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August 24, 2010

Centers for Medicare and Medicaid Services
Department of Health and Human Services
Re: CMS – 1503-P
P.O. Box 8013
Baltimore, MD 21244

Submitted Electronically: http://regulations.gov

Re: Federal Register 40039-40718, 42 CFR 405, 409, et. al. (July 13, 2010)

To Whom It May Concern:

The seven organizational member advocacy workgroup representing the National Falls FreeTM Coalition appreciates the opportunity to provide comments on the proposed rule Payment Policies Under the Physician Fee Schedule, of the Department of Health and Human Services Centers for Medicare & Medicaid Services, in reference to regulation CMS-1503-P.

We applaud the Affordable Care Act’s creation of expanded Medicare coverage under Part B to include an Annual Wellness Visit, Providing Personalized Prevention Plan Services. In order to ensure that older adults enjoy the best possible health, it is essential to offer a yearly wellness visit as a covered medical service. With the rise of preventable chronic disease and falls-related injuries among older adults, an annual preventative medical visit is critical to the identification of risk factors for chronic disease and falls—and for referral to health and community services that can provide interventions to diminish or eliminate these risk factors.

One third of adults over age 65 fall each year. Among those older adults who fell in 2007, nearly 2.1 million were treated in hospital emergency departments and approximately 550,000 were hospitalized after treatment. In 2008, more than 18,000 older adults died as a direct result from injuries related to unintentional falls. As the population ages and the number of older adults at risk increases, it becomes imperative to provide evidence-based, fall risk reduction and prevention services. In 2000, direct medical costs for fall-related injuries for adults aged 65 and older totaled more than $19 billion. The financial toll for older adult falls is expected to increase as the population ages, and may reach $54.9 billion by 2020 (adjusted to 2007 dollars).

Evidence-based programs that are multifactorial assist in reducing falls, fall risk, falls related injuries, and the escalating costs. These programs facilitate cost-effective interventions, such as comprehensive clinical assessments, exercise programs to improve balance and gait, management of medications, correction of vision, and the reduction of home hazards. Simple screening for falls history or gait and balance issues as part of the wellness visit protocol can begin the process leading to actual reduction in falls incidence.

The Coalition is pleased that the Annual Wellness Visit includes the establishment of, or an update to, the individual’s medical and family history. However, absent from the law and proposed regulation concerning the benefit’s definition of medical and family history is a specific history of falls. The Coalition recommends that the regulations explicate that falls history is a critical component ensuring that the Wellness Visit is an effective benefit for the elderly population. The recently published American Geriatrics Society/British Geriatrics Society Clinical Practice Guidelines specifies that all older individuals should be asked if they have fallen in the past year. Falls in the recent past are the best predictor of risk for future falls. Older adults who have fallen are two to three times more likely to fall again in the near future. Reference in the regulations would help to promote understanding that inclusion of this key screening question is crucial to achieving the goal of the visit: improving long term health and well-being, and reducing the risk of falling and injury associated costs.

For beneficiaries who have not previously fallen, screening should consist of an assessment of gait and balance. Patients who have fallen or who have a gait or balance problem are at higher risk of future falls. The National Falls FreeTM Coalition members urge CMS to adopt the AGS/BGS guidelines for assessing falls risk, its management and subsequent referral to appropriate clinical and/or other services to enhance the clinical management of identified risks. The undersigned urge CMS to use these guidelines to clarify components of the wellness visit including the terms falls risk and home safety.

The Coalition also suggests that more information should be provided in the regulations about the expectation that the wellness visit is to be viewed as part of a comprehensive approach that guides and monitors follow-up to risk management through appropriate interventions. The regulation should emphasize that referrals and collaboration with needed clinical and/or other services is a critical component of an effective approach to prevention of disease and disability.

In addition to the clinical services that address fall risks, gait and balance disorders, and other clinical risk factors, there are evidence-based community programs serving older adults that should be considered as part of the referral system for long term management of falls risk and falls history. CDC National Center for Injury Prevention and Control recognizes fourteen community-based programs, three of which are being promoted in the US including Tai Chi: Moving for Better Balance Otego, and Stepping On. In 2009, CDC conducted an economic analysis of three evidence-based fall prevention programs (the Otago Exercise Programme, Stepping On, and Tai Chi: Moving for Better Balance.) The returns on investment ranged from 70% or $1.70 for every $1.00 invested Otago when delivered to people aged 80+; to 100% or $2.00 for every $1.00 invested in Stepping On; to 160% or $2.60 for every $1.00 invested Tai Chi: Moving for Better Balance, delivered to people aged 65+. In addition, in randomized controlled trials, “A Matter of Balance,” now offered in 34 states, has demonstrated significantly improved falls self-management and self-efficacy outcomes to address the growing problem of fear of falling among older adults; delivered through a peer led model it is proving cost effective. We strongly urge that provider reimbursement be based on initial screening, appropriate clinical referral and referral to evidence-based community programs.

It appears there is no required follow-up in the subsequent years’ visits to inquire on falls history, yet the risk of being seriously injured in a fall increases with age. In 2001, the rate of fall injuries for adults 85 and older was four to five times that of adults aged 65 to 74. In fact, risk factors for falls in the elderly include increasing age. Moreover, people 75 and older who fall are four to five times more likely to be admitted to a long-term care facility for a year or longer. As beneficiaries, age providing an ongoing screen for falls history, gait and balance problems, cognitive issues, and other falls risk factors, becomes more imperative to maintain health status.

As a part of subsequent Wellness Visits, we also recommend that an updated personalized prevention plan include information about which health education, preventive counseling services, or other evidence-based programs individual beneficiaries were referred to, and whether or not they enrolled in and completed these programs. Once again, maintaining a strong link of provider reimbursement to falls risk screening, appropriate clinical referral, and utilization of evidence-based community programs is strongly urged.

Finally, the Safety of Seniors Act of 2007 (Public Law 110-202) was enacted to amend the Public Health Service Act (42 U.S.C. 280b et seq.) to create a national fall prevention education campaign aimed at older adults, their families, and healthcare providers. It is essential that CMS include information on fall prevention in its educational materials to older adults, and that it offer provider training in its online training materials to raise understanding that falls are preventable and that there are effective evidence-based fall prevention practices. Bringing about an increased awareness of the preventative and risk reduction possibilities regarding falls and initiating a dialogue among beneficiaries, their caregivers, and providers is imperative. Providing more direction in these regulations and related educational materials is a critical part of achieving the outcome of reducing falls, improving long term health and well-being, and reducing costs.

Thank you for the opportunity to provide comments on this important regulation.

Respectfully submitted on behalf of the Falls FreeTM Coalition:
American Occupational Therapy Association
American Physical Therapy Association
National Council on Aging
National Safety Council
Rebuilding Together
National Association of RSVP Directors
Home Safety Council

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