Report to Congress

RTC_CommunityBasedWellnessPrograms.pdf

Prospective Evaluation of Evidence-Based Community Wellness and Prevention Programs (CMS-10509)

Report to Congress

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Report to Congress: The Centers
for Medicare & Medicaid Services’
Evaluation of Community-based
Wellness and Prevention
Programs under Section 4202 (b)
of the Affordable Care Act

Table of Contents
Executive Summary ................................................................................................................................ 4
Introduction ........................................................................................................................................ 4
Evidence Review of Community-Based Wellness and Prevention Programs .................................... 5
Environmental Scan of Community-Based Wellness and Prevention Programs ............................... 6
Retrospective Study of Program Effects ............................................................................................. 7
Global Conclusions, Future Directions, and Policy Recommendations ............................................ 10
Introduction .......................................................................................................................................... 12
Section 1: Evidence Review of Existing Community-Based Wellness and Prevention Programs ....... 16
Introduction ...................................................................................................................................... 16
Evidence Review Methods ............................................................................................................... 17
Evidence Review Results .................................................................................................................. 19
Physical Activity Promotion Programs ......................................................................................... 19
Obesity Reduction Programs ........................................................................................................ 22
Diet and Nutrition Programs ........................................................................................................ 23
Falls Prevention Programs ............................................................................................................ 24
Chronic Disease Self-Management Programs .............................................................................. 25
Mental Health Programs .............................................................................................................. 27
Discussion ......................................................................................................................................... 28
Section 2: Environmental Scan of Existing Community-Based Wellness and Prevention Programs .. 30
Analytic Approach ............................................................................................................................ 30
2

Key findings ...................................................................................................................................... 31
Discussion ......................................................................................................................................... 36
Section 3: Retrospective Study of Select Community-Based Wellness and Prevention Interventions
.................................................................................................................................................................... 38
Overview of Wellness and Prevention Programs ............................................................................. 40
Analytic Approach ............................................................................................................................ 44
Results .............................................................................................................................................. 46
Chronic Disease Self-Management Programs .............................................................................. 48
Physical Activity Programs............................................................................................................ 53
Falls Prevention ............................................................................................................................ 62
Additional Subgroup Analyses ...................................................................................................... 65
Discussion ......................................................................................................................................... 66
Section 4: Global Conclusions, Future Directions, and Policy Recommendations .............................. 69
Summary of Results .......................................................................................................................... 69
Gaps in the Evidence ........................................................................................................................ 70
Research Agenda .............................................................................................................................. 72
Prospective Study of Program Effects .......................................................................................... 72
CMS Center for Medicare and Medicaid Innovation Initiatives ................................................... 74
Conclusion: Ongoing Efforts to Promote Wellness and Prevention................................................. 75
Works Cited .......................................................................................................................................... 77

Executive Summary
Introduction
The Affordable Care Act (the Act), passed in March 2010, contains several provisions relating to
prevention under Medicare, Medicaid, and private health insurance coverage. In Section 4202,
subsection (b), entitled “Evaluation and Plan for Community-based Prevention and Wellness Programs
for Medicare Beneficiaries”, Congress directed the Secretary of Health and Human Services to conduct
an evaluation of community-based prevention and wellness programs and to develop a plan for
promoting healthy lifestyles and chronic disease self-management for Medicare beneficiaries. The Act
specifically required that the Secretary examine programs focused on increasing physical activity,
reducing obesity, improving diet and nutrition, reducing falls, promoting chronic disease management,
and better managing mental health issues.

For the purposes of this evaluation work, The Centers for Medicare & Medicaid Services (CMS)
defined community-based prevention and wellness programs as being programs or interventions that
are primarily delivered in a community setting, that are either applicable or potentially applicable to the
Medicare population, and that are focused on one or more of the six prevention focus areas articulated
Section 4202 subsection (b) of the Act. Because of the potentially large number of community-based
wellness and prevention programs that might be relevant to this evaluation, CMS adopted a multi-phase
approach to evaluating the impacts of these programs on Medicare beneficiaries. The first phase of
CMS’s research efforts consisted of an environmental scan, evidence review, and pilot evaluation of the
Chronic Disease Self-Management Program (CDSMP), a nationally disseminated chronic disease
management intervention developed and administered by Stanford University with support from the
Administration for Community Living. The purpose of the pilot evaluation of the CDSMP was to test
methodologies for linking program participants to Medicare administrative records and assessing claims-

based outcomes. The second phase of CMS’s research built upon the work conducted in the first phase
and consisted of a retrospective analysis of a select group of wellness and prevention programs. The
third phase of CMS’s research, which is ongoing, consists of a prospective study of program effects that
seeks to round out CMS’s understanding of how community based wellness and prevention programs
affect Medicare beneficiaries.

This report presents the results of the first two phases of CMS’s research, describes CMS’s plans for
phase 3 of our ongoing evaluation, and briefly discusses ongoing work to promote wellness and
prevention among Medicare beneficiaries.

Evidence Review of Community-Based Wellness and Prevention Programs
The first key step in CMS’s evaluation of the potential impacts of community-based wellness and
prevention programs on Medicare beneficiaries was to conduct a review of the literature surrounding
the effects of existing intervention programs. The goal of this evidence review was to both gain an
understanding of the global landscape of community-based wellness and prevention interventions and
to identify which interventions had the strongest evidence base.

The body of evidence-based, community-delivered interventions that were reviewed was diverse in
both focus and approach. The interventions focused on a wide range of conditions, from diabetes to
arthritis, and adopted a variety of approaches, from self-paced, Internet-based delivery to highly
structured group programs. The results of the evidence review also showed varying levels of evidence
for these programs. Some programs had extensive support in the form of randomized controlled trials
(RCTs), while others had little to no published evidence related to their efficacy.

While the efficacy of the best-supported programs is generally accepted, much less is known about
their effectiveness in reducing healthcare utilization and costs. Only a handful of interventions included

in the evidence review had research that specifically addressed program effects on health care
utilization and costs. In the few studies where utilization outcomes were addressed, studies rarely had
sufficient power to identify statistically significant effects. This lack of information on how communitybased wellness and prevention programs affect healthcare utilization and costs may prove to be a
significant barrier to more widespread dissemination and implementation of these interventions.

Environmental Scan of Community-Based Wellness and Prevention
Programs
In addition to the review of the existing literature surrounding community-based wellness and
prevention programs, CMS also conducted an environmental scan of existing programs. The purpose of
this exercise was to gain greater insight into how wellness and prevention programs are being
implemented across the country, how wellness and prevention interventions are translated from
research studies into operating programs, and how best to interface with programs on future evaluation
efforts.

CMS’s environmental scan revealed that there was significant diversity in both the range of
community-based interventions that were being offered and in how community-based organizations
were operationalizing interventions and implementing programs. Often, interventions were not offered
to the community in isolation from one another, but rather in conjunction with a broader portfolio of
services offered by community-based organizations.

generating an evidence base for program effects and translating interventions from research to practice,
grant funding alone is likely not a viable solution for sustaining programs in the long term. More
consistent funding streams that can capture some of the benefits that these programs generate to the
healthcare system as a whole would be helpful in promoting greater and more sustainable
dissemination. Community-based programs are particularly interested in establishing partnerships with
various payers in the healthcare system to directly finance operations. Creating these relationships,
however, has been far from straightforward as many interventions have not been specifically evaluated
under a cost-benefit analysis framework, which is important from a payer’s point of view.

Retrospective Study of Program Effects
In the course of its environmental scan of community-based programs, CMS identified 12 nationally
disseminated intervention programs that have maintained registries of participants with sufficiently
detailed personal identifiers to facilitate potential matching to CMS’s administrative databases. These
programs include:


The Chronic Disease Self-Management Program (CDSMP), a chronic disease management
intervention for patients with multiple chronic conditions developed and administered by
Stanford University



The Diabetes Self-Management Program (DSMP), a version of the CDSMP tailored to diabetes
patients developed and administered by Stanford University



The Arthritis Foundation Arthritis Self-Management Program (ASMP), a chronic disease selfmanagement program similar to the CDSMP developed by Stanford University for arthritis
patients and formerly administered by the Arthritis Foundation



EnhanceWellness (EW), a chronic disease management intervention developed by the University
of Washington and administered by Project Enhance (a partnership between Senior Services of
7

Seattle, the University of Washington, and Group Health, dedicated to disseminating evidencebased health promotion programs for older adults)


EnhanceFitness (EF), a fitness program for older adults developed by the University of
Washington and administered by Project Enhance



The Arthritis Foundation Exercise Program (AFEP), a physical activity program for adults with
arthritis developed and administered by the Arthritis Foundation



The Arthritis Foundation Aquatics Program (AFAP), an aquatic physical activity program for
adults with arthritis developed and administered by the Arthritis Foundation



The Arthritis Foundation Tai Chi Program (AFTCP), a physical activity and balance program
developed by Dr. Paul Lam and administered by the Arthritis Foundation



Fit & Strong (FAS), a physical activity program for patients with osteoarthritis developed and
administered by the University of Illinois at Chicago



Matter of Balance (MOB), an intervention designed to reduce fear of falling and promote
physical activity for older adults developed by Boston University and administered by the
Partnership for Healthy Aging (A public-private partnership dedicated to linking clinicians,
evidenced-based programs, and community services)



Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors), an awareness and
depression management program for older adults developed by the Baylor College of Medicine
and administered by Care for Elders (a public-private partnership dedicated to increasing access
to services, improving the quality of care, and enhancing the quality of life for older adults and
their families)



Program to Encourage Active, Rewarding Lives for Seniors (PEARLS), a depression treatment
intervention for older adults developed by the University of Washington and administered by
the PEARLS Program at the University of Washington
8

In order to get a preliminary assessment of potential program impacts, CMS decided to conduct a
retrospective study of program effects. The basic premise of this evaluation was to identify Medicare
beneficiaries who participated in a wellness and prevention program between 2 and 3 years ago, link
their identifying information to Medicare administrative data, and compare changes in subsequent
health outcomes and levels of health-care utilization and cost with those of a similar, administratively
defined comparison group of beneficiaries who had not participated in a wellness and prevention
program. The analyses followed an intention-to-treat (ITT) framework, in which outcomes were
evaluated based on beneficiary intentions to participate in a program, not the actual level of beneficiary
participation. In other words, beneficiaries were classified as being in the treatment group if they signed
up for a program, regardless of whether they actually attended a program session. Participant
identifiers from the wellness programs were obtained from the program managers and linked (when
possible) to Medicare claims data. CMS was ultimately able to match a sufficient number of program
participants to administrative data to evaluate the CDSMP, EW, EF, AFEP, AFAP, AFTCP, and MOB
programs.

The main outcomes evaluated during the year after program enrollment were total medical costs,
costs by Medicare setting (e.g., inpatient, emergency department, outpatient), and health services
utilization by Medicare setting. Additionally, medication adherence, physical and occupational therapy
use, and incidence of falls and fall-related fractures were also evaluated, as appropriate, considering the
goals of each wellness program.

CMS compared changes in pre-participation and post-participation outcomes between participants
and matched controls to quantify potential program effects. This difference in pre-post differences in
outcomes is known as the differences-in-differences estimator (DiD) and can be interpreted as the
marginal association between program participation and the observed outcome.

CMS’s analysis found some initial evidence for total cost savings in EF, AFEP, AFTCP, and MOB.
These programs were associated with lower unplanned inpatient costs and fewer unplanned
hospitalizations. Participation in CDSMP and AFAP, while not associated with savings in overall medical
costs, was associated with reductions in unplanned inpatient costs, suggesting that these programs have
the potential to generate future cost savings.

Global Conclusions, Future Directions, and Policy Recommendations
Both the published literature examined in CMS’s evidence review and CMS’s initial evaluations of
potential program effects indicate that some community-based wellness and prevention programs may
have the potential to improve beneficiary health outcomes and reduce healthcare costs.

CMS’s review of the literature found several established wellness and prevention programs with a
firm evidence base. These programs typically demonstrated improvements in health behaviors and
proximate health outcomes. Results for chronic disease self-management and physical activity
programs were especially promising.

CMS’s initial evaluation of program impacts examined claims-based measures of utilization and
costs for a select group of wellness and prevention programs where there was sufficient participant
level information to match to CMS administrative data. These analyses found some promising evidence
suggesting that four nationally disseminated programs (EF, AFEP, AFTCP, and MOB) may have driven
down total healthcare costs for participating beneficiaries. The CDSMP and several physical activity
programs also demonstrated reductions in unplanned hospital utilization and costs, which may suggest a
potential for future long-term savings.

Taken together, these results are promising in that they demonstrate that evidence-based
community wellness and prevention programs can improve outcomes and in some cases reduce costs

for Medicare beneficiaries. However, there are some gaps in the established evidence that make more
widespread implementation of programs challenging.

First, while CMS’s retrospective analysis of program effects found some evidence of cost savings for
select programs, the overall evidence of program effects on cost and utilization outcomes is still
somewhat limited. To date, there have only been a handful of studies that have directly addressed cost
and utilization outcomes. More evidence of cost savings would be helpful in promoting more direct
financing of these prevention activities in the healthcare system.

Finally, it is unclear how to best implement a sustainable payment model to finance the delivery of
these services in the long term. Traditional fee for service payment structures are likely ill-suited to
financing community based interventions, as many programs occur outside of the formal clinical
settings that CMS’s administrative systems are set up to oversee and regulate.

Moving forward, the Department of Health and Human Services (HHS), through CMS and other
agencies, will continue to help build the evidence base to determine the effectiveness of wellness and
prevention programs in reducing healthcare utilization and costs, through both the ongoing research
activities highlighted in this report and future research and evaluation work. Specifically, HHS
anticipates conducting studies geared towards establishing a firm business case for direct financing of
the most effective programs, including formal cost-benefit and cost effectiveness analyses, studies

designed to estimate beneficiary demand for community-based preventive services, and eventually
studies and initiatives designed to both develop new wellness and prevention interventions tailored to
the Medicare population and to test viable payment models for these services.

In conclusion, HHS recommends maintaining existing support for community-based wellness and
prevention activities, consistent with the emphasis on bolstering effective prevention in the President’s
FY2014 budget, while HHS, CMS, and other public and private partners work to fill these gaps in the
evidence through additional studies and pilot programs. Community-based wellness and prevention
programs currently depend on limited grant dollars from various Federal funding streams, and thus their
reach is limited. Designing and implementing direct payment mechanisms for these programs and
incentives for other healthcare stakeholders, including managed care plans and health systems
participating in shared savings programs, to partner with and finance programs could substantially
increase the number of Americans that can benefit. Research to date indicates that these programs
have the potential to improve health outcomes for Medicare beneficiaries and reduce costs. More
research, development, and implementation work however is needed before these benefits can be fully
leveraged in the healthcare system.

Introduction
The Affordable Care Act (the Act), passed in March 2010, contains several provisions relating to
prevention under Medicare, Medicaid, and private health insurance coverage. In Section 4202,
subsection (b), entitled “Evaluation and Plan for Community-based Prevention and Wellness Programs
for Medicare Beneficiaries”, Congress directed the Secretary of Health and Human Services to conduct
an evaluation of community-based prevention and wellness programs and to develop a plan for
promoting healthy lifestyles and chronic disease self-management for Medicare beneficiaries. The Act
specifically required that the Secretary examine programs focused on increasing physical activity,
12

reducing obesity, improving diet and nutrition, reducing falls, promoting chronic disease management,
and better managing mental health issues. The Act required CMS to conduct an evaluation that would
include both an evidence review and an independent evaluation of existing evidence-based community
prevention and wellness programs, in consultation with the Assistant Secretary for Aging. These
evaluation efforts would then form the basis for recommendations to Congress for policy and regulatory
reforms to promote healthy lifestyles and improved chronic disease self-management behaviors for
Medicare beneficiaries. This report summarizes the Centers for Medicare & Medicaid Services’ (CMS)
evaluation work to date.

Under the first phase, CMS conducted an environmental scan of all of the potential programs to be
evaluated under this provision, an extensive and exhaustive review of the literature surrounding
community-based wellness and prevention programs, including evidence of their effectiveness and
factors surrounding their implementation, and a pilot evaluation of the Chronic Disease SelfManagement Program (a nationally disseminated chronic disease management intervention developed
and administered by Stanford University with support from the Administration for Community Living) to
test methodologies for linking program participants to Medicare administrative records and assessing
claims-based outcomes1. CMS is using the information generated in this phase to both help define the

requirements for future evaluation work and to prepare the evidence review portion of this report to
Congress.

In the second phase of the evaluation, CMS built upon the work in the phase one pilot evaluation to
conduct a retrospective evaluation of existing community-based wellness and prevention programs.
The basic premise of this evaluation was to identify Medicare beneficiaries who participated in a
wellness and prevention program between 2 and 3 years ago, link their identifying information to
Medicare administrative data, and compare changes in subsequent health outcomes and levels of
health-care utilization and cost with those of a similar, administratively defined comparison group of
beneficiaries who had not participated in a wellness and prevention program. This retrospective
evaluation effort primarily focused on evaluating the following nationally disseminated programs:


The Chronic Disease Self-Management Program (CDSMP), a chronic disease management
intervention for patients with multiple chronic conditions developed and administered by
Stanford University



The Diabetes Self-Management Program (DSMP), a version of the CDSMP tailored to diabetes
patients developed and administered by Stanford University



EnhanceWellness (EW), a chronic disease management intervention developed by the University
of Washington and administered by Project Enhance (a partnership between Senior Services of
Seattle, the University of Washington, and Group Health, dedicated to disseminating evidencebased health promotion programs for older adults)



EnhanceFitness (EF), a fitness program for older adults developed by the University of
Washington and administered by Project Enhance



The Arthritis Foundation Exercise Program (AFEP), a physical activity program for adults with
arthritis developed and administered by the Arthritis Foundation



The Arthritis Foundation Aquatics Program (AFAP), an aquatic physical activity program for
adults with arthritis developed and administered by the Arthritis Foundation



The Arthritis Foundation Tai Chi Program (AFTCP), a physical activity and balance program
developed by Dr. Paul Lam and administered by the Arthritis Foundation



Fit & Strong (FAS), a physical activity program for patients with osteoarthritis developed and
administered by the University of Illinois at Chicago



Matter of Balance (MOB), an intervention designed to reduce fear of falling and promote
physical activity for older adults developed by Boston University and administered by the
Partnership for Healthy Aging (a public-private partnership dedicated to linking clinicians,
evidenced-based programs, and community services)



Phase 3 of CMS’s evaluation, which is ongoing, aims to round out CMS’s understanding of how
community-based wellness and prevention programs impact Medicare beneficiaries and what cost
15

saving opportunities exist for the Medicare program. Specifically, this evaluation effort aims to 1)
describe the readiness of Medicare beneficiaries to engage with community-based wellness and
prevention programs, 2) better adjust for selection biases in the evaluation of individual programs and
interventions using beneficiary level survey data, 3) evaluate program impacts on health behaviors, selfreported health outcomes, and claims-based measures of utilization and costs, and 4) better describe
program operations and cost in relation to the expected benefits. The results of these analyses will be
used to inform both CMS’s and HHS’s wellness and prevention activities in the future.

The remainder of this report is divided into four sections. Section 1 will present an overview of
CMS’s initial review of the published evidence surrounding community-based wellness and prevention
programs. Section 2 will present an overview of CMS’s environmental scan of existing programs
including both a landscape of existing programs and key insights into their operations. Section 3 will
present an overview of CMS’s retrospective study of selected community-based wellness and
prevention programs including the study’s methodology and key results. Section 4 will discuss the
global results of CMS’s evaluation efforts, describe ongoing and future research, and present an initial
policy recommendation to continue current support of evidence-based programs.

Section 1: Evidence Review of Existing Community-Based
Wellness and Prevention Programs
Introduction
One of the key first steps in CMS’s evaluation of the potential impacts of community-based wellness
and prevention programs on Medicare beneficiaries was to conduct a review of the literature
surrounding the impacts of existing intervention programs. The goal of this evidence review was to both

gain an understanding of the global landscape of community-based wellness and prevention
interventions and to identify which interventions had the strongest evidence base.

In late 2010, CMS awarded a contract to the Altarum Institute to conduct this evidence review. The
work on the evidence review occurred primarily in the first half of 2011 and was performed in
conjunction with a broader environmental scan of community-based programs. The full results of this
evidence review can be found in Altarum’s final evidence review report, titled “Environmental Scan of
Community-Based Prevention and Wellness Programs in the United States: Evidence Review Report.” 2
The remainder of this section will provide a brief summary of Altarum’s methods and key findings from
the review.

Evidence Review Methods
The Altarum team implemented a comprehensive online search and review of peer-reviewed
research to identify and collect published and grey literature about evidence-based, communitydelivered wellness and prevention programs and evaluate that evidence base to determine the strength
and quality of the evidence. Sources for searches included traditional electronic resources like Medline,
the Cochrane Review Database, and Google Scholar. Additional sources included clinical trial registries,
the Agency for Healthcare Research and Quality (AHRQ) Innovations Exchange, and other Web sites
identified by key informants and searches conducted for the environmental scan. Altarum did not
exclude negative or neutral trials from the search or review, but no reports with only negative findings
were uncovered during the review process.

In the course of the review, 639 documents and resources were identified, covering 209 distinct
interventions. In order to be further considered in the evidence review, Altarum required that the
interventions be either currently or recently delivered in a community setting, either primarily focused
on or potentially applicable to the Medicare beneficiary population, and focused on at least one of the
17

six focus areas named in section 4202(b) of the Affordable Care Act (ACA), namely, increasing physical
activity, reducing obesity, improving diet and nutrition, reducing falls, chronic disease management, and
mental health. After applying these selection criteria, a total of 75 programs were eligible for further
analysis.

For the formal evidence review, publications were only included in a program’s evidence base if it
was published in a peer-reviewed journal and reported original empirical results on program effects.
Some of the 75 programs identified in Altarum’s initial canvassing of the literature and subject matter
experts did not appear to be supported by any studies meeting these criteria.

The Evidence Review Team, consisting of two Ph.D.-level reviewers, systematically worked through
the selected evidence base to evaluate each publication and independently assign an evidence rating,
using the U.S. Preventive Services Task Force’s strength of evidence scale. 3 This scale grades evidence
using the following criteria:


Level I: Evidence obtained from at least one properly designed randomized controlled trial
(RCT).



Level II-1: Evidence obtained from well-designed controlled trials without randomization.



Level II-2: Evidence obtained from well-designed cohort or case control analytic studies,
preferably from more than one center or research group.



Level II-3: Evidence obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled trials might also be regarded as this type of evidence.



Level III: Opinions of respected authorities, based on clinical experience, descriptive studies,
or reports of expert committees.

All publications received two separate and independent reviews. After the review process was
complete, disagreements between reviewers were settled by discussion and reexamination of the
evidence until consensus was achieved on a rating. The evidence review focused on studies that
addressed the efficacy and effectiveness of the interventions as defined by the research authors. The
majority of studies did not consider cost or address issues of implementation or translation.

Evidence Review Results
The Altarum team completed written assessments of the level and nature of evidence supporting
each of the 75 interventions that were the focus of the evidence review. In addition, the team
summarized the overall evidence level for each intervention in order to identify the subset of
interventions with the strongest evidence base.

The following discussion provides a high-level overview of the results of the evidence review.
Within each emphasis area highlighted in section 4202(b) of the Act, interventions have been ordered by
the number of publications included in the evidence review. While many interventions have extensive
support from RCTs and quasi-experimental research designs, a handful of interventions have little to no
evidentiary basis.

Physical Activity Promotion Programs
Many of the interventions (26 of 75) included in the evidence review focused on physical activity.
These interventions represent a wide variety of approaches, from in-home one-on-one instruction to
more traditional gym-based exercise classes. Table 1 provides a summary of the evidence surrounding
the physical activity promotion programs that were reviewed.

Table 1: Summary of Physical Activity Promotion Program Evidence

Intervention Name

Total
Studies
Reviewed
4

Level I

Level II-1

Level II-2

Level II-3

Level III

AF Exercise Program (AFEP)8,9

AF Tai Chi Program (AFTCP)

Strong for Life15,16,17

Fit and Strong! (FAS)18,19,20,21

Active Choices22,23,24,25

EnhanceFitness (EF)26,27,28,29

People Exercising Program30

Active for Life After Cancer31

Community Healthy Activities
Model Program for Seniors
(CHAMPS)32,33,34

Active Living Every Day
(ALED)35,36

Sisters in Motion37

Reach out to EnhanceWellness
in Older Cancer Survivors
(RENEW)38

AF Aquatic Program (AFAP)4,5,6,7

10,11,12,13,14

Intervention Name

Level I

Level II-1

Level II-2

Level II-3

Level III

AF Walk With Ease (WWE)39

Total
Studies
Reviewed
1

Better Bones & Balance40,41

Health EASE Move Today

Active Start42

SilverSneakers Fitness
Program43,44

Live Long, Live Well Walking
Program

Alive! (A Lifestyle Intervention
via E-mail)45

Get Fit for Active Living

Healthy Moves for Aging Well46

ExerStart47

Resources and Activities for LifeLong Independence (RALLI)48

Wisdom Steps

First Step to Active Health

The AF Aquatic Program, AF Exercise Program, AF Tai Chi Program, Strong for Life, Fit and Strong,
and Active Choices all had multiple Level I studies demonstrating their effectiveness. In addition to

these programs, the EnhanceFitness, People Exercising, Active Life after Cancer, Community Healthy
Activities Model Program for Seniors (CHAMPS), Active Living Every Day (ALED), Sisters in Motion, and
Reach out to EnhanceWellness in Cancer Survivors (RENEW) programs were also supported by at least 1
Level I study. Evaluations of these physical activity interventions primarily focused on measuring
improvements in physical activity, physical functioning, quality of life, strength, balance, agility, aerobic
fitness, and reductions in health care utilization and costs. A complete description of both these
physical activity programs and the specific study outcomes that were assessed can be found in Appendix
A of Altarum’s evidence review report.2

Obesity Reduction Programs
The evidence review only identified two interventions specifically focused on reducing obesity.
Table 2 provides a summary of the evidence surrounding two obesity reduction programs that were
reviewed.
Table 2: Summary of Obesity Prevention Program Evidence

Intervention Name

Coordinated Approach to Child
Health (CATCH) Healthy Habits

Group Lifestyle Balance
(GLB)49,50,51

Total
Studies
Reviewed
0

Level I

Level II-1

Level II-2

Level II-3

Level III

Neither of the obesity specific programs identified in the review was supported by a Level I study.
Group Lifestyle Balance (GLB) was supported by 1 Level II-2 and 2 Level II-3 studies, making it the
program with the largest evidence base in Altarum’s review. The evaluations GBL focused on assessing
weight loss, waist circumference and physical activity. While the Coordinated Approach to Child Health
(CATCH) program has been widely evaluated, no publications specifically focused on the older adult
component of the intervention were found to meet the inclusion criteria for this evidence review. More
22

detail on the obesity reduction programs and the outcomes that were assessed can be found in
Appendix A of Altarum’s evidence review report.2

Diet and Nutrition Programs
Twelve interventions were identified during the evidence review aimed at improving diet and
nutrition. These programs typically focused on providing seniors greater access to healthy foods and
promoting better dietary choices. Table 3 provides a summary of the evidence surrounding nutrition
programs that were reviewed.
Table 3: Summary of Diet and Nutrition Program Evidence

Intervention Name

Total Studies
Reviewed

Level I

Level II-1

Level II-2

Level II-3

Level III

Stanford Nutrition Action
Program (SNAP)52

Partners in Wellness (PIW)53

Healthy Eating Every Day
(HEED)54

Healthy Body/Healthy Spirit55

Group-Organized YMCA
Diabetes Prevention Program
(YDPP)56

Eat Smart Live Strong

Senior Farmers Market
Nutrition Program
(SFMNP)57,58,59

Steps to Healthy Aging: Eating
Better and Moving More
(EBMM)60

Healthy Eating for Life Program
(HELP)61,62

Elderly Nutrition
Program63,64,65,66

Intervention Name

Total Studies
Reviewed

Level I

Level II-1

Level II-2

Level II-3

Level III

Heart Smart for Women
(HSFW)

Healthy Eating for Successful
Living in Older Adults

The Stanford Nutrition Action Program (SNAP), Partners in Wellness (PIW), Healthy Eating Every Day
(HEED), and Health Body/Healthy Spirit were all supported by at least 1 Level I study. The YMCA’s
Diabetes Prevention program was supported by 1 Level II-1 study. Typical outcomes in these studies
included nutrient intake, adherence to dietary guidelines, physical activity, and weight loss. More
information on these diet and nutrition programs and the outcomes that were evaluated can be found
in Appendix A of Altarum’s evidence review report.2

Falls Prevention Programs
Eleven interventions had a primary focus on falls prevention. The interventions discussed in this
section include approaches as diverse as educational programs to address the fear of falling, home
environmental modifications to reduce fall hazards, and progressive exercise programs designed to
improve strength and balance. Table 4 provides a summary of the evidence surrounding the fall
prevention programs that were reviewed.
Table 4: Summary of Fall Prevention Program Evidence

Intervention Name

Total Studies
Reviewed

Level I

Level II-1

Level II-2

Level II-3

Level III

Otago Exercise Program
(OEP)67,68,69,70,71,72,73

Osteofit74,75

Stay Active and Independent
for Life (SAIL)76,77

Stepping On: Building
Confidence and Reducing
Falls78

Intervention Name

Total Studies
Reviewed

Level I

Level II-1

Level II-2

Level II-3

Level III

Farewell to Falls/Sit and Be Fit

Fall Proof!

Fit and Fall Proof

Healthy Steps for Older Adults

Tai Chi—Moving for Better
Balance79

No More Falls (NMF)80

MoB-Volunteer Lay Leader
(MOB) 81,82,83

The Otago Exercise Program (OEP) and Osteofit were both supported by multiple Level I studies,
indicating that these programs had the strongest evidence base among those reviewed by Altarum. The
OEP, Osteofit, Stay Active and Independent for Life (SAIL), and Stepping on: Building Confidence and
Reducing Falls programs were all supported by at least 1 Level I study. The Matter of Balance-Volunteer
Lay Leader program was also supported by 3 observational studies demonstrating that the lay leader
model was equally effective as the professional based program that was evaluated in the original trials
of the program. Studies evaluating these programs typically focused on assessing impacts on falls, fall
risk, balance, agility, mobility, and physical activity. Detailed information on these fall prevention
programs and the specific outcomes that were assessed in their evaluations can be found in Appendix A
of Altarum’s evidence review report.2

Chronic Disease Self-Management Programs
The chronic disease self-management focus area has numerous offerings relevant to Medicare
beneficiaries. Our evidence review identified 14 interventions with a primary focus on helping
individuals to manage chronic diseases. Interventions in this category offer education on chronic
disease management generally, as well as for specific conditions such as arthritis and diabetes, and
25

employ various modes of delivery, including self-paced workbooks, in-person classes, and Internetbased delivery. Table 5 provides a summary of the evidence surrounding the Chronic Disease Selfmanagement programs that were reviewed.
Table 5: Summary of Disease Self-management Program Evidence

Intervention Name

Total Studies
Reviewed

Level I

Level II-1

Level II-2

Level II-3

Level III

CDSMP84,85,86,87

Arthritis Toolkit88

Tomando Control de su Salud
(Spanish CDSMP)89,90

Healthier Living with Arthritis.91

Diabetes Self-Management
Program (DSMP) Stanford92

EnhanceWellness (formerly
Health Enhancement
Program)93,94,95

Arthritis Self-Management
Program (ASMP) 96,97

Better Choices, Better Health
(Internet-based CDSMP)98,99

Programa de Manejo Personal
de la Diabetes (Spanish
DSMP)100

Programa de Manejo Personal
de la Artritis (Spanish ASMP)101

On the Road to Living Well
With Diabetes102

Healthy Changes103

Healthy Bones

Live Well, Be Well (LWBW)

The Chronic Disease Self-Management Program (CDSMP) appeared to have the strongest evidence
base in Altarum’s review, with multiple Level I studies providing evidence of the program’s benefits. The
26

CDSMP, Arthritis Toolkit, Tomando de su Salud (Spanish Language CDSMP), Healthier Living with
Arthritis, Diabetes Self-Management (DSMP), EnhanceWellness, Arthritis Self-management Program
(ASMP), Better Choices Better Health (Internet-based CDSMP), Programa de Manejo Personal de la
Diabetes (Spanish DSMP), and Programa de Manejo Personal de la Artritis (Spanish ASMP) all were
supported by at least one Level I study. Evaluations of these programs typically focused on assessing
changes in self-reported health status, physical functioning, physical activity, specific health behaviors
(such as diet and condition-specific disease management), and pain. More details on these chronic
disease self-management programs and the outcomes that were assessed in their evaluations can be
found in Appendix A of Altarum’s evidence review report.2

Mental Health Programs
Altarum’s review identified 10 interventions that addressed mental health. Interventions in this
category include programs that focus on screening community-dwelling elders through existing case
management programs or by training employees of businesses that frequently encounter older adults in
their homes. Table 6 provides a summary of the evidence surrounding the mental health programs that
were reviewed.
Table 6: Summary of Mental Health Program Evidence

Intervention Name

Total Studies
Reviewed

Level I

Level II-1

Level II-2

Level II-3

Level III

Program to Encourage Active,
Rewarding Lives for Seniors
(PEARLS)104,105

Reducing Disability in
Alzheimer’s Disease
(RDAD)106,107

Staff Training in Assisted-Living
Residences–Caregivers (STARC)108

Intervention Name

Total Studies
Reviewed

Level I

Level II-1

Level II-2

Level II-3

Level III

Senior Odyssey109,110

Memory PLUS (Canada only)

GateKeeper Program111

Healthy Identifying Depression,
Empowering Activities for
Seniors (IDEAS)112

ElderVention

OASIS

Elder Community Care (ECC)

The Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) was supported by 2 Level I
studies, making it the program with the largest evidence base among the mental health interventions
that Altarum reviewed. The PEARLS, Reducing Disability in Alzheimer’s Disease (RDAD), and the StaffTraining in Assisted-Living Residences—Caregivers were all supported by at least 1 Level I study.
Evaluations of these mental health interventions typically focused on measuring reduction of
depression, awareness of depression symptoms, improvements in physical and role functioning, quality
of life, and improvements in health behaviors. More detail on these Mental Health program and the
outcome that were assessed in their respective evaluations can be found in Appendix A of Altarum’s
evidence review report.2

Discussion
28

The body of evidence-based, community-delivered interventions reviewed by Altarum was diverse
in both focus and approach. The interventions focused on a wide range of conditions, from diabetes to
arthritis, and adopted a variety of approaches, from self-paced, Internet-based delivery to highly
structured group programs. The results of the evidence review also showed varying levels of evidence
for these programs. Some programs had extensive support in the form of randomized controlled trials
(RCTs), while others had little to no published evidence related to their efficacy.

As a result of the fairly stringent criteria Altarum used in defining the level of evidence, some
programs that are termed “evidence based” by their developers or disseminators may not have been
considered evidence-based for the purposes of this review. Program developers often extract elements
from various interventions known to be effective from published trials. While some of these
reformatted programs go on to collect evidence of their own effectiveness, others are implemented
without additional testing. These latter programs are often termed “evidence based” to the extent that
they have been developed from other evidence-based elements.

While efficacy of the best-supported programs is generally accepted, much less is known about their
effectiveness in reducing healthcare utilization and costs. Only a handful of interventions included in the
evidence review had research that specifically addressed program effects on health care utilization and
costs. In the few studies where utilization outcomes were addressed, unless the effects were dramatic,
studies infrequently had sufficient power to identify statistically significant effects. This lack of
information on how community-based wellness and prevention programs impact healthcare utilization
and costs may prove to be a significant barrier to more widespread dissemination and implementation
of these interventions.

Section 2: Environmental Scan of Existing Community-Based
Wellness and Prevention Programs
In addition to the review of the existing literature surrounding community-based wellness and
prevention programs, CMS also conducted an environmental scan of existing programs. The purpose of
this exercise was to gain greater insight into how wellness and prevention programs are being
implemented across the country, how wellness and prevention interventions are translated from
research studies into operating programs, and how best to interface with programs on future evaluation
efforts.

In late 2010, CMS awarded a contract to the Altarum Institute to conduct this environmental scan.
The work on the environmental scan occurred primarily in the first half of 2011 and was performed in
conjunction with the evidence review described in Section 1. The full results of this environmental scan
can be found in Altarum’s final environmental scan report, titled “Environmental Scan of CommunityBased Prevention and Wellness Programs in the United States: Environmental Scan and Site Selection
Report.”113 The remainder of this section will describe Altarum’s approach to the environmental scan
and provide an overview of the results.

Analytic Approach
Altarum’s approach to the environmental scan moved forward in two main components. The first
component consisted of developing a comprehensive catalog of potential wellness and prevention
programs for further examination. The second component consisted of an in-depth examination of
selected wellness and prevention programs that included site visits, interviews with key stakeholders,
and a detailed examination of program operations and data infrastructure.

The development of the catalog of potential programs and interventions to examine went hand-inhand with the evidence review described in Section 1. Altarum conducted comprehensive online
30

searches to identify evidence-based wellness and prevention interventions for further review. During
this process, Altarum also contacted key Federal informants, grantees and other experts via e-mail and
telephone to learn of promising programs that were either not extensively reported on in the literature
or were still under development.

Once the wellness and prevention programs were identified, Altarum reached out to intervention
sponsors and site representatives to obtain more specific information about the programs and how they
were being implemented. The Altarum team then selected sites for in-person visits based on their
nomination as an exemplar by one or more key informants, their mix of supported interventions, the
program site’s maturity and stability, the availability and quality of program data, the site’s location and
focus population, and the site’s availability and willingness to participate in site visits and future
evaluation efforts.

Altarum conducted site visits at 34 locations, assessing interventions from mid-March to mid-May
2011. Two-person teams visited sites, often participating in classes or workshops offered as part of
interventions, such as Matter of Balance, EnhanceFitness, and Walk with Ease. During the site visits,
team members obtained more detailed information about the sites and interventions, including
assessing what works, what doesn’t, and why.

Key findings
This report describes findings from the 34 site visits conducted by Altarum. The specific sites
examined by Altarum were purposely selected to represent a cross section of exemplar programs
offering a broad range of evidence-based interventions in diverse contexts and settings. The primary
goal of the review was to examine community-based wellness and prevention programs operating at
their best in order to gain a better understanding of the potential impact of these activities. Table 7
describes the community-based programs that were reviewed and the interventions that were offered
31

at the various program sites. A complete description of all of the programs and interventions included
in the environmental scan can be found in Altarum’s final environmental scan report and accompanying
appendices.
Table 7: Community-based Wellness and Prevention Programs and Interventions

Location

Program Site

Interventions Offered

Los Angeles, CA

Partners in Care Foundation–
Los Angeles




Walk with Ease
Healthy Moves for Aging Well

Los Angeles, CA

OASIS



CATCH Healthy Habits

Broward County, FL

YMCA




Tomando Control de su Salud (Spanish CDSMP)
Tomando Control de su Diabetes (Spanish
DSMP)

Ft. Lauderdale, FL

First Presbyterian Church of
Ft. Lauderdale



EnhanceFitness

Miami, FL

Miami Jewish Health Services



Healthy Ideas

Tampa, FL

West Central Fla. AAA






Active Living Every Day
Matter of Balance (English and Spanish
Language)
Tai Chi-Moving for Better Balance
Chronic Disease Self-Management Program
(CDSMP)
Tomando Control de su Salud (Spanish CDSMP)




Westin, FL

Sheinberg YMCA



Fit and Strong!

Wilton Manors, FL

Pride Center/Gay and Lesbian
Community Center



EnhanceFitness

Atlanta, GA

Atlanta AAA




Walk with Ease
Senior Farmers’ Market Nutrition Program

Atlanta, GA

Senior Center



Chronic Disease Self-Management Program
(CDSMP)

Location

Program Site

Interventions Offered

Atlanta, GA

Arthritis Foundation




Arthritis Foundation Aquatics Program
Arthritis Self-Help Program

Cedar Rapids, IA

Aging Resources




Matter of Balance
Chronic Disease Self-Management Program
(CDSMP)

Des Moines, IA

Aging Resources





Matter of Balance
Healthy Ideas
Program to Encourage Active, Rewarding Lives
for Seniors (PEARLS)
Chronic Disease Self-Management Program
(CDSMP)



Des Moines, IA

Des Moines Veterans Aging



Chronic Disease Self-Management Program
(CDSMP)

Waterloo, IA

Marshalltown YMCA





Silver Sneakers
Eat Better, Move More
Rusty Hinges (YMCA Arthritis)

Evanston, IL

Evanston Community Street
Services



Fit and Strong!

Boston, MA

MA General



EnhanceWellness

Boston, MA

Action For Boston Community
Development



Healthy Eating for Successful Living

Boston, MA

Hebrew Senior Life




Chronic Disease Self-Management Program
(CDSMP)
Diabetes Self- Management Program

Framingham, MA

Advocates




Healthy Ideas
Elder Community Care

Augusta, ME

Spectrum Generations AAA




Matter of Balance
Chronic Disease Self-Management Program
(CDSMP)

Belfast, ME

Waldo County YMCA




Matter of Balance
Arthritis Foundation Aquatics Program

Gilford, ME

Friends of Community Fitness




EnhanceFitness
Matter of Balance

Location

Program Site

Interventions Offered

Portland, ME

Southern Maine AAA




Matter of Balance
Chronic Disease Self-Management Program
(CDSMP)

Ann Arbor, MI

National Kidney Foundation



Chronic Disease Self-Management Program
(CDSMP)
Diabetes Self-Management Program


Detroit, MI

Detroit AAA




EnhanceFitness
Chronic Disease Self-Management Program
(CDSMP)

Flint, MI

National Kidney Foundation



Chronic Disease Self-Management Program
(CDSMP)

Lansing, MI

Oak Valley YMCA



EnhanceFitness

Central MN AAA



Healthy Eating for Successful Living

Minneapolis, MN

Wilder Foundation




Health Moves for Aging Well
Healthy Ideas

Minneapolis, MN

Native American Community
Clinic



Chronic Disease Self-Management Program
(CDSMP)

Minneapolis, MN

Dakotas Regional Office



Arthritis Foundation Aquatics Program

St. Louis, MO

OASIS






Active Living Every Day
CATCH Healthy Habits
Chronic Disease Self-Management Program
(CDSMP)
Diabetes Self-Management Program

Dayton, OH

YMCA



YMCA Diabetes Prevention Program

Providence, RI

YMCA



YMCA Diabetes Prevention Program

Houston, TX

Sheltering Arm



Healthy Ideas

Seattle, WA

Central Area Senior Center




EnhanceFitness
Chronic Disease Self-Management Program
(CDSMP)

Seattle, WA

Seattle Senior Services




EnhanceWellness
Senior Farmers’ Market Nutrition Program

Seattle, WA

Chinese Information and
Service Center



Matter of Balance

The community-based programs that Altarum examined “lived” in diverse community contexts,
from inner city neighborhoods to suburban communities and remote rural areas. They were delivered in
urban teaching hospitals like University of Chicago, University of Washington, and Massachusetts
General Hospital; Area Agencies on Aging networks; local YMCAs; small community organizations; and
even outdoor parks and walking paths. Some interventions were supported by a rich infrastructure of
other programs and services. Others pieced together programs as they could, with limited funding and
resources. The availability of local resources can make the difference between seniors attending one of
two or three independent wellness and prevention programs in the community, or accessing a full range
of programs as part of a framework of supports for seniors, from housing, meals, and transportation, to
exercise and fitness classes, and chronic disease self-management.

Most of the evidence-based interventions identified during the environmental scan, key-informant
interviews, and evidence reviews were developed as part of funded research investigations.
Interventions that have been successfully translated to the community setting are usually those that
were identified by groups with entrepreneurial intentions within or outside the research setting that
adapt, market, and disseminate the program.

The path from research to translation to the field can take many directions. However, the
interventions that were identified as broadly disseminated and scaled through the environmental scan
share some commonalities:

•

Community-based, evidence-based interventions may originate in the research setting or be
developed with the intention of dissemination throughout the community, but an individual
or organizational champion is essential to identify its potential as a target for broader
implementation at the community level.

•

In the current environment emphasizing evidence-based programs, some potentially
beneficial programs that initially focus only on service delivery, and do not incorporate data
collection as part of a rigorous research design, will face a difficult path toward
dissemination.

•

Interventions that do not require expensive equipment or resources, or can be delivered by
lay leaders rather than professionals, tend to be popular and feasible choices across all
settings.

•

Successful models and dissemination strategies are found in the public, nonprofit, and
private sectors. Networks of community partners are important channels for dissemination
and key to effectively spread and scale interventions.

•

Data collection and monitoring are feasible when required as a part of obtaining permission
to deliver an evidence-based intervention from the respective program’s administrator.
Data collection and monitoring, on the other hand, may be quite site-specific if providers are
not specifically required to collect and report data.

Importantly, the conditions for translating and scaling evidence-based interventions to the
community can be supported and enhanced when funding is targeted to translation efforts, and
combined with community networks. While some networks, such as the Aging Services Networks, are
already established and can be leveraged to disseminate and scale interventions, networks can also be
established with previously unaffiliated partners. Data collection and reporting can be supported with
modest investment in central infrastructure to process and maintain participant information, provided
by the sponsoring organization directly, or provided through subcontracting arrangements.

Discussion

In summary, Altarum observed that there was significant diversity in both the range of communitybased interventions that were being offered and in how community-based organizations were
operationalizing interventions and implementing programs. Often, interventions were not offered to
the community in isolation from one another, but rather in conjunction with a broader portfolio of
services offered by community-based organizations. Future evaluation work should take both this vast
heterogeneity of program offerings and the interconnectedness of interventions in programs into
account in determining impacts on Medicare beneficiaries.

Federal funding of community-based wellness and prevention programs has played an important
role in financing and promoting community-based prevention efforts. For example, recent expansions
in the implementation of the CDSMP and other evidenced-based interventions were made possible
under separate grant funding from the ACL and CDC. While direct federal financing of programs has
been helpful in generating an evidence base for program effects and translating interventions from
research to practice, grant funding alone is likely not a viable solution for sustaining programs in the
long term. Indeed, during site visits to programs implementing CDSMP, many program administrators
expressed concerns about the sustainability of operations past the end of their current grant funding
from ACL under the American Recovery and Reinvestment Act. The relatively short funding horizon of
programs also has implications for future evaluation work as it could limit the availability of future
partners.

More consistent funding streams that can capture some of the benefits that these programs
generate to the healthcare system as a whole would be helpful in promoting greater and more
sustainable dissemination. Of particular interest to community-based programs is establishing
partnerships with various payers in the healthcare system to directly finance operations. Creating these
relationships however has been far from straightforward as many interventions have not been

specifically evaluated under a cost-benefit analysis framework from a payer’s point of view and many
community-based organizations may lack the institutional capability, infrastructure, and community
stature to successfully form these partnerships.

Section 3: Retrospective Study of Select Community-Based
Wellness and Prevention Interventions
In the course of its environmental scan of community-based programs, CMS identified 12 nationally
disseminated intervention programs that have maintained registries of participants with sufficiently
detailed personal identifiers to facilitate potential matching to CMS’s administrative databases. These
programs include:


The Chronic Disease Self-Management Program (CDSMP), a chronic disease management
intervention for patients with multiple chronic conditions developed and administered by
Stanford University



The Diabetes Self-Management Program (DSMP), a version of the CDSMP tailored to
diabetes patients developed and administered by Stanford University



EnhanceWellness (EW), a chronic disease management intervention developed by the
University of Washington and administered by Project Enhance (a partnership between
Senior Services of Seattle, the University of Washington, and Group Health dedicated to
disseminating evidence-based health promotion programs for older adults)



EnhanceFitness (EF), a fitness program for older adults developed by the University of
Washington and administered by Project Enhance



The Arthritis Foundation Exercise Program (AFEP), a physical activity program for adults
with arthritis developed and administered by the Arthritis Foundation



The Arthritis Foundation Aquatics Program (AFAP), an aquatic physical activity program for
adults with arthritis developed and administered by the Arthritis Foundation



The Arthritis Foundation Tai Chi Program (AFTCP), a physical activity and balance program
developed by Dr. Paul Lam and administered by the Arthritis Foundation



Fit & Strong (FAS), a physical activity program for patients with osteoarthritis developed and
administered by the University of Illinois at Chicago



Matter of Balance (MOB), an intervention designed to reduce fear of falling and promote
physical activity for older adults developed by Boston University and administered by the
Partnership for Healthy Aging (a public-private partnership dedicated to linking clinicians,
evidenced-based programs, and community services)



Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors), an awareness
and depression management program for older adults developed by the Baylor College of
Medicine and administered by Care for Elders (a public-private partnership dedicated to
increasing access to services, improving the quality of care, and enhancing the quality of life
for older adults and their families)



Program to Encourage Active, Rewarding Lives for Seniors (PEARLS), a depression treatment
intervention for older adults developed by the University of Washington and administered
by the PEARLS Program at the University of Washington

In order to get a preliminary assessment of potential program impacts in time for this Report to
Congress, CMS decided to conduct a retrospective study of program effects by linking participant
39

identities to CMS administrative data and examining changes in healthcare utilization and cost before
and after program participation. In early 2012, CMS contracted with a new contractor, Acumen LLC, to
complete these analyses. The remainder of this section will provide a brief overview of the programs
that were examined in this study, a description of Acumen’s analytic approach, a summary of the
results, and a discussion of the global implications of the findings and directions for future research. A
more detailed treatment of this retrospective study can be found in Acumen’s final evaluation report,
titled “Retrospective Study of Community-Based Wellness and Prevention Programs Final Report.”114

Overview of Wellness and Prevention Programs
The ten programs included in this report are grouped into three intervention areas: chronic disease
self-management, falls prevention, and physical activity. Analyses of the two mental health
interventions (Healthy IDEAS and PEARLS) that were identified have not been completed due to
unforeseen methodological challenges and will not be discussed in this report. Most of the programs
that were examined were national in scope and offered well-defined, standardized classes taught by
trained leaders at community centers, YMCAs, and places of worship across the United States. Detailed
information about each of the programs that were examined is summarized in Table 8.

Table 8: Overview of Community-based Wellness and Prevention Programs Included in the Evaluation

Program

Description

Duration
Providers
and
Intensity
Chronic Disease Self-Management Programs

Content

Potential Impact

CDSMP

Group class for
individuals with
one or more
chronic
conditions, and
their caregivers or
significant others

6 weeks
2.5
hrs/week

Two trained
leaders, one or
both of whom
are non-health
professionals or
peers with
chronic
diseases

Techniques to manage:
 Frustration and pain
 Chronic disease
risk and symptoms
Knowledge to
improve:
 Diet and exercise
 Medication use
 Communication with
healthcare providers

DSMP

Group class for
individuals with
diabetes, and
their caregivers or
significant others.

6 weeks
2.5
hrs/week

Two trained
leaders,
including one
with diabetes

Similar to CDSMP but
specific to diabetes

ASMP

Group class for
individuals with
rheumatic
diseases including
osteoarthritis,
rheumatoid
arthritis,
fibromyalgia, and
lupus.

6 weeks
2 hrs/week

Two trained
leaders,
including one
with arthritis

Similar to CDSMP but
specific to arthritis

Similar to CDSMP
but specific to
arthritis including:
 Improvement in
mobility,
strength, and
balance
 Reduction in use
of pain
medications

Individualized
class for older
adults with one or
more chronic
conditions.

6 months at
varied
frequency

Two healthcare
professionals
(i.e., a nurse
and a social
worker)

Participants identify
personal strengths and
risks, develop a health
action plan, and work
with providers to meet
health goals in the areas
of chronic disease
management, exercise,
mental health, social
isolation, and nutrition.

Dependent on
chosen health
goal including
improvements
in:
 Self-efficacy
 Physical activity
 Ease with
activities of daily
living (ADLs)

Improvement in:
 Self-efficacy
 Medication
adherence
 Chronic disease
risk and
symptom
management
Reduction in:
 Progression of
chronic disease
Similar to CDSMP
but specific to
diabetes

Physical Activity Programs

Program

Description

Duration
and
Intensity
Ongoing
classes
2-3
times/week

Providers

Group exercise
class for older
adults.

AFEP

Content

Potential Impact

Fitness
instructor
trained in EF
protocols

Physical activity training
for:
 Stretching
 Cardiovascular
endurance
 Strength training
 Balance and flexibility

Improvements in:
 Self-efficacy
 Strength,
balance, and
mobility
Reduction in:
 Pain
 Falls, and
related fractures
 Progression of
chronic disease

Group exercise
class for
individuals with
arthritis and
related conditions

6-8 weeks
3
times/week

AF-trained
instructor

Health education
Exercises:
 Endurance-building
routines
 Relaxation
 Balance
 Range of motion
(ROM)
 Strength building

Improvements in:
 Functional
ability, and
strength
 Self-efficacy
Reduction in:
 Depression
 Pain, and
stiffness

AFAP

Group waterbased exercise
class targeted at
individuals with
arthritis and
related
conditions.

6-8 weeks
3
times/week

AF-trained
instructor

Similar to AFEP but the
exercises are performed
in heated pools

Improvements in:
 Functional
ability, range of
motion
 Knee and hip
flexibility
 Strength in leg
muscle
 Aerobic fitness
Reduction in:
 Pain

AFTCP

Group Tai Chi
class targeted at
individuals with
arthritis and
related conditions

6-8 weeks
3
times/week

AF-trained
instructor

Sun-style Tai Chi and
other gentle exercises.

Improvements in:
 Movement
 Balance,
strength and
flexibility
Reduction in:
 Pain
 Falls

Program

Description

FAS

Group exercise
class targeted at
sedentary and deconditioned
adults with lower
extremity
mobility
challenges, with
or without
arthritis.

Duration
and
Intensity
8 weeks
3
times/week
(90-minute
classes)

Providers

Content

Potential Impact

Certified
exercise
instructor

Health education
Goal-setting
Problem solving
Exercises:
 Stretching and
balance
 Low-impact aerobics
 Strength training

Improvements in:
 Physical activity
 Lower-extremity
strength,
mobility
Reduction in:
 Lower-extremity
pain and
stiffness
 Falls
 Depression and
anxiety

8 two-hour
sessions
over several
weeks

Trained lay
volunteers

Coping strategies to:
 Reduce fear of falling
 Set realistic goals for
increasing activity
 Change the
environment to
reduce falls risk
factors.

Improvements in:
 Strength,
mobility, and
balance
 Social activity
Reductions in:
 Fear of falling
 Incidence of
falls and fallrelated fractures

Falls Prevention
MOB

Group class to
reduce the fear of
falling and to
prevent falls.

The four chronic disease self-management programs that Acumen examined in this analysis were
the CDSMP, the DSMP, the ASMP, and EW. The first three programs were developed by the Stanford
Patient Education Research Center, and based on the same model: two trained peer-leaders, at least
one of whom had a chronic condition, led weekly group meetings to teach participants how to manage
their conditions, set goals, and review their progress according to a detailed curriculum.
EnhanceWellness, on the other hand, was a less circumscribed program developed by University of
Washington that offered individuals the opportunity to set goals and review their progress one-on-one
with health professionals over several months. These four programs were focused on improving
participants’ self-efficacy through exposure to others’ successes, verbal encouragement, and/or planned
and informed action to achieve health goals.

The five physical activity wellness programs that Acumen examined in this analysis were EF, FAS, the
AFEP, the AFAP, and the AFTCP. EF was targeted at all older adults. FAS was targeted at older adults
with osteoarthritis. The three Arthritis Foundation programs were targeted at all adults with arthritis
and related conditions. These programs taught participants aerobic exercises and movements that
promote strength, flexibility, and balance. They were all based on the theory that a supportive exercise
class environment would increase participants’ ability to perform these activities on their own, resulting
in improved physical function and mental health, and slower progression of any chronic conditions.
EnhanceFitness was developed by University of Washington, while Fit&Strong! was developed by the
University of Illinois-Chicago.

The MOB program, developed by Boston University, is the most widely implemented falls
intervention program in the United States. The intervention was organized into eight group sessions led
by a trained volunteer, who emphasized strategies to help individuals deal with the fear of falling such
as engaging in appropriate exercise and modifying their environment to reduce falls risk factors. This
program was based on the theory that minimizing risk factors and improving balance and strength
would improve participants’ confidence to decrease their vulnerability to severe falls.

Analytic Approach
Acumen used a retrospective cohort study design to investigate how Medicare beneficiary
participation in each of the wellness programs that were examined was associated with health
outcomes and resource utilization. Acumen obtained Medicare fee-for-service (FFS) claims data from
1999 through 2012.

The analyses followed an intention-to-treat (ITT) framework, in which outcomes were evaluated
based on beneficiary intentions to participate in a program, not the actual level of beneficiary
participation. In other words, beneficiaries were classified as being in the treatment group if they signed
44

up for a program, regardless of whether they actually attended a program session. The intention-totreat framework is a conservative approach to estimating program effects that seeks to limit the bias
introduced from healthier participants being more likely to complete the interventions being evaluated.

Participant identifiers from the wellness programs were obtained from the program managers and
linked (when possible) to Medicare claims data. Data starting one year prior to enrollment and
continuing through one year post-participation was collected for each participant. Using these data,
Acumen calculated participant sample sizes needed to detect a 20% or greater change in the main
outcome measure and total medical costs for each program at 80% power with 95% confidence. For
programs where there was a reasonable expectation of detecting program effects, Acumen pursued
further analysis using a differences-in-differences (DiD) approach to estimate cost savings and
reductions in utilization. The DiD approach compares changes in pre- and post-participation outcomes
with those of a similar, administratively defined, comparison group. The difference in the pre-post
differences in outcomes between these two groups can be interpreted as the program’s effect on
outcomes. Comparison groups for each wellness program were selected for analysis from the universe
of beneficiaries enrolled in the Medicare FFS program. Program participants were matched to control
beneficiaries on important combinations of characteristics including preceding medical cost trends,
comorbid medical conditions, and demographic variables in a one-year pre-enrollment period for each
program.

The outcomes evaluated during the year after program enrollment were total medical costs, costs
by Medicare setting (e.g., inpatient, emergency department, outpatient), health services utilization by
Medicare setting, medication adherence, physical and occupational therapy use, and incidence of falls
or fall-related fractures. Outcomes were evaluated, as appropriate, considering the goals of each

wellness program. A break-down of the various outcomes that were assessed by intervention can be
found in Table 9.
Table 9: Evaluation Outcomes by Program

Program

Healthcare
Costs

CDSMP

√

Health
Service
Utilization
√

Falls or FallRelated
Fractures

Physical and
Occupational
Therapy Use

Medication
Adherence
√

DSMP

√

AF ASMP

√

AFEP

√

AFAP

√

AFTCP

√

FAS

√

MOB

√

Acumen used a DiD estimator to compare changes in outcomes between the wellness program
participants and the matched control populations during the 12-month period following initial program
enrollment, relative to the baseline period of 12 months preceding participation. Because of an
observed lower rate of outcome period survival in controls as compared to participants, Acumen also
performed sensitivity analyses by analyzing only beneficiaries surviving through the outcome period to
better remove the effect of increased health service use for end-of-life care.

Results
The CDSMP, EW, EF, AFEP, AFAP, AFTCP, and MOB all met the sample size requirements for further
testing with the differences-in-differences method. The DSMP, the ASMP, and FAS were excluded
because available sample sizes were too small to reasonably detect program effects. A breakdown of
the inclusion criteria for each of the programs that were studied, how these criteria impacted sample
sizes, and the minimum required sample sizes for further analysis can be found in Table 10.

Table 10: Sample Sizes, Exclusions, and Required Sample Sizes to Detect Program Effects

Chronic Disease Self-Management
a
Programs

Selection
Criteria

CDSMP

DSMP

AF ASMP

AFEP

AFAP

AFTCP

FAS

Falls
Prevention
a
Programs
MOB

In Program
b
Data

86,691

11,554

5,610

2,521

30,065

14,157

23,618

7,659

787

17,616

Linked to
Medicare
Data

28,449

3,545

2,487

983

10,719

8,786

11,189

3,962

428

9,622

Enrolled in
Wellness
Workshops
that started
before
January 1,
2013

25,046

2,925

2,417

977

10,649

8,100

10,812

3,431

379

9,537

Enrolled in
Medicare
FFS
throughout
the Study
Period

13,536

1,483

1,249

477

5,286

4,737

5,708

1,773

249

6,188

With No
End-Stage
Renal
Disease
(ESRD)

13,432

1,468

1,245

477

5,268

4,726

5,705

1,770

248

6,174

Not
Receiving
Hospice
Care
Not
Receiving
Long-Term
Institutional
c
(LTI) Care

13,411

1,465

1,245

476

5,264

4,706

5,701

1,768

247

6,164

13,338

1,454

Data Not
c
Available

Data Not
Available

247

6,139

N/A

Claimsidentified
Diabetes
(Only for
DSMP)

N/A

989

Physical Activity Programs

Chronic Disease Self-Management
a
Programs

CDSMP

DSMP

AF ASMP

AFEP

AFAP

AFTCP

FAS

Falls
Prevention
a
Programs
MOB

Claimsidentified
Arthritis
and Related
Conditions
(Only for AF
ASMP)

N/A

400

N/A

3,615

4,749

1,324

187

N/A

Included in
Final
Intervention
Group

13,338

989

1245

400

5,264

3,615

4,749

1,324

187

6,139

Required
Sample Size
to Detect
20%
reduction in
total costs
at 80%
power

973

997

815

974

1,190

818

737

791

922

1,011

Selection
Criteria

Physical Activity Programs

Chronic Disease Self-Management Programs
Participants in CDSMP and EW did not have significant differences from controls in their total
medical costs during the outcome period. However, there were some differences by care setting. These
results are illustrated in Table 11 and 12. CDSMP participation was associated with a $245 reduction in
average inpatient (IP) unplanned costs (95% CI: $437 to $52). This was slightly offset by a $27 increase
in emergency outpatient (ER OP) costs among CDSMP participants. EW participants and matched
controls did not have statistically significant differences in medical cost changes in any Medicare setting.

Table 11: Chronic Disease Self-management Program Cost Analyses

Setting a
Total
IP Planned
IP Unplanned
ER OP

Pre-Enrollment Period b Costs
Participants
Controls
$9,976

Outcome Period c Costs
Participants
Controls

$10,141

$12,012

$12,298

Differences-inDifferences
Estimator d

Standard
Error

-$122

$193

95% Confidence Interval
-$500

$256

$828

$913

$1,074

$1,093

$66

$67

-$65

$197

$1,873

$1,997

$2,766

$3,136

-$245*

$98

-$437

-$52

$309

$288

$353

$304

$27*

$46

Non ER OP

$1,828

$1,530

$1,881

$1,574

$42

-$74

$90

$3,568

$3,782

$3,791

$3,946

$60

$41

-$21

$140

$596

$723

$642

$752

$17

$19

-$21

$55

SNF

$501

$480

$1,030

$1,083

-$74

$52

-$176

$29

DME

$473

$427

$475

$411

$18

$13

-$8

$44

a. IP = Inpatient, ER OP = Outpatient Emergency Room, Non ER OP = Outpatient, Non-Emergency Room setting, PB = services furnished by
non-institutional providers in all settings, including office visits, some surgical procedures, diagnostic and therapeutic services, etc., HH=
Home Health, SNF = Skilled Nursing Facility, DME = Durable Medical Equipment.
b. The pre-enrollment period is the 12 months before each individual’s program start date. Costs were adjusted to January 2012 U.S. dollars
using the BLS CPI index for Medical Care Services.
c. The outcome period is the 12 months after each individual’s program start date. Costs were adjusted to January 2012 U.S. dollars using
the BLS CPI index for Medical Care Services.
d. The differences-in-differences estimator measures the difference between the participant and comparison groups'

Table 12: EnhanceWellness Cost Analyses

Setting a
Total

Pre-Enrollment Period b Costs
Participants
Controls

Outcome Period c Costs
Participants
Controls

Differences–
in-Differences
Estimator d

Standard
Error

95% Confidence Interval

$11,085

$11,134

$13,160

$13,120

$89

$643

-$1,171

$1,349

IP Planned

$1,241

$1,234

$1,443

$1,347

$89

$266

-$433

$611

IP Unplanned

$2,402

$2,543

$3,496

$3,673

-$36

$338

-$699

$627

$280

$211

$302

$220

$13

$23

-$32

$57

Non ER OP

$1,800

$1,399

$1,893

$1,389

$103

$116

-$126

$331

$3,946

$4,113

$4,162

$4,310

$19

$117

-$211

$248

$476

$563

$542

$644

-$13

$59

-$130

$103

SNF

$423

$599

$876

$1,043

$10

$162

-$308

$328

DME

$519

$473

$446

$494

-$94

$57

-$206

$17

ER OP

c. The outcome period is the 12 months after each individual’s program start date. Costs were adjusted to January 2012 U.S. dollars using
the BLS CPI index for Medical Care Services.
d. The differences-in-differences estimator measures the difference between the participant and comparison groups' change in total and
category costs from the pre-enrollment period to the outcome period. Costs were adjusted to January 2012 U.S. dollars using the BLS CPI
index for Medical Care Services.

Participation in CDSMP and EW was not associated with reductions in healthcare utilization in any of
the Medicare settings; instead, CDSMP participation was associated with an increase in ER OP visits and
physician office visits, and EW participation was associated with an increase in physician office visits.
The health services utilization results for CDSMP and EW are shown in Table 13 and 14. CDSMP
participation was associated with 0.03 additional ER OP visits per participant, or one additional ER OP
visit per 33 program participants on average in the outcome period. CDSMP and EW participants also
had an average of 0.41 and 0.36 additional physician office visits respectively in the outcome period
compared with controls.
Table 13: Chronic Disease Self-management Program Utilization Analyses

Setting a
IP Planned

Pre-enrollment Period b Visits
Participants
Controls

Outcome Period c Visits
Participants
Controls

DifferencesinDifferences
Estimatord

Standard
Error

95% Confidence Interval

0.05

0.06

0.00

0.01

IP Unplanned

0.22

0.23

0.30

0.32

-0.01

0.01

-0.03

0.00

ER OP

0.52

0.50

0.57

0.51

0.03*

0.01

0.06

Physician Office

9.88

9.69

9.94

9.34

0.41*

0.05

0.31

0.51

*Significant at the p=.05 level
a. IP = Inpatient, ER OP = Outpatient Emergency Room, Non ER OP = Outpatient, Non-Emergency Room setting, PB = Non-institutional Part ,
HH= Home Health, SNF = Skilled Nursing Facility, DME = Durable Medical Equipment.
b. The pre-enrollment period is the 12 months before each individual’s program start date.
c. The outcome period is the 12 months after each individual’s program start date.
d. The differences-in-differences estimator measures the difference between the participant and comparison groups' change in the average
number of visits from the pre-enrollment period to the outcome period.

Table 14: EnhanceWellness Utilization Analyses

Setting a

Pre-enrollment Period b Visits
Participants
Controls

Outcome Period c Visits
Participants
Controls

DifferencesinDifferences
Estimator d

Standard
Error

95% Confidence Interval

Setting a
IP Planned

Pre-enrollment Period b Visits
Participants
Controls

Outcome Period c Visits
Participants
Controls

DifferencesinDifferences
Estimator d

Standard
Error

95% Confidence Interval

0.06

0.07

0.08

0.07

0.01

-0.01

0.04

IP Unplanned

0.25

0.26

0.33

0.35

-0.01

0.03

-0.06

0.04

ER OP

0.54

0.41

0.57

0.41

0.04

0.03

-0.03

0.10

Physician Office

9.82

9.14

10.03

9.00

0.36*

0.16

0.04

0.68

In addition to examining healthcare cost and utilization outcomes, Acumen also examined the
impact of program participation on medication adherence outcomes for subpopulations of CDSMP
participants and controls that were enrolled in Medicare Part D throughout the study period and
actively taking chronic disease maintenance medications at the beginning of that period. Unfortunately,
small sample sizes prevented Acumen from performing a similar analysis on EnhanceWellness
participants. Individual control groups were created to measure adherence to each of the six
medication regimens of interest.

As shown in Table 15, Acumen did not find statistically significant associations between participation
in CDSMP and adherence to most of the assessed medication regimens. However, CDSMP participation
was associated with an 8% increase in average adherence (proportion of days covered) to chronic
obstructive pulmonary disease (COPD) combination regimens of long-acting anticholinergics (LAAC) and
long-acting beta-agonists (LABA) over controls. Adherence to all assessed regimens decreased from the
pre-enrollment period to the outcome period among both participants and controls in each disease
cohort, and the decrease did not differ significantly between participants and controls in most cases.

Table 15: Chronic Disease Self-management Medication Adherence Analyses

Condition and Medication
Regimens a b

Medication
Adherence
Measure c

Pre-enrollment Period d

Outcome Period e

Participants

Controls

Participants

Controls

DifferencesinDifferences
Estimatorf

Standard
Error

95%
Confidence
Interval

CHF ACE/ARB/beta-blockers

Avg. PDC

89%

90%

85%

86%

-1%

N=716

% with
PDC≥80%

83%

77%

-1%

-4%

COPD LABA

Avg. PDC

63%

55%

-1%

-4%

N=186

% with
PDC≥80%

40%

39%

33%

36%

-4%

-10%

COPD LAAC

Avg. PDC

67%

58%

59%

-1%

-5%

N=126

% with
PDC≥80%

41%

47%

39%

43%

-7%

COPD LABA + LAAC

Avg. PDC

57%

58%

53%

46%

8%*

15%

N=45

% with
PDC≥80%

33%

36%

31%

28%

-5%

16%

Diabetes Oral Medications

Avg. PDC

90%

88%

85%

84%

-2%

N=987

% with
PDC≥80%

81%

80%

77%

75%

-2%

Hypertension

Avg. PDC

88%

87%

83%

81%

-1%

N=2,878

% with
PDC≥80%

80%

78%

74%

72%

-2%

*Significant at the p=.05 level
a. ACE = angiotensin-converting enzyme inhibitors, ARB =angiotensin receptor blockers, LAAC= long-acting anticholinergic, LABA = longacting beta-agonists.
b. Participants were defined as taking a medication regimen if they were continuously enrolled in Part D during the study period, were in
possession of a medication regimen at the beginning of the pre-enrollment period, and were identified as having the associated medical
condition category (CC) in inpatient, outpatient, or carrier claims.
c. PDC = Proportion of Days covered by a medication. PDC was calculated by examining Part D claims for each medication in question to
determine the proportion of days during the 12 month period when an individual possessed any of the specified medications. For the LABALAAC drugs, individuals must have had supply of both a LABA and a LAAC to be counted as having full possession of their COPD regimen on
each day.
d. The pre-enrollment period is the 12 month period prior to an individual enrolling in the wellness program.
e. The outcome period is the 12 months after each individual’s program start date.
f. The differences-in-differences estimator measures the difference between the participant and comparison groups' change in the
percentage who were adherent to a medication regimen from the pre-enrollment period to the outcome period. A positive value is
associated with greater medication adherence among program participants as opposed to controls.

One key observation from the analysis of the chronic disease self-management programs was that
participants tended to have lower mortality rates in the outcome period than their matched controls
(e.g., 1.5% among CDSMP participants vs. 3.4% among controls). While both CDSMP and EW may have
an effect on mortality, it is also possible that the mortality differentials between cases and controls may

have been indicative of selection effects on program participation. To investigate whether the results of
the analyses were robust to the differences in mortality, Acumen performed the cost and utilization
comparisons on a subset of participants and controls that survived through the entire outcome period.

Similar to the base case results, the analysis on survivors did not find a difference in total costs for
surviving program participants compared with controls; however, the results for some of the other
outcomes differed. The previous result of unplanned hospitalization cost savings for CDSMP participants
was not found in this analysis on survivors. The increase in non-institutional Part B costs that was
previously insignificant among CDSMP participants became statistically significant in this analysis.
Increased emergency outpatient costs and visits and increased physician office visits associated with
CDSMP participation remained a stable finding for survivors. The increase in physician office visits
among EW participants, however, did not remain statistically significant. Results of analyses on
surviving beneficiaries for other cost and utilization outcomes were similar to those from the base case
analyses for CDSMP and EW, and are detailed in Acumen’s final evaluation report.114

Physical Activity Programs
Participation in three of the four physical activity programs (EF, AFEP, and AFTCP) was associated
with total medical cost savings during the outcome period (Tables 16-19). EF program participants
incurred an estimated total cost savings of $945 (95% CI: $1,480, $411). Similarly, AFEP and AFTCP
participants incurred an estimated total cost savings of $761 (95% CI: $1,452, $70), and $1,111 (95% CI: $2,074, -$148), respectively. AFAP participation was not associated with statistically significant total
medical cost savings.

Acumen also examined program effects on costs by setting and found that all physical activity
programs were associated with cost savings in the IP unplanned setting, and EF, AFEP and AFAP were
also associated with cost savings in the skilled nursing facility (SNF) setting (Table 16-19). EF
53

participation was associated with cost savings of $545 (95% CI: $817, $272) in the IP unplanned setting
and $139 (95% CI: $276, $3) in the SNF setting. AFEP participation was associated with cost savings of
$670 (95% CI: $953, $387) in the IP unplanned setting, and $227 (95% CI: $438, $15) in the SNF setting.
AFAP participation was associated with cost savings of $526 (95% CI: $815, $238) in the IP unplanned
setting, and $158 (95% CI: $295, $21) in the SNF setting. Participation in AFTCP was associated with a
cost saving of $594 (95% CI: $1,089, $98) in the IP unplanned setting but the cost saving estimate in the
SNF setting was not statistically significant for AFTCP.
Table 16: EnhanceFitness Cost Analyses

Setting a
Total
IP Planned
IP Unplanned
ER OP

Pre-Enrollment Period b Costs
Participants
Controls
$7,995

$8,076

Outcome Period c Costs
Participants
Controls
$9,175

$10,201

Differences-inDifferences
Estimator d

Standard
Error

-$945*

$273

-$1,480

95% Confidence Interval
-$411

$980

$895

$973

$1,058

-$170

$98

-$362

$21

$1,392

$1,570

$1,873

$2,596

-$545*

$139

-$817

-$272

$177

$175

$203

$202

-$1

$11

-$23

$21

Non ER OP

$1,365

$1,153

$1,510

$1,254

$43

$54

-$62

$149

$3,035

$3,098

$3,266

$3,444

-$116

$62

-$238

$454

$426

$536

$522

-$13

$28

-$68

$41

SNF

$355

$449

$567

$800

-$139*

$70

-$276

-$3

DME

$237

$311

$246

$325

-$5

$12

-$28

$18

*Significant at the p=.05 level
a. IP = Inpatient, ER OP = Outpatient Emergency Room, Non ER OP = Outpatient, Non-Emergency Room setting, PB = services furnished by
non-institutional providers in all settings, including office visits, some surgical procedures, diagnostic and therapeutic services, etc., HH=
Home Health, SNF = Skilled Nursing Facility, DME = Durable Medical Equipment.
b. The pre-enrollment period is the 12 months before each individual’s program start date. Costs were adjusted to January 2012 U.S. dollars
using the BLS CPI index for Medical Care Services.
c. The outcome period is the 12 months after each individual’s program start date. Costs were adjusted to January 2012 U.S. dollars using
the BLS CPI index for Medical Care Services.
d. The differences-in-differences estimator measures the difference between the participant and comparison groups' change in total and
category costs from the pre-enrollment period to the outcome period. Costs were adjusted to January 2012 U.S. dollars using the BLS CPI
index for Medical Care Services.

Table 17: Arthritis Foundation Exercise Program

Setting a
Total

Pre-Enrollment Period b Costs
Participants
Controls

Outcome Period c Costs
Participants
Controls

Differences-inDifferences
Estimator d

Standard
Error

-$761*

$353

-$1,452

95% Confidence Interval

$10,365

$10,816

$11,700

$12,912

IP Planned

$1,136

$1,217

$1,309

$1,269

$122

$137

-$146

$390

IP Unplanned

$1,793

$2,040

$2,221

$3,137

-$670*

$144

-$953

-$387

ER OP

-$70

$250

$257

$277

$16

-$25

$37

Non ER OP

$1,692

$1,455

$1,753

$1,539

-$22

$67

-$154

$109

$3,802

$4,011

$4,047

$4,182

$74

$81

-$85

$233

$532

$651

$609

$774

-$47

$40

-$124

$31

SNF

$862

$837

$1,182

$1,384

-$227*

$108

-$438

-$15

DME

$297

$348

$300

$349

$13

-$25

$28

Table 18: Arthritis Foundation Aquatics Program Cost Analyses

Setting
Total

Pre-Enrollment Period b Costs
Participants
Controls

Outcome Period c Costs
Participants
Controls

Differences-inDifferences
Estimator d

Standard
Error

95% Confidence Interval

$11,397

$11,053

$12,382

$12,444

-$405

$321

-$1,034

$223

IP Planned

$2,054

$1,713

$1,951

$1,529

$80

$138

-$190

$351

IP Unplanned

$1,714

$1,820

$2,125

$2,756

-$526*

$147

-$815

-$238

-$1

$13

-$26

$24

ER OP

$201

$238

$214

$252

Non ER OP

$1,850

$1,575

$1,918

$1,607

$34

$70

-$104

$173

$4,437

$4,291

$4,655

$4,359

$150

$78

-$3

$302

$365

$516

$458

$601

$30

-$51

$66

SNF

$441

$517

$710

$944

-$158*

$70

-$295

-$21

DME

$334

$384

$353

$395

$15

-$21

$37

*Significant at the p=.05 level

Table 19: Arthritis Foundation Tai Chi Program

Setting a
Total
IP Planned
IP Unplanned
ER OP

Pre-Enrollment Period b Costs
Participants
Controls

Outcome Period c Costs
Participants
Controls

Differences-inDifferences
Estimator d

Standard
Error

95% Confidence Interval

$8,864

$8,865

$10,521

$11,633

-$1,111*

$491

-$2,074

-$148

$912

$952

$1,053

$1,304

-$211

$172

-$548

$125

$1,289

$1,199

$1,989

$2,493

-$594*

$253

-$1,089

-$98

$173

$229

$198

$253

$23

-$43

$46

Non ER OP

$1,583

$1,395

$1,647

$1,531

-$73

$105

-$279

$133

$4,005

$3,892

$4,299

$4,131

$55

$112

-$165

$275

$250

$453

$330

$589

-$57

$50

-$154

$40

SNF

$377

$419

$741

$1,005

-$221

$135

-$486

$43

DME

$273

$326

$263

$328

-$12

$24

-$59

$36

Participation in all four physical activity programs (EF, AFEP, AFAP, and AFTCP) was associated with
reductions in unplanned hospitalizations in the inpatient setting, and participation in the Arthritis
Foundation physical activity programs was associated with increases in physician office visits. The
results of Acumen’s analyses of health service utilization can be found in Tables 20-23. EF, AFEP, AFAP,
and AFTCP participants experienced decreases in unplanned hospitalizations by 0.04-0.05 per patient
56

per year, which implied that one unplanned hospitalization was prevented during the outcome period
for every 20-25 participants. Along with the decrease in unplanned hospitalizations, AFAP participation
was associated with an increase in planned hospitalizations by 0.02 per patient in the inpatient setting.
Participation in the three Arthritis Foundation programs (AFEP, AFAP, and AFTCP) was also associated
with increases in physician office visits by 0.36-0.51 per person per year.

Table 20: EnhanceFitness Utilization Analyses

Setting a
IP Planned

Pre-enrollment Period b Visits
Participants
Controls

Outcome Period c Visits
Participants
Controls

DifferencesinDifferences
Estimatord

Standard
Error

95% Confidence Interval

0.06

0.05

0.06

-0.01

0.01

-0.02

0.00

IP Unplanned

0.16

0.17

0.19

0.26

-0.05*

0.01

-0.07

-0.04

ER OP

0.31

0.32

0.34

0.35

0.00

0.01

-0.02

0.02

Physician Office

7.77

7.69

7.96

7.82

0.06

0.07

-0.08

0.19

Table 21: Arthritis Foundation Exercise Program Utilization Analysis

Setting a
IP Planned

Pre-enrollment Period b Visits
Participants
Controls

Outcome Period c Visits
Participants
Controls

DifferencesinDifferences
Estimator d

Standard
Error

95% Confidence Interval

0.07

0.08

0.07

0.00

0.01

-0.01

0.02

IP Unplanned

0.20

0.22

0.26

0.32

-0.04*

0.01

-0.07

-0.02

ER OP

0.39

0.43

0.42

0.44

0.03

0.02

-0.01

0.06

Physician Office

10.35

10.13

10.44

9.86

0.36*

0.10

0.17

0.54

*Significant at the p=.05 level

a. IP = Inpatient, ER OP = Outpatient Emergency Room, Non ER OP = Outpatient, Non-Emergency Room setting, PB = Non-institutional Part ,
HH= Home Health, SNF = Skilled Nursing Facility, DME = Durable Medical Equipment.
b. The pre-enrollment period is the 12 months before each individual’s program start date.
c. The outcome period is the 12 months after each individual’s program start date.
d. The differences-in-differences estimator measures the difference between the participant and comparison groups' change in the average
number of visits from the pre-enrollment period to the outcome period.

Table 22: Arthritis Foundation Aquatics Program Utilization Analysis

Setting a
IP Planned

Pre-enrollment Period Visits
Participants
Controls

Outcome Period Visits
Participants
Controls

DifferencesinDifferences
Estimatord

Standard
Error

95% Confidence Interval

0.13

0.11

0.13

0.09

0.02*

0.01

0.00

0.03

IP Unplanned

0.18

0.20

0.21

0.28

-0.05*

0.01

-0.07

-0.03

ER OP

0.34

0.42

0.34

0.42

0.01

-0.02

0.04

Physician Office

11.57

10.62

11.70

10.35

0.41*

0.09

0.25

0.58

Table 23: Arthritis Foundation Tai Chi Program Utilization Analysis

Setting a
IP Planned

Pre-enrollment Period b Visits
Participants
Controls

Outcome Period c Visits
Participants
Controls

DifferencesinDifferences
Estimatord

Standard
Error

95% Confidence Interval

0.06

0.07

0.08

0.00

0.01

-0.02

0.02

IP Unplanned

0.14

0.21

0.26

-0.05*

0.02

-0.09

-0.01

ER OP

0.31

0.39

0.34

0.40

0.02

0.03

-0.03

0.07

Physician Office

10.90

10.27

11.19

10.05

0.51*

0.17

0.18

0.84

*Significant at the p=.05 level

Acumen found that participation in all physical activity programs was associated with increases in
physical therapy (PT) use, while participation in EF, AFAP, and AFTCP was associated with mixed effects
on occupational therapy (OT) use (Table 24). The number of participants in EF, AFEP, AFAP, and AFTCP
with any physical therapy visit increased by 1.8%-6.8% from the pre-enrollment period to the outcome
period compared with matched controls. The average number of physical therapy visits per person also
increased by 0.8 for the AFEP, 1.12 for the AFAP, and 1.1 for the AFTCP. While EF and AFTCP
participation was associated with reductions in the average number of occupational therapy visits by 0.1
and 0.3 per person respectively, the number of AFAP participants with any occupational therapy visit
increased by 1.0% in the outcome period.

Table 24: Physical Activity Program Physical and Occupational Therapy Utilization Analyses

Physical or Occupational Therapy
Program a

Setting b

Measure

Pre-enrollment Period c
Participants

Physical
Therapy
EF
Occupationa
l Therapy

Physical
Therapy
AFEP
Occupationa
l Therapy

Physical
Therapy
AFAP
Occupationa
l Therapy

Physical
Therapy
AFTCP
Occupationa
l Therapy

Controls

Outcome Period d
Participants

Controls

Avg. #
Visits

2.8

2.7

2.8

% with a
Visit

21.4%

22.2%

20.4%

Avg. #
Visits

0.3

0.4

% with a
Visit

4.1%

5.0%

Avg. #
Visits

5.0

5.3

4.5

% with a
Visit

35.1%

35.8%

30.2%

Avg. #
Visits

0.8

0.9

% with a
Visit

8.0%

9.0%

Avg. #
Visits

6.6

% with a
Visit

42.8%

Avg. #
Visits
% with a
Visit
Avg. #
Visits
% with a
Visit
Avg. #
Visits
% with a
Visit

Differences
–inDifferences
Estimator e

Standard
Error

95% Confidence Interval

-0.1

0.1

-0.3

0.1

1.8%*

0.7%

0.5%

3.1%

-0.1*

0.0

-0.2

0.0

-0.1%

0.4%

-0.8%

0.6%

0.8*

0.2

0.4

1.2

5.6%*

1.0%

3.7%

7.5%

0.0

0.1

-0.2

0.1

8.8%

0.2%

0.6%

-0.9%

1.3%

5.7

4.6

1.12*

0.2

0.7

1.5

42.8%

37.6%

30.8%

6.8%*

0.9%

5.1%

8.5%

0.5

0.6

0.0

0.1

-0.1

0.1

7.0%

7.7%

6.6%

1.0%*

0.5%

0.1%

2.0%

5.5

5.6

5.3

4.3

1.1*

0.3

0.4

1.7

38.9%

35.4%

29.6%

5.8%*

1.6%

2.6%

9.0%

0.7

0.6

0.4

0.6

-0.3*

0.1

-0.5

0.0

6.5%

6.8%

6.9%

-0.1%

0.9%

-1.8%

1.6%

0.5
5.1%

*Significant at the p=.05 level
a. EF= EnhanceFitness, AFTCP= Arthritis Foundation Tai Chi Program, AFAP= Arthritis Foundation Aquatics Program, AFEP= Arthritis
Foundation Exercise Program.
b. Physical Therapy = Physical therapy claims in the HH, OP, and PB settings. Occupational Therapy = Occupational therapy claims in the HH,
OP and PB settings.
c. The pre-enrollment period is the 12 months before each participant’s program start date.
d. The outcome period is the 12 months after each participant’s program start date.
e. The differences-in-differences estimator (DiD) measures the difference between the participant and comparison groups' change in the
average # of visits and the % with a visit from the pre-enrollment period to the outcome period. The DiD averaged # of visits for all
individuals, including individuals who had no healthcare visits for a particular healthcare service category

Acumen also investigated changes in the incidence of falls or fall-related fractures among physical
activity program participants and matched controls from the pre-enrollment period to the outcome
period. This analysis did not find statistically significant associations between physical activity program
participation and the incidence of medically-attended falls or fall-related fractures (Table 25).
Table 25: Physical Activity Program Medically-attended Falls or Fall Related Fracture Analyses

Pre-enrollment Period Falls b
Program

Participants

Controls

Outcome Period Falls c
Participants

Controls

Differences–
inDifferences
Estimatord,

Standard
Error

Confidence Interval

5.61%

6.52%

6.94%

-0.42%

0.43%

-1.27%

0.43%

AFEP

10.12%

11.84%

11.51%

0.33%

0.68%

-1.00%

1.65%

AFAP

7.79%

8.21%

9.13%

-0.92%

0.52%

-1.94%

0.10%

AFTCP

7.25%

8.76%

9.60%

-0.84%

1.00%

-2.79%

1.11%

*Significant at the p=.05 level
a. EF = EnhanceFitness, AFTCP = Arthritis Foundation Tai Chi Program, AFAP = Arthritis Foundation Aquatics Program, AFEP = Arthritis
Foundation Exercise Program.
b. The pre-enrollment period is the 12 months before each participant’s program start date.
c. The outcome period is the 12 months after each participant’s program start date.
d. The differences-in-differences estimator measures the difference between the participant and comparison groups' change in average
incidence of falls and fall-related fractures from the pre-enrollment period to the outcome period.

As was the case with the chronic disease self-management programs, the mortality rate among
physical activity program participants was lower than that of matched controls (e.g., 1.4% among EF
participants vs. 2.9% among controls). While program participation may have had an effect on
mortality, it is also possible that the observed difference in mortality rates may have been the result of
healthier beneficiaries self-selecting into the physical activity programs. To investigate whether the
results of the analyses were robust to the differences in mortality, Acumen performed the cost and
utilization comparisons on a subset of participants and controls that survived through the entire
outcome period.

While the key results for EF was robust to the observed differences in mortality, several results for
the AF programs were not. As in the full cohort analysis, EF participants surviving through the outcome
61

period experienced statistically significant total medical savings. However, total medical cost savings
found for AFEP and AFTCP participants in the full cohort analysis were no longer statistically significant
in the survivors’ analysis. The reductions in unplanned IP costs and utilization remained statistically
significant for the cohort of survivors participating in EF, AFEP, and AFAP but not for survivors
participating in AFTCP. The magnitude of the savings estimates for both total medical costs and
unplanned IP costs was smaller in the analysis on survivors for all programs, which is detailed in
Acumen’s final evaluation report.114

Falls Prevention
MOB participation was associated with total medical cost savings, and cost savings in the unplanned
IP, skilled nursing facility (SNF), and home health (HH) settings. MOB participation was associated with a
$938 decrease in total medical costs per year (CI: -$1,498, -$379). This finding was driven by a $517
reduction in unplanned hospitalization costs, a $234 reduction in skilled nursing facility costs, and an
$81 reduction in home health costs (Table 26).
Table 26: Matter of Balance Cost Analyses

Setting a
Total
IP Planned

Pre-Enrollment Period b Costs
Participants
Controls
$9,835

Outcome Period c Costs
Participants
Controls

$9,646

$11,747

$12,496

Differences–
in-Differences
Estimator d

Standard
Error

-$938*

$285

-$1,498

95% Confidence Interval
-$379

$963

$970

$1,005

$1,130

-$117

$96

-$305

$71

$1,795

$1,839

$2,651

$3,212

-$517*

$129

-$769

-$265

$250

$229

$312

$267

$23

$12

-$1

$47

$1,593

$1,294

$1,666

$1,381

-$15

$51

-$114

$85

$3,576

$3,684

$3,873

$3,974

$58

-$106

$121

$535

$669

$591

$807

-$81*

$31

-$141

-$20

$745

$591

$1,285

$1,365

-$234*

$91

-$413

-$55

$378
*Significant at the p=.05 level

$368

$364

$359

-$5

$38

-$79

$68

IP Unplanned
ER OP
Non ER OP
PB
HH
SNF
DME

b. The pre-enrollment period is the 12 months before each individual’s program start date. Costs were adjusted to January 2012 U.S. dollars
using the BLS CPI index for Medical Care Services.
c. The outcome period is the 12 months after each individual’s program start date. Costs were adjusted to January 2012 U.S. dollars using
the BLS CPI index for Medical Care Services.
d. The differences-in-differences estimator measures the difference between the participant and comparison groups' change in total and
category costs from the pre-enrollment period to the outcome period. Costs were adjusted to January 2012 U.S. dollars using the BLS CPI
index for Medical Care Services.

MOB participation was also associated with significant changes in health services utilization in the
inpatient and physician office settings (Table 27). MOB participation was associated with a reduction in
unplanned hospitalizations of 0.05 per person per year, which implies that one unplanned
hospitalization was prevented for every 20 MOB participants in the outcome period. MOB participation
was also associated with an increase in physician office visits of 0.43 per person per year, or one
additional physician office visit per year for every 2.3 participants.
Table 27: Matter of Balance Utilization Analyses

Pre-enrollment Period Visits b

Outcome Period Visits c

DifferencesinDifferences
Estimatord

Standard
Error

Setting a
IP Planned

Participants
0.06

0.06

-0.01

0.00

-0.02

0.00

IP Unplanned

0.20

0.21

0.28

0.33

-0.05*

0.01

-0.07

-0.03

ER OP

0.40

0.38

0.46

0.42

0.02

0.01

-0.01

0.05

Physician Office

9.51

9.28

9.87

9.21

0.43*

0.07

0.29

0.56

Controls

Participants

Controls

95% Confidence Interval

MOB participation was associated with increased use of physical therapy (PT) and occupational
therapy (OT) services in the outcome period (Table 28). MOB participation was associated with an
average increase in physical therapy visits of 0.5 per person, which implies one additional physical
therapy visit for every two participants. The number of MOB participants who had any physical therapy

visit increased by 5.2% compared with controls in the outcome period. The number of participants who
had any occupational therapy visit also increased by 1.3% compared with controls.
Table 28: Matter of Balance Physical and Occupational Therapy Utilization Analyses

Physical
Therapy

Avg. # Visits

Participants
4.3

Controls
4.4

Participants
4.3

Controls
3.9

Differences–
inDifferences
Estimator e
0.5*

% with a Visit

30.6%

31.9%

26.8%

5.2%*

Occupational
Therapy

Avg. # Visits

0.6

0.7

0.0

0.1

-0.1

0.1

% with a Visit

8.1%

9.3%

8.0%

1.3%*

0.5%

0.4%

2.2%

Physical or Occupational Therapy
Program

Setting

Measure

MOB

Pre-enrollment Period

Outcome Period

Standard
Error

95% Confidence
Interval

0.1

0.2

0.8

0.7%

3.8%

6.6%

*Significant at the p=.05 level
a. MOB=Matter of Balance
b. Physical Therapy = Physical therapy claims in the HH, OP, and PB settings. Occupational Therapy = Occupational therapy claims in the HH,
OP and PB settings.
c. The pre-enrollment period is the 12 months before each participant’s program start date.
d. The outcome period is the 12 months after each participant’s program start date.
e. The differences-in-differences estimator (DiD) measures the difference between the participant and comparison groups' change in the
average # of visits and the % with a visit from the pre-enrollment period to the outcome period. The DiD averaged # of visits for all
individuals, including individuals who had no healthcare visits for a particular healthcare service category

Acumen also investigated changes in the incidence of falls or fall-related fractures among falls
prevention program participants and matched controls from the pre-enrollment period to the outcome
period. This analysis did not find a statistically significant association between MOB participation and
the incidence of falls or fall-related fractures (Table 29).

Table 29: Matter of Balance Medically-Attended Falls or Fractures Analysis

Pre-enrollment Period Falls b
Program a
MOB

Outcome Period Falls c

Participants

Controls

Participants

Controls

10.57%

11.48%

11.13%

Differences–
inDifferences
Estimatord,

Standard
Error

0.35%

0.52%

Confidence Interval
-0.67%

1.38%

*Significant at the p=.05 level
a. MOB=Matter of Balance
b. The pre-enrollment period is the 12 months before each participant’s program start date.
c. The outcome period is the 12 months after each participant’s program start date.
d. The differences-in-differences estimator measures the difference between the participant and comparison groups' change in average
incidence of falls and fall-related fractures from the pre-enrollment period to the outcome period.

Acumen observed a notably lower mortality rate among MOB participants compared with matched
controls in the outcome period; only 2.4% of MOB participants died during the one-year period
following program enrollment compared with 4.2% of individuals in the comparison group. While the
Matter of Balance program may have had an effect on mortality, the magnitude of the mortality
difference between participants and controls during the outcome period could indicate selection bias in
the participant population. To investigate whether the results of the analyses were robust to the
differences in mortality, Acumen performed the cost and utilization comparisons on the subset of MOB
participants and controls that survived through the entire outcome period.

After eliminating individuals who died during the outcome period, total medical cost savings as well
as savings in the unplanned IP, HH, and SNF settings remained statistically significant. The magnitude of
savings estimates in the unplanned IP and HH settings were attenuated, while the magnitude of the
savings estimate in the SNF setting was slightly larger in the cohort of survivors. The decrease in
unplanned hospitalizations and increase in physician office visits also remained statistically significant
but slightly attenuated in magnitude for the cohort of survivors. However, the increase in ER OP costs,
which was not statistically significant in the analyses on the full cohort, became significant when
restricting the cohort to survivors. The analysis results on survivors are detailed in Acumen’s final
evaluation report.114

Additional Subgroup Analyses
Acumen did additional subgroup analysis to determine which participants in the wellness
programs had the highest yield in terms of cost and utilization outcomes, as well as whether or not the
intensity of the interventions modified effects. They found that top responders to wellness programs
were characterized by much higher medical costs and higher rates of health service utilization in the
pre-enrollment period, and higher incidence of most observed chronic conditions compared with other
65

participants across programs. Additionally, enrollees with the highest frequency of participation
generally had higher estimates of cost saving in CDSMP, MOB and EF; the programs for which
attendance data was available. For example, an additional sub-analysis of the relationship between the
class attendance and cost savings in the CDSMP program showed beneficiaries attending all 6 class
sessions experienced a statistically significant cost savings of $944. These results, however, should be
interpreted cautiously as beneficiaries in worse and declining health may be both less able to complete
the course and more likely to incur higher spending in the outcome period. These findings offer insight
into how to target wellness programs to beneficiaries that would benefit most, as well as the
importance of encouraging regular attendance.

Discussion
Acumen’s analysis found evidence of total cost savings for four of the seven wellness programs that
were examined using the differences-in-differences estimation method. EF, AFEP, AFTCP, and MOB
were associated with total medical cost savings; primarily driven by reductions in unplanned inpatient
admissions and costs. Participation in the CDSMP and AFAP, while not associated with savings in total
medical costs, was associated with inpatient cost savings.

Acumen also found evidence of program effects on health service utilization. Participation in EF,
AFEP, AFAP, AFTCP, and MOB was associated with reductions in unplanned hospitalizations.
Participation in the CDSMP, EW, AFEP, AFAP, AFTCP, and MOB, on the other hand, was associated with
increases in physician office visits, possibly owing to increased levels of patient activation and a shift
toward more primary care based services resulting from the interventions.

Acumen did not find that participation in CDSMP affected most medication adherence outcomes in
patients with congestive heart failure (CHF), diabetes mellitus (DM), hypertension, and chronic

obstructive pulmonary disease (COPD). CDSMP participation was only associated with increased
adherence to one of the six medication regimens that were assessed, a combined regimen for COPD.

While there was no evidence that any physical activity or falls prevention program reduced the
incidence of falls or fall-related fractures, all physical activity and falls prevention programs were
associated with increases in the use of physical therapy services, and with mixed effects on the use of
occupational therapy services. Participation in EF, AFEP, AFAP, AFTCP, and MOB was associated with
increased physical therapy use. One explanation for the increase in physical therapy use may be that
that increases in levels of physical activity resulting from program participation may increase beneficiary
demand for physical therapy services as they attempt to acclimate themselves to a more active lifestyle.
Participation in AFAP and MOB was also associated with increased occupational therapy use, while
participation in EF and AFTCP was associated with decreased occupational therapy use.

This research has some key limitations worth noting. First, in spite of efforts to match program
participants with appropriate controls, there were key differences in baseline demographics and health
service utilization between the two intervention and comparison groups. While the differences-indifferences approach minimized this concern, it is possible that the differences between participants
and controls could have introduced bias into the analyses. Beneficiaries who self-selected into
programs may also have been different from control populations in their motivations or behaviors,
which are hard to capture using administrative data, and these differences may have influenced the
study outcomes. To the degree that such differences existed, we may find positive (or negative) effects
attributed to program participation, which were actually related to behavioral characteristics or other
confounding factors differing between populations. For example, the difficulty in matching controls to
program participants on mortality during the outcome period that Acumen experienced may have been
indicative of such a selection bias. Most of the key results for the physical activity and falls prevention

programs, however, were robust to these observed differences in mortality while a few were not. For
example, the finding of total medical cost savings remained statistically significant for EF and MOB but
not for AFEP and AFTCP.

Second, Acumen’s efforts to detect effects of wellness program participation on outcomes were
hindered by small sample sizes. Sample sizes were diminished by difficulties in linking program
participants to claims data, lack of Medicare eligibility during the full pre-participation period, and a lack
of claims-based evidence of specific chronic conditions (e.g., arthritis) among participants receiving
disease-specific interventions. Ultimately, only 7 of the 10 interventions that Acumen originally sought
to evaluate had sufficient sample sizes to support analyses.

Additionally, the retrospective cohort design of the analysis was limited in its ability to control and
account for unobserved variables (confounders) that also could affect the outcomes. While Acumen
attempted to control for observable differences in important medical conditions, demographic factors,
and preceding health care utilization levels and trends, it is possible that additional variables, if
available, may have influenced the results.

Finally, the one-year outcome period for assessing effects of program participation may not
correspond to the actual time horizon in which many of the wellness programs would be expected to
influence outcomes. For example, initiating a sustained exercise or improved chronic disease selfmanagement program could be expected to influence patient health trajectories more towards the end
of life as chronic illness and debility are often delayed, and may occur many years after program
enrollment as opposed to the initial year. As such, the outcome period for this research project may
have been too short to detect the full range of program benefits.

The broader research question of wellness program effects on cost and resource utilization would
benefit from additional methods of analysis. Prospective analysis, if carefully done, would allow for a
richer set of potential explanatory variables to be collected on participants choosing to enroll in these
programs. These new variables could be developed with involvement from wellness program experts
and would serve to better capture attributes differing between participants and controls in important
ways. Prospective analyses could also include additional variables facilitating the investigation of
specific program interventions or operational aspects; and the frequency, durability, or intensity of
specific interventions on outcomes.

Acumen’s analyses found some initial evidence that that EF, AFEP, AFTC, and MOB participation may
have been associated with medical cost savings and decreased use of health care services at least for
one year following program enrollment. Additionally, the finding of total medical cost savings and
unplanned inpatient hospital cost savings for EF and MOB remained robust even after restricting the
cohort to outcome period survivors. One commonality of these programs is that they encourage
patients to engage in sustained physical activity over time, which may play an important role in
achieving positive results. Other avenues whereby these programs exert their positive effects should be
considered, researched, and disseminated. This research further suggested that participation in CDSMP,
and AFAP, while not associated with total savings, was associated inpatient cost savings. The reason for
the lack of overall medical savings for these programs is unclear and may warrant further exploration.

Section 4: Global Conclusions, Future Directions, and Policy
Recommendations
Summary of Results

Both the published literature examined in CMS’s evidence review and CMS’s initial evaluations of
potential program effects indicate that some community-based wellness and prevention programs may
have the potential to improve beneficiary health outcomes and reduce healthcare costs.

Evidence in the literature surrounding program impacts on healthcare utilization and costs however
was much more limited. Only a handful of published studies evaluated these outcomes. 115, 116, 117,118,119, 120, 121,
122

Among studies that specifically examined utilization and cost outcomes, analyses of impacts were

often based on self-reports.

CMS’s initial evaluation of program impacts, described in Section 3, examined claims-based
measures of utilization and costs for a select group of wellness and prevention programs where there
was sufficient participant level information to match to CMS administrative data. These analyses found
some promising evidence suggesting that four nationally disseminated programs (EnhanceFitness (EF),
Arthritis Foundation Exercise Program (AFEP), Arthritis Foundation Tai Chi Program (AFTCP), and Matter
of Balance (MOB)) may have driven down total healthcare costs for participating beneficiaries. The
Chronic Disease Self-Management Program (CDSMP) and several physical activity programs also
demonstrated reductions in unplanned hospital utilization and costs, which may suggest a potential for
future long-term savings.

Gaps in the Evidence

Taken together, these results are promising in that they demonstrate that evidence-based
community wellness and prevention programs can improve outcomes and in some cases reduce costs
for Medicare beneficiaries. However, there are some gaps in the established evidence that make more
widespread implementation of programs challenging. First, while CMS’s retrospective analysis of
program effects found some evidence of cost savings for select programs, the overall evidence of
program effects on cost and utilization outcomes is still somewhat limited. To date, there have only
been a handful of studies that have directly addressed cost and utilization outcomes. Further, even
when these outcomes were examined, results were rarely framed in context with program costs. As
such, there is little direct evidence suggesting that the benefits of these programs would exceed their
costs on a population level.

Second, most of the effort in promoting community-based wellness and prevention programs (both
in the public and private sphere) has been focused on testing specific interventions and building
program capacity. Very little attention however has been paid to examining the demand for these kinds
of programs in the general beneficiary population. Most of the evaluation studies to date have
examined relatively small populations of participants and controls that were specifically recruited for
research purposes. It is unclear whether these individuals are representative of the larger communities
from which they are drawn in terms of their willingness to engage with and participate in communitybased prevention efforts. As such, it is difficult to estimate the scale to which potential benefits could
accrue in a national implementation of a program.

Finally, assuming that a compelling business case for the direct funding of community-based
wellness and prevention programs could eventually be established, it is unclear how to best implement
a payment model to finance the delivery of these services. Community-based interventions are often,
by design, delivered by lay practitioners in community settings. While this framework is critical to

keeping program costs low, it is not clear that such a delivery system could support the quality,
regulatory, and financial controls necessary to maintain program integrity without sacrificing some of its
efficiency. More research is needed to develop a sustainable framework for supporting a healthy
ecosystem of community-based providers while not exposing the Medicare program to undue risk.

Research Agenda
Moving forward, HHS, through CMS and other agencies, will attempt to both fill these gaps in the
evidence and round out understating of how these programs can benefit Medicare beneficiaries through
ongoing research efforts mandated under the Affordable Care Act. Specifically, HHS anticipates
conducting studies geared towards establishing a firm business case for the direct financing of
programs, complete with formal cost-benefit and cost effectiveness analyses, studies designed to
estimate beneficiary demand for community-based preventive services, and studies and pilot programs
designed to both develop new wellness and prevention interventions tailored to the Medicare
population and to test viable payment models for these programs. Additionally, HHS will explore
fielding new studies to examine the impact of community-based programs on vulnerable subpopulations
within the Medicare population, including young disabled, dually eligible, and End Stage Renal Disease
beneficiaries. The following research efforts are currently underway at CMS to meet these objectives.

Prospective Study of Program Effects
In early June 2013, CMS awarded a contract to Acumen to perform a large-scale prospective
evaluation of community-based wellness and prevention programs. The overall objective of this
research effort is to analyze the overall interest of Medicare beneficiaries in participating in communitybased wellness and prevention programs and to assess the impact of beneficiary participation in these
programs on subsequent health behaviors, self-reported health outcomes, and health service utilization

rates and costs. CMS envisions this research effort consisting of 6 inter-related components with work
spanning 4 years.

The first component of this research project will consist of recruiting and partnering with
established community-based wellness and prevention programs. CMS intends to invite applications
from promising programs with sufficient infrastructure and beneficiary enrollments to be part of the
evaluation study. CMS has set a goal of partnering with at least 10 large-scale community-based
programs.

The second component of this research project will consist of a population-based survey of
beneficiary readiness to engage with community-based wellness and prevention programs. This
beneficiary population-based survey will serve the dual purposes of 1) providing national estimates of
beneficiary interest and readiness to engage in community-based wellness and prevention activities,
and 2) providing a comparison group for the participants entering the wellness and prevention programs
that will be examined in this study.

The third component of this research will consist of a survey-based evaluation of program impacts
on self-reported health behaviors and outcomes. The goal of this analysis is to identify and test for
improvements over baseline values in relevant self-reported beneficiary outcomes at 6 months and 1
year following program participation.

The fourth component of this research project will consist of a claims-based evaluation of program
impacts on Medicare utilization and cost outcomes. These claims-based analyses will identify and test
for changes in pre-and-post beneficiary participation utilization and costs.

The fifth component of this research will consist of a qualitative description of the various programs’
operations and costs with an eye toward determining best practices and how to better spread the
73

various programs and interventions. A critical aspect of this component will be to cost out the various
labor and technical inputs required to implement and operate each of the prevention programs’
operations and interventions, both to provide a basis for estimating the cost-benefit and costeffectiveness of the various prevention activities and to provide a roadmap to others seeking to
implement similar programs.

The results of the analyses performed under Components 2-5 of this research will be integrated with
one another in the sixth study component to provide a global synthesis of the various programs’
operations and impacts. This analysis will include both formal cost-benefit and cost-effectiveness
analyses and projections of savings that could be achieved through national dissemination of programs.

CMS Center for Medicare and Medicaid Innovation Initiatives
In addition to the ongoing evaluation work to evaluate existing community-based wellness and
prevention programs, CMS is also testing a variety of new payment and service delivery models at the
Center for Medicare and Medicaid Innovation (Innovation Center). Some of these models include
community-based wellness and prevention activities, such as the Community-Based Care Transitions
Program123, Health Care Innovation Awards124, and the State Innovation Models Initiative.125

The Community-Based Care Transitions Program focuses on improving care transitions and requires
the participation of community-based organizations to help improve quality of care for high-risk
Medicare beneficiaries. Under this program, the community-based organizations, or acute care
hospitals that partner with community-based organizations, provide care transition services across the
continuum of care, which may include patient-centered self-management support specific to the
beneficiary’s condition and comprehensive medication review and management.

Examples of Health Care Innovation Awards focusing on community-based prevention efforts
include cooperative agreements with the National Council of Young Men's Christian Associations of the
United States of America (YMCA) and Finity Communications, Inc. YMCA received a Health Care
Innovation Award for a national diabetes prevention lifestyle change program to prevent the
progression of pre-diabetes to diabetes at community centers across the country. Finity
Communications received a Health Care Innovation Award to develop health information technology to
track and monitor over 120,000 at-risk patients, create a participant engagement program, develop
integrated health profiles and care management plans, and evaluate and reassess treatment on a
continuing basis.

Examples of community-based wellness and prevention activities under the State Innovation Models
program include initiatives in Arkansas and Minnesota. Under the model, Arkansas will partner with
CMS to test a sustainable, patient-centered health care system. Under provisions of the plan, by 2016, a
majority of Arkansans will have access to a patient-centered medical home, which will provide
comprehensive, team-based care with a focus on chronic care management and preventive services.
Under the State Innovation Models, CMS is also partnering with the State of Minnesota to better
integrate care and services for the whole person across the continuum of care. The Minnesota model
for health system transformation will emphasize community health, preventive services, behavioral
health, and other support services.

Conclusion: Ongoing Efforts to Promote Wellness and Prevention
The Department of Health and Human Services (HHS), through CMS and other agencies within the
Department, will continue to help build the evidence base establishing the effectiveness of wellness and
prevention programs in reducing healthcare utilization and costs, through both the ongoing research
activities highlighted in this report and future research and evaluation work. Critical aspects of this

research and development work will be to both further develop a business case for direct financing of
these programs and to devise and test a viable payment model for community-based wellness and
prevention services that will support a healthy ecosystem of programs and providers. In conclusion, HHS
recommends maintaining existing support for community-based wellness and prevention activities,
consistent with the emphasis on bolstering effective prevention in the President’s FY2014 budget, while
HHS, CMS, and other public and private partners work to fill the gaps in the evidence through additional
studies and pilot programs. Community-based wellness and prevention programs currently depend on
limited grant dollars from various Federal funding streams, and thus their reach is limited. Designing and
implementing direct payment mechanisms for these programs and incentives for other healthcare
stakeholders, including managed care plans and health systems participating in shared savings
programs, to partner with and finance programs could substantially increase the number of Americans
that can benefit. Research to date indicates that these programs have the potential to improve health
outcomes for Medicare beneficiaries and reduce costs. More research, development, and
implementation work however is needed before these benefits can be fully leveraged in the healthcare
system.

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File Type	application/pdf
Author	BENJAMIN HOWELL
File Modified	2013-11-29
File Created	2013-11-29