alterative reimbursement models and provide support staff, such as health coaches. They have led to better health outcomes, patient satisfaction, and quality, she says.

The Innovation Center will test integrated care in the Medicare population and the legislation also provides grants for state Medicaid programs that create new payment models. She says those provisions are positive steps.

Medicare and the pre-Medicare populations are areas in which population health management programs can help improve health, says Stone.

Keeping middle-aged and seniors healthy will save the country long-term health-related costs and will lead to a healthier Medicare population. This will be especially important as baby boomers move into Medicare.

"It doesn't take a lot of risk reduction to equal real dollars," he says.

Changes to CBO scoring

Another positive for population health is a provision that asks the Congressional Budget Office (CBO) to work with Congress to develop "better methodology to score wellness programs," says Moorhead.

Industry cynics question whether wellness and disease management programs actually save money. CMS highlighted these concerns last year when it alleged a Medicare project that tested disease management programs didn't meet necessary savings requirements. Though population health management leaders point to CMS' project design and patient selection as flaws that doomed the project, the aftershocks from that project remain in the minds of some industry insiders.

The CBO provision could prove important for population health management companies because savings associated with their programs may take years.

Currently, CBO can't look beyond a five- or 10-year window when estimating the cost of legislation, she says. This change within health reform could allow CBO the flexibility to gauge cost savings for longer range programs, such as obesity initiatives.

Though wellness advocates are pleased overall with health reform, Sidorov says there were also missed opportunities. One example is refunding $250 to Medicare Part D beneficiaries. Instead of refunding the money, Sidorov says Congress could have given $300 vouchers to exercise programs with an option of $200 cash for those who didn't want to take part. Those kinds of options are flexible enough to allow people to take advantage of community-level wellness programs.

"That is an example of flexibility that DC and the mainframe thinking is unable to accomplish," says Sidorov.