This article, “Reframing Prevention in the Era of Health Reform,” was co-authored by Dr. Howard Koh, Dr. , and me in the September 13 2016 issue of the Journal of the American Medical Association:
The 2010 passage of the Affordable Care Act (ACA) raised numerous opportunities for disease prevention. Of the 10 legislative titles comprising the ACA legal framework, Title 4 (“Prevention of Chronic Disease and Improving Public Health”) initially held the most promise for delivering new financial resources as well as effective policy for prevention.1 Six years later, Title 4 outcomes show mixed results. In the meantime, however, other ACA innovations are redesigning health systems by incorporating prevention into a range of new care models. Doing so connects the clinic and the community in ways not necessarily envisioned in the statute, thereby broadening possibilities for the future of population health.
To date, Title 4 has had a number of implementation challenges. For example, the Prevention and Public Health Fund offered new dedicated prevention monies that advanced key initiatives such as immunizations, tobacco media counteradvertising, and smoking quit lines sponsored by the Centers for Disease Control and Prevention (CDC). However, the fund has also been subject to regular debates about allocation priorities, whether it should be used to supplant or supplement existing programs, and even repeal efforts. Designed to increase to $2 billion annually, the Prevention and Public Health Fund is now capped at about half that amount. Furthermore, even though fund-supported CDC Community Transformation Grants (promoting community partnerships to prevent disease and reduce health disparities) reached $226 million (in fiscal year 2012), discontinuation of the grants 2 years earlier than anticipated (in fiscal year 2013) precluded formal evaluation. In other examples, the National Prevention Strategy, created at the direction of Title 4 and based on principles of Healthy People 2020, has not led to sustained implementation. Efforts to finalize menu-labeling requirements for certain chain restaurants have faced repeated delays, with potential release now slated for 2017.
However, one ACA prevention initiative has realized meaningful progress: removing out-of-pocket costs as a barrier for individuals to access high-value, evidence-based clinical preventive services. The ACA improved access to such services (eg, those graded A or B by the US Preventive Services Task Force [USPSTF]) for 76 million more people. It now reaches an estimated 137 million US adults and children covered by private plans (that were new as of fall 2010).2 Examples of services recommended by the USPSTF that are covered without cost sharing include tobacco use counseling, cervical cancer screening, colorectal cancer screening, and dental caries prevention for children. Furthermore, Medicare also covers high-value clinical preventive services, with an estimated 39 million beneficiaries as of 2014 receiving at least 1 preventive service without out-of-pocket cost.3 Regarding Medicaid, as of 2013, states can receive a 1-percentage-point increase in their federal Medicaid match rate for preventive services if they cover without cost sharing all the high-value adult preventive services. As of 2014, at least 40 states offer some high-value clinical preventive services without cost sharing, although fewer than 10 states offer all of them.
More time and effort are needed to broaden awareness and availability of these services and determine if increased access leads to improved health outcomes. A 2014 Kaiser Family Foundation survey4 estimated that only 43% of US adults were aware of the new clinical preventive benefits for individuals; approximately 20% still cited cost concerns as a reason to forgo or postpone them.5 Although federal guidance has clarified the exact nature of the services covered in some areas (eg, removal of and pathology reading for polyps found through colonoscopy), further efforts should address other areas for which decisions are often left to “reasonable medical management” (eg, periodicity of screening and number of covered counseling sessions).
Nevertheless, early evaluation suggests improved uptake of some preventive services.6 The ACA Dependent Coverage Expansion (allowing young adults to remain part of their parents’ insurance plans up to age 26 years) is associated with an increased proportion of early-stage diagnosis of cervical cancer7 and higher rates of human papillomavirus vaccination for young adult women. While more data on outcomes are needed, further studies link the ACA with increased receipt of blood pressure measurement, cholesterol testing, and influenza vaccination among privately insured adults aged 18 to 64 years6 as well as increased colonoscopy rates among men enrolled in Medicare.8
Meanwhile, as these efforts have proceeded, innovative health system redesign efforts have also integrated prevention into new health care payment and delivery models. Leveraging authority in ACA Title 3 (“Improving the Quality and Efficiency of Health Care”), the Centers for Medicare & Medicaid Services (CMS) are testing nontraditional strategies that improve care between patient visits, increase collaboration with community organizations to enhance nonmedical services, and address the social determinants of health to advance community-based prevention.
Such models explore opportunities linking the clinic and the community to move toward value-based health systems. In this way, population health has become a priority for
accountable care organizations, a set of population-based programs that offer shared savings opportunities to providers (such as physicians and hospitals) to improve health care quality, reduce total cost, and link payment to performance on 8 preventive quality indicators; early evaluation suggests modest but significant improvements in some clinical preventive measures, such as those used by beneficiaries with diabetes in both the Pioneer accountable care organization model and the Medicare Shared Savings Program;
accountable health communities, which test (for high-risk beneficiaries at 44 sites) intensive community service navigation regarding social determinants of health, such as interpersonal violence, transportation limitations, food insecurity, and housing instability; and
state innovation models, involving 38 states that have received nearly $1 billion, which focus on population health and integrate public health, community-based, and behavioral health services across the entire care continuum. Oregon, for example, has established 16 locally governed organizations accountable for access, quality, and health spending in Medicaid; as one measure of progress, Oregon now reports statewide improvement in screening, brief intervention, and treatment referral for alcohol and substance use.9
For all these models, long-term evaluation must assess not just the uptake of preventive services but also the effect on health outcomes. Appropriate evaluation of these programs is critical. Those that show no benefit should be discontinued or changed and those that show benefit should receive strong consideration for further implementation.
Documenting positive results could translate into new national prevention investments. For example, the Department of Health and Human Services recently designated the Y-USA Diabetes Prevention Program as the first preventive health model to meet the statutory criteria for national expansion. Between February 2013 and March 2015, this CMS-funded, YMCA-delivered national program provided evidence-based counseling interventions to nearly 6000 Medicare beneficiaries with prediabetes.10 Specifically, lifestyle coaches train participants to promote long-term dietary change, physical activity, and behavioral change, resulting in weight loss and associated risk reduction in developing type 2 diabetes. The independent CMS Actuary has now certified that expansion of the Y-USA Diabetes Prevention Program would not increase spending; instead, statistically significant gross savings in the intervention group (compared with a matched control population) through each of the first 5 quarters of the program totaled an estimated $2650 per Medicare beneficiary.10 The CMS now moves into a rule-making process regarding proposed expansion for older adults.
New prevention and population health resources may also arise from the ACA requirement that the estimated 2900 US nonprofit acute care hospitals provide community benefits (after completing community health assessments) as part of maintaining federal tax-exempt status. As one example, the Catholic Health Association, the nation’s largest group of nonprofit health care practitioners, has committed to addressing childhood obesity through nutrition and physical activities in its surrounding communities. Again, evaluation of these programs is critical.
Reframing prevention through health system redesign offers a new approach. Doing so widens the national lens from sick care to a broader view of population health. The goals are ambitious. Full implementation and evaluation will determine if such innovation can yield long-awaited systems of prevention that help people reach their full potential for health.