The Patient Protection and Affordable Care Act and the corresponding changes made by the Reconciliation Act (together, the “Act”), includes several elements of prevention and wellness initiatives. The following is a summary of some of those provisions.
- The Act establishes a national Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge. (Effective January 1, 2012 through December 31, 2016.) If the pilot program achieves the stated goals of improving or not reducing quality and reducing spending, a plan for expanding the pilot program will be developed.
- The Act includes a program to fund community health teams to support the development of medical homes by increasing access to comprehensive, community-based, coordinated care. It creates the “Independence at Home” demonstration program to provide high-need Medicare beneficiaries with primary care services in their home and allow participating teams of health professionals to share in any savings if they reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of healthcare services, and achieve patient satisfaction. (Effective January 1, 2012.)
- The Act also establishes a hospital value-based purchasing program in Medicare to pay hospitals based on performance on quality measures and extend the Medicare physician quality reporting initiative beyond 2010. (Effective October 1, 2012.) It also calls for the development of plans to implement value-based purchasing programs for skilled nursing facilities, home health agencies, and ambulatory surgical centers. (Reports to Congress due January 1, 2011.)
- The Act supports comparative effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute to identify research priorities and conduct research that compares the clinical effectiveness of medical treatments. The Institute will be overseen by an appointed multi-stakeholder Board of Governors and will be assisted by expert advisory panels. The findings from comparative effectiveness research may not be construed as mandates, guidelines, or recommendations for payment, coverage, or treatment or used to deny coverage. (Funding available beginning fiscal year 2010.
- The Act directs the federal Health and Human Services (HHS) Secretary to plan and implement a national public-private partnership for a prevention and health promotion outreach and education campaign. The campaign will be focused on raising public awareness of health improvements across the life span. The measure includes “Community Transformation” grants to state and local governmental agencies and community-based organizations. The grants would be used for the implementation, evaluation, and dissemination of proven evidence-based community preventive health activities to reduce chronic disease rates, address health disparities, and develop a stronger evidence base of effective prevention.(Funds appropriated for five years beginning fiscal year 2010.)
- The Act provides Medicare beneficiaries access to a comprehensive health risk assessment and creation of a personalized prevention plan. (Health risk assessment model developed within 18 months following enactment.) It provides incentives to Medicare and Medicaid beneficiaries to complete behavior modification programs (effective January 1, 2011 or when program criteria is developed, whichever is first), and it requires Medicaid coverage for tobacco cessation services for pregnant women. (Effective October 1, 2010.)
- The Act includes the “Healthy Aging, Living Well” program by authorizing the Centers for Disease Control (CDC) to award grants to states or local health departments to conduct pilot programs in the 55 to 64-year-old population in order to improve the health status of the pre-Medicare-eligible population to help control chronic disease and reduce Medicare costs.
- The Act provides grants to states to improve the provision of recommended immunizations for all ages. It allows HHS to negotiate and enter into contracts with manufacturers of vaccines for the purchase and delivery of vaccines for adults. The Act further allows states to purchase additional adult vaccines directly from manufacturers at HHS negotiated prices.
- The Act provides grants to certain smaller businesses that establish workplace wellness programs. The program must include: 1) health awareness initiatives; 2) efforts to maximize employee engagement and participation; 3) initiatives to change unhealthy behaviors and lifestyle choices; and 4) supportive environment efforts such as policies to encourage healthy lifestyles. (Funds appropriated for five years beginning fiscal year 2011.)
In conclusion, the Act includes many provisions for coverage of health prevention and wellness measures in an effort to yield savings through improved population health and lower costs for treatment of major illnesses.
Joseph "Rusty" Ross is a partner in the firm’s Healthcare and Real Estate Development and Finance Practices. Mr. Ross is the former senior vice president and general counsel of Memorial Health University Medical Center, Inc. Mr. Ross received his bachelor's degree from Vanderbilt University and his M.B.A. and law degree from the University of Georgia.