Payment Reform Key to Incentivizing Prevention

“We must turn off the faucet instead of just mopping the floor.”

American College of Cardiology (ACC) President Kim Allan Williams, Sr, MD, opened the ACC’s 65th Annual Scientific Session & Expo in Chicago this week with those profound words, which reflect the realization that the development of new therapies, including devices, catheters, and drugs cannot keep pace with a country that does not value and support prevention. First Lady Michelle Obama and David B Nash, MD, MBA, also spoke during the opening ceremonies, reiterating the need for intensive health lifestyle modifications.

This is not new. We have known for decades that lifestyle was a factor leading to the overall decline in the nation’s health. Much of the HMO movement, which started in earnest in the 1970s, focused on prevention and the need to create well-designed intervention programs, leading to an entire disease management industry. Overall, these programs have, at best, slowed the rates of prediabetes and diabetes but have not stopped these diseases from becoming a national crisis.

What was needed was payment reform.

This is now slowly happening. Higher co-pays, deductibles, and co-insurance offerings in the insurance marketplace are being forced on the consumer to incentivize prevention.

In a related development, just last week, CMS stated that it will issue payment for diabetes prevention in their 2017 Medicare Physician Fee Schedule, to be released in mid-2016 for fiscal year 2017.

But how will physicians respond? They are up to their eyebrows in government mandates, ranging from e-prescribing, electronic medical records, ICD-10, and more.

Physicians have little time to spend on prevention without widely expanding their team and allowing—as well as promoting—the use of technologies. They also need to seriously consider partnering with companies focused on providing these services in order to coordinate the needed behavioral training and behavioral management with their medical care. This will be a difficult transition that involves more integration into the electronic health record as well as physician workflow.

But there are numerous companies, both new and old, that are more than willing to step up to assist in this national effort.

In the coming weeks, I will highlight a number of companies and their visions for changing the health of our nation in a way unforeseen even a decade ago.

Sir Winston Churchill has been attributed with saying, “You can depend upon the Americans to do the right thing. But only after they have exhausted every other possibility.”

When it comes to health lifestyle modifications, perhaps we have at last reached that point!

Thomas Morrow, MD, is the chief medical officer of Next IT. He is a member of the First Report Managed Care editorial advisory board and a past president of the National Association of Managed Care Physicians.