Putting Prevention in Place

By Robin Schepper

The Affordable Care Act (ACA) was created to improve the delivery and access of healthcare. Now that over 7.1 million Americans have enrolled under the ACA, what's next?

We need to be looking at ways to promote an optimized healthcare system instead of our current "sickcare" system. One of the less highlighted, but most significant parts of the ACA legislation is the focus on prevention.

To better understand prevention or 'prevention intervention' under the ACA, we must first understand what makes us 'well'. Today, 88% of US healthcare dollars are spent on medical services, yet there are many other factors that constitute for our health. Our behavioral choices like eating, exercise, sleep and stress management alone determines 50% of our health status. Additional factors including genetics, socioeconomics, availability of care and access to healthy choices also play a significant role in our health. What if we focused more on these factors that would make (or keep) us healthy?

Consider this: we spend more time outside of the physician's office than inside. We must think about the settings that affect our health attitudes and behaviors on a daily basis — our homes, schools, workplaces, and community. With community-based prevention interventions, we can address these social and environmental factors in shaping our optimal health status. The ACA accelerates a shift towards prevention and wellness in both the clinic and the community in several ways.

Cost Sharing
Under the ACA there is a mandated requirement for cost-sharing free coverage of certain preventive and wellness services by private insurers (including exchanges) and Medicaid. Preventive and wellness services, including chronic disease management, are 1 of 10 categories of care required for the Essential Health Benefit (EHB).

More Prevention Providers
Another key development was the expanded definition of who can provide preventive services. In July 2013, Center of Medicaid Services (CMS) issued a rule stating that preventive services could be "recommended by" physicians or other licensed providers instead of delivering those services directly. This opens up the door to a broader array of sources for preventive services, such as medical assistants, dietitians or community health workers. Each state must update their plan's amendment with a summary of who they propose to be included as 'prevention provider', along with a summary of their qualifications.

Testing New Models
Another initiative includes several states applying for waivers to test new models of care in Medicaid. Oregon, for example, is testing Coordinated Care Networks . They are taking a holistic approach to health by thinking about upstream factors, such as the environment. To test this new model of care, Governor Kitzhaber supplied an air conditioner to an elderly woman who repeatedly suffered asthma exacerbations during the summer months, helping her reduce her visit to the ER for her chronic condition.

Penalizing Re-admissions
The ACA also incentivizes hospitals to lower re-admissions for certain conditions including heart failure, pneumonia, and Acute Myocardial Infarcation. If re-admissions occur within 30 days of discharge hospitals will be penalized.

Working with Wellness
An additional focus is the increase of allowable spending percentages to incentivize participation in workplace wellness programs - an increase from ~ 30% to 50% for certain programs. The ACA also includes grants to small businesses for comprehensive wellness programs. Many small businesses can't afford to set up wellness programs on their own. Under ACA, $200 million is available for small businesses to create comprehensive wellness programs for employees.

The money is flowing to these enhancements to healthcare. The Prevention and Public Health Fund is a significant financial commitment and signal of importance of prevention. The nation's first mandatory fund dedicated to prevention is scheduled to invest over $10 billion in prevention from 2010 to 2022. The fund is designed to test interventions to improve health especially health eating, active living and tobacco cessation.

Prevention is a step in the right direction. Essentially, if we want to achieve optimal health, we need to focus on what makes us healthy and not just on what to do once we are sick. Thankfully the ACA starts that process and new technologies will help make it a reality.