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Medicare Preventive Services

Medicare Lifestyle Modification Program Demonstration

Summary of Demonstration

The Centers for Medicare & Medicaid Services (CMS), Center for Beneficiary Choices (CBC) is implementing the Medicare Lifestyle Modification Program Demonstration.

Recent research has suggested that aggressive risk factor reduction may slow, stop, or even reverse the progress of coronary artery disease. Lifestyle modification programs are increasingly becoming an approach to the secondary prevention of coronary disease morbidity. Participation in these programs may lead to improved health outcomes for Medicare beneficiaries with cardiovascular disease and potentially reduce Medicare costs.

The demonstration is designed to test the effectiveness of providing payment for cardiovascular lifestyle modification program services to Medicare beneficiaries age 65 or older with moderate to severe coronary artery disease. The treatment outcomes of Medicare beneficiaries who complete the lifestyle modification program will be compared to those of similar patients who receive more traditional services under the Medicare program.

The demonstration will include two multiple site, cardiovascular lifestyle modification program models that offer a twelve-month, multi-disciplinary, clinical outpatient treatment program. Each lifestyle program model can enroll up to 1800 Medicare Part B eligible beneficiaries who meet the clinical enrollment criteria and voluntarily elect to participate in the demonstration. The two program models selected are:

The Dr. Dean Ornish Program for Reversing Heart Disease® developed by Dr. Dean Ornish and offered through the joint efforts of the Preventive Medicine Research Institute, Sausalito, California and Lifestyle Advantage, Pittsburgh, Pennsylvania; and The Cardiac Wellness Extended Program developed by Dr. Herbert Benson and offered through the Mind/Body Medical Institute Boston, Massachusetts.

All Medicare certified medical facilities licensed to provide either program are eligible to participate as demonstration sites during the demonstration period. The demonstration period began on October 1, 1999, and will provide a multi-year enrollment period ending on February 28, 2005, with payment through February 2006.

Medicare payment is based on a negotiated amount reached with the parent or licensing entity for the multi-site lifestyle modification program and applies to all sites offering that program model. The demonstration sites will receive 80 percent of the total payment amount for their 12-month program for each beneficiary who completes the treatment program.

Demonstration sites providing the Dr. Dean Ornish Program for Reversing Heart Disease® will receive 80% of $5,650 or $4,520. Sites offering the Cardiac Wellness Extended Program will receive 80% of $4,800 or $3,840. The beneficiary is responsible for paying the remaining 20%. A demonstration site may waive the amount due from the beneficiary, but it must do so for all beneficiaries.

Payments to sites will be made on a quarterly basis at 35%, 15%, 15%, and 35% of the total rate, respectively, for each enrolled beneficiary. However, if a beneficiary disenrolls from the program prior to completion, the demonstration site will receive a pro-rated portion of the total payment.

The Delmarva Foundation for Medical Care, Inc., a Medicare Peer Review Organization, has been contracted to provide quality monitoring and review of the treatment provided to Medicare patients enrolled at the demonstration sites.

The Schneider Institute for Health Policy, Brandeis University has been contracted to provide an independent evaluation of the demonstration. The evaluation will focus on a comparison of clinical outcomes of Medicare beneficiaries enrolled in the demonstration with those of a matched-paired control group consisting of Medicare patients with similar demographic characteristics and disease severity. The evaluation will also assess the quality of care delivery and patient satisfaction under the demonstration as well as the potential savings of lifestyle modification treatment services to the Medicare program.