Obesity Prevention Inside and Outside the Doctor's Office

Current Status

Traditionally, care inside the doctor's office and support to help people follow their doctors' advice in their daily lives have operated separately. And, public and private insurers have typically focused on reimbursing activities that happen directly within a healthcare setting.

However, there is growing evidence that Americans cannot achieve health goals and effectively follow their doctors' advice without support in their daily lives – in neighborhoods, workplaces and schools.

The Affordable Care Act calls for increased attention to obesity prevention and control at the doctor's office and provides new opportunities for insurers to expand coverage for proven community-based programs outside the clinical setting.

  • The ACA requires new plans from private and self-insurers and Medicare to cover the most beneficial and cost-effective prevention services without co-payments. This gives doctors increased ability to provide obesity screening and counseling to patients. Incentives are provided to encourage state Medicaid programs to cover more preventive services. However, nearly half of all Americans currently do not access to many commonly recommended preventive services.1
  • Outdated regulations and billing systems have constrained insurers from paying for programs that are not directly delivered by doctors and licensed medical providers, or that help support the health of an entire neighborhood rather than focusing on a specific individual who is tied to a specific billing code. Recently, a few private insurers have begun covering some evidence-based community prevention programs, but these efforts are limited. In addition, in 2013, the Centers for Medicare and Medicaid Services (CMS) took a first step with a proposed rule that would give states greater flexibility in what kinds of prevention programs they cover, such as for obesity education and counseling activities. CMS has not finalized this rule or provided best practices or specific examples to states.

Why Better Integration of Medical Care and Support Where People Live, Learn, Work and Play Matters

Why Better Integration of Medical Care and Support Where People Live, Learn, Work and Play Matters
  • To maximize effectiveness, providers and insurers, including state Medicaid programs, can take an integrated approach to include community-based prevention and public health to provide support for patients to be able to follow doctors' advice in their daily lives. For instance, a new model that created an Affordable Care Community (ACC) in Akron, Ohio, involves a coordinated clinical-community prevention approach and has reduced the average cost per month of care for individuals with type 2 diabetes by more than 10 percent per month over 18 months. A second project, a diabetes self-management program, resulted in estimated program savings of $3,185 per person per year. This initiative also led to a decrease in diabetes-related emergency department visits.
  • Efforts such as the National Diabetes Prevention Program (DPP) that help provide support to allow patients to follow doctors' advice in their daily lives, are showing results in improving health and bringing down costs. Participants in the YMCA's DPP lost an average of 4.8 percent of their body weight, with some participants losing up to 7 percent of body weight. NIH studies have shown this to be sufficient change to prevent the onset of diabetes.
  • The American Heart Association published a review of more than 200 studies and concluded that most cardiovascular disease could be prevented or at least delayed until old age through a combination of direct medical care and community-based prevention programs and policies.2

Policy Recommendations

  • New health system approaches, including Accountable Care Organizations and other approaches to organizing and financing healthcare, must incorporate community obesity-prevention programs to be successful in reaching goals to improve health and lower costs. Accountable Care Organizations are groups of health care providers that prioritize coordinated care and quality goals to achieve overall health for their patients while reducing health care costs.
  • Government and private insurers should implement policies and programs to increase the use of preventive services, particularly among communities where services are underutilized.
  • Medicaid should expand coverage of community prevention programs, including moving forward on regulations to allow states to reimburse a broader array of health providers and entities and pay for additional services.
  • Medicaid should identify and disseminate community prevention best practices by Medicaid programs.
  • Private insurance coverage should incentivize coordinated clinical and community care, and expand coverage of community prevention programs.

Additional Resources

Transforming Health By Developing an Accountable Care Community. J. Janosky. Austen BioInnovation Institute in Akron.

Total Health: Public Health and Health Care in Action Case Study. T. Norris. Kaiser Permanente.

Expert Commentary

Connecting Care Inside and Outside the Doctor's Office in Iowa

By Kala Shipley, Executive Officer, Health Promotion, Division of Health Promotion and Chronic Disease Prevention, Iowa Department of Health

Kala Shipley

"Obesity is already taking a serious health and economic toll on the state."

Right now, 30.4 percent of adults and 13.6 percent of children in Iowa are obese. According to the 2012 F as in Fat report, if things continue on their current course, the state's obesity rates could climb to 54.4 percent by 2030.

Obesity is already taking a serious health and economic toll on the state. Currently, nearly 30 percent of Iowa adults have hypertension and 9.7 percent have diabetes. If we don't take action, in the next 20 years, we could see the number of new cases of type 2 diabetes, heart disease and stroke, hypertension, arthritis, obesity-related cancer and other diseases continue to rise, and obesity-related healthcare costs could grow by 3.7 percent. (see F as in Fat, 2012: How Obesity Threatens America's Future)

We've decided it's time to do things differently. One thing that has never made sense is the disconnect between the care patients receive in the doctor's office and the lack of support there is in communities to be able to follow the doctor's advice in daily life.

This is particularly important for obesity and related health conditions. For instance, a doctor finds a patient has prediabetes. Unfortunately, there is no special pill to prescribe as a cure, but, rather, the prescription is making better decisions about nutrition and being more physically active. To make the connection between the clinical setting and daily life, Iowa's local Community Transformation Grant (CTG) projects are making it easier for people who want to follow the doctor's orders to do so in their community by creating environments that support access to healthy foods and physical activity.

To help connect individuals with community resources, we launched the Iowa Community Referral Project so Iowans will stay healthier longer and delay or avoid serious negative health outcomes.

We've partnered the Iowa Primary Care Association (IPCA) and Local Boards of Health so that doctors will now have access and information about programs in communities, and will be able to refer and match their patients to those resources. As part of our CTG, we are bringing together partners, including medical providers, local departments of public health, community groups and others to identify evidence-based programs and efforts.

Now, doctors in many counties will have the information they need to connect their patients with effective programs. In essence, the prediabetic patient will be able to receive a referral from their doctor to programs in their community that can help them get healthier and potentially avoid developing diabetes. The Community Referral Project connects individuals to the entire spectrum of care — providing patients with better opportunities to follow their doctor's advice, whether it be healthy eating, increased physical activity or something else.

Examples of some types of programs include:

  • The Black Hawk County Board of Health has built a referral system that connects members of the community with healthy choices and better chronic disease self-management. The evidence-based Stanford Chronic Disease Self-Management Program helps manage chronic conditions such as diabetes or prediabetes by empowering individuals to set personalized goals for health improvement. At the Aging and Disability Resource Center serving Iowans in Black Hawk County and the Hawkeye Valley Area, counselors help seniors find practical ways to self-manage their condition, starting with understanding the health, mobility and physical activity levels of individuals and making referrals to community programs such as the Stanford Chronic Disease Self-Management classes, exercise classes, farmer's markets and disability resources.
  • As part of the recently upgraded electronic medical record system in Decatur County, physicians can now give patients an "exercise prescription," which can include information about ways to increase physical activity and connect people with fitness centers and exercise programs.
  • In Polk County, medical clinics, the YMCA Health Living Center and the county health department are working together to connect patients with the Stanford Chronic Disease Self-Management Program. Physicians at Mercy Medical Centers refer patients with chronic health conditions, such as high blood pressure or high cholesterol, to health coaches at the hospital and wellness coaches at the YMCA who work with individuals and hold workshops to improve their health.
  • In Dallas County, the county health department has built a referral system with county Mercy Medical clinics that participate in the Iowa Medicaid Enterprise (IME) Health Home program. The clinics now regularly refer patients to a Health Navigation program run by the county health department, which connects them with local services including housing assistance, food assistance, enrolling in public programs, medication assistance, behavioral health, wellness options and other programs.

One of the objectives of the CTG is to reduce obesity by 5 percent. We believe this project is one important piece in helping to reach that goal. By creating more overt and direct connections between care in the doctor's office with opportunities to be healthier in daily life, we can achieve better results.

Last year's F as in Fat report demonstrated the impact these types of changes can have. If we reduce the average body mass index (BMI) of adults in the state, we could reduce healthcare spending by more than $2 billion in 10 years and $5.7 billion in 20 years, while helping thousands of Iowans from developing preventable diseases.

By better coordinating care for those who have obesity-related illnesses, we can prevent situations from getting worse — for instance, stopping people with pre-diabetes from developing type II diabetes — and save lives and money.

It's time we involve the whole healthcare system in preventing diseases and keeping us all healthier, rather than just treating conditions after they have already happened.

Notes

1 Centers for Disease Control and Prevention. Use of Selected Clinical Preventive Services Among Adults - United States, 2007-2010. MMWR, 61, 2012.

2 Weintrub WS et al. AHA Policy Statement: Value of Primordial and Primary Prevention for Cardiovascular Disease. Circulation, 124: 967-990, 2011.