Obesity Prevention Inside and Outside the Doctor's Office
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- Outdated regulations and billing systems have constrained insurers from paying for programs that are not directly delivered by doctors and licensed medical providers,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
- 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
- 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.
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.
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.