Obesity Prevention Inside and Outside the Doctor's Office

Americans cannot achieve health goals and effectively follow their doctor's advice without support in their neighborhoods, workplaces and schools. The Affordable Care Act provides new opportunities to expand coverage for proven community-based programs.

Current Status

Many Americans only have doctor's appointments once or twice a year. The rest of the year they are often on their own to try to find ways to follow their doctor's advice in their daily lives. A growing body of evidence shows that Americans cannot achieve health goals — including eating healthier, increasing physical activity and managing obesity and related health problems — without support in their neighborhoods, workplaces and schools.1

"Health professionals are adept at treating a vast range of diseases, injuries and other medical conditions. But their training and healthcare delivery incentives do not emphasize addressing the root causes of health problems that occur outside of the healthcare system — factors such as education, access to healthy food, job opportunities, safe housing, environment and toxic stress — that fundamentally shape how long or well people live," according to a report by the RWJF Commission to Build a Healthier America.2

For instance, individuals whose doctors counsel them that they are at risk for health problems related to obesity, such as prediabetes, are often left to try to follow their doctors' advice on their own in their daily lives where nutritious foods are costly and can be hard to access, and it is hard to find time and convenient, safe places for physical activity. Connecting healthcare inside the doctor's office with community-based health and other social service programs and resources can provide ongoing support, education and opportunities to improve health where people live, learn, work and play.

Approaches can range from doctors providing direction and information for patients, such as writing prescriptions for healthy, active living, including good nutrition and physical activity to educating families about the importance of healthy eating habits, regular activity and sleep at every well-child visit to referring patients to resources or health management programs in their community, such as at their local YMCA or nutrition counseling support.

These approaches, however, are often not taken because the U.S. health system has traditionally focused on covering activities that occur directly within a healthcare setting and are aimed at helping someone who is sick get well. The old, disjointed fee-for-service model and siloed systems have dis-incentivized coordinated care, and have been ineffective at preventing chronic disease and reducing healthcare costs.3

For example, outdated regulations and billing practices have constrained insurers from paying for programs that are not directly delivered by doctors and other licensed medical providers, such as community health workers and obesity counselors, or that help support the health of an entire neighborhood rather than focusing on a specific individual who is tied to a specific diagnosis and billing code. Currently, nearly half of all Americans do not access many commonly recommended preventive services, which can include obesity and nutrition education or prediabetes and blood pressure screenings.4 Some private insurers cover some evidence-based community prevention programs, such as the Diabetes Prevention Program (DPP), but these efforts are limited and not well known or understood in the provider community.

In response, many public and private insurers are increasingly expanding coverage for proven community-based programs to achieve better results for improving health and reducing obesity rates. One factor that contributed to this was the enactment of the Affordable Care Act (ACA), which has helped create incentives and mechanisms for new models to improve focus on a coordinated continuum of care that begins with a focus on prevention - inside and outside the doctor's office. Several provisions that help support the prevention and control of obesity and related diseases include:

  • Requiring new plans (private, self-insurers and Medicare) to cover screening and counseling for obesity with no cost to the patient through co-payments, co-insurance or deductibles.
  • Providing incentives to encourage state Medicaid programs to cover more preventive services. In 2013, the Centers for Medicare and Medicaid Services (CMS) issued a rule that would give states greater flexibility in what types of providers could provide recommended preventive services, such as for obesity education and counseling activities.
  • Integrating public health and healthcare via new approaches, such as Accountable Care Organizations (ACOs) and global payment and "wellness trust" models. Coordination efforts can increase the focus on improving the overall health of the insurance pool and offer strong incentives to providers to deliver the most effective care strategies possible, and to maximize effectiveness, including community-based prevention programs and services to provide support to patients to be able to follow doctor's advice in their daily lives. ACOs are groups of healthcare providers that prioritize coordinated care and quality goals to achieve improved health for their patients which reduce costs.5
  • Updating tax-exempt hospitals' community benefit requirement by requiring a community health needs assessment and implementation strategy in order to maintain tax-exempt status. New U.S. Treasury Regulations on community benefit administered by the Internal Revenue Service could address whether a community benefit implementation strategy may include activities related to obesity prevention.

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

  • To maximize effectiveness and better help patients follow their doctors' advice, providers and insurers, including state Medicaid programs, can use an integrated approach that focuses on community-based prevention and public health. 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.6 This initiative also led to a decrease in diabetes-related emergency department visits.
  • Reviews of the CDC-led National Diabetes Prevention Program, an evidence-based lifestyle change program, show that it can help people cut their risk of developing type 2 diabetes in half. One study found that making modest behavior changes helped program participants lose 5 percent to 7 percent of their body weight (10 to 14 pounds for a 200-pound person). Participants work with a lifestyle coach in a group setting for one year. The program includes 16 core sessions (usually one per week) and six post-core sessions (one per month).7
  • 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 (65 and older) through a combination of direct medical care and community-based prevention programs and policies.8
  • There are approximately 2,900 nonprofit hospitals in the United States and financial benefits to these hospitals from federal, state and local tax preference was estimated to be worth $12.6 billion annually in 2002. Some of this funding can be used to promote population health improvement that extends beyond hospital walls and in to the community.9

Policy Recommendations

  • Encourage and incentivize new health system approaches, such as ACOs, to incorporate community obesity prevention programs to help them be successful in improving health and lowering costs.
  • Government and private insurers should implement policies and programs to increase the use and improved integration of clinical and community-based preventive services, particularly among communities where services are underutilized.
  • Medicaid should provide additional technical assistance and education to increase uptake in use of the new regulations for preventive services that allow states to reimburse a broader array of health providers and entities.
  • Medicaid should identify and disseminate community prevention best practices by Medicaid programs, including Medicaid Managed Care Organizations.
  • Broader healthcare delivery reform efforts, such as the CMS Innovation Center-funded State Innovation Models, should ensure that community-based prevention to control obesity costs are included.
  • The U.S. Department of Treasury should continue to clarify the use of community benefit dollars by nonprofit hospitals to improve population health.

Examples of Improving the Clinical-Community Continuum of Care

  • A number of providers have been using the Chronic Disease Self-Management Program (also known as Better Choices, Better Health), which helps doctors connect patients to community-based health workshops. Referred patients have an extended opportunity during a series of workshops to learn about effective exercise, good nutrition, communicating with health professionals and families about needs and other strategies. The program, which is based on an evidence-based model developed at Stanford University, has shown results in improved health outcomes, reduced utilization of healthcare and increase use of self-management techniques.10
  • A number of health systems and providers are also creating referral systems to connect patients with community-support programs. For example:
    • The Division of Health Promotion and Chronic Disease Prevention in the Iowa Department of Health has partnered with the Iowa Primary Care Association (IPCA) and local boards of health to create a Community Referral Project, so doctors have access and information about programs in their communities and can refer and match patients to those resources.
    • The Boston Medical Center and Boston Bikes have partnered to create a Prescribe-a-Bike program. Doctors and nurses can write prescriptions for the local bike share program, New Balance Hubway, that allow their patients to rent a bike for $5 to $80 less than the regular charge. The program helps support health, equity and access to affordable transportation for more lower-income Boston residents.11
  • Integrating clinical care with community-based programs is a focus of HHS's Million Hearts®, a national initiative that aims to prevent 1 million heart attacks and strokes by 2017. A key objective is reducing uncontrolled high blood pressure — which obesity can contribute to — by supporting improved nutrition, increased physical activity, integrated medical care and other strategies.

Additional Resources

Commentary

Connecting Diabetes Care from the Clinic to the Community

by Johnna Reed, vice president, business development, Bon Secours Health System

In 2011, the Bon Secours St. Francis Health System in Greenville, South Carolina created a Diabetes Integrated Practice Unit (IPU) to foster a new environment that improves the health of patients with, or at risk of developing, type 2 diabetes.

Since most of the factors that influence health exist outside of the doctor's office, we've learned the importance of connecting our patients to resources in their communities. This helps them in their daily lives and better supports their ongoing medical care.

The goal of the Diabetes IPU is to connect patients with community resources that can help benefit their health through improved nutrition, increased physical activity and support to manage their condition. The program also ensures that physicians and other caregivers have sufficient time to focus on their patient's needed care. This added time also allows providers and patients to work together to understand how obesity, prediabetes and diabetes can affect health and daily life and to set goals that work for each patient's unique circumstances.

The program also emphasizes the importance of prevention, to avoid developing additional health risks or problems in the future. We help prediabetics avoid the progression to diabetes and help diabetics avoid developing additional conditions.

The program is designed around a network of community and clinical resources, providers and technology. While the program hub is at St. Francis Millennium, the programs themselves are delivered where patients are — at work, home, and throughout the community.

The Diabetes IPU includes an extensive coordinated team of care givers, including a primary care physician, ophthalmology, cardiology, nephrology and podiatry services, and an endocrinologist who consults with the primary care physicians regarding innovations in diabetes care and assists with the care of patients facing particular medical challenges.

The medical care is managed by a registered nurse care coordinator. It's also important to note that our care team includes a psychologist, social worker, registered dietician, diabetes educator, pharmacist, and an exercise physiologist to help patients get to a healthy weight. It is not just a clinical-centered approach — it's a total community health approach.

How the IPU Works

A patient's initial visit with the diabetes team begins with a fasting blood draw to determine blood glucose, HbA1c, cholesterol, and other relevant lab values. Following the blood draw, patients are provided a diabetes?appropriate breakfast. Next, the patient is asked to participate in a small group discussion about issues they have in dealing with diabetes, led by a diabetes educator and nurse. Facilitators are continually surprised at the level of engagement in these groups — patients tend to share readily and openly.

The group discussion not only introduces patients to others who share similar health and lifestyle challenges — including being overweight or obese and struggling to engage in physical activity and eat healthy — but also enables the nurse?facilitator to determine the best match for the patient with individual caregivers. After the discussion, the entire group receives an introduction to exercise with an exercise physiologist who provides an easy, low stress overview of exercise options.

In the course of this first morning, the patient sees the primary physician, psychologist, diabetes educator, and registered dietitian. Each patient also receives a retinal scan and foot exam. Finally, patients are served a diabetes-friendly lunch with the clinical team present to answer questions about the food or anything else related to diabetes.

However, our work doesn't stop when the patient leaves the clinic. Because the needs of patients with type 2 diabetes require support and resources in the community, our diabetes program provides worksite and home services. After their visit, a team member meets with patients in their home to assess the support network available and to identify areas where patients will face particular challenges. Our teams then work with family and employers to inform and facilitate improvements in the home and work environments and sometimes in the local grocery stores and pharmacies.

Often, the care team conducts a thorough workplace assessment to determine how each patient's work setting impacts his or her health. For example, if there is no access to healthy foods, we work with the employer to improve the food options at a worksite. It might be surprising that employers have been incredibly supportive, however they fully understand the importance of having a healthy, happy, and productive workforce.

From the patient perspective, the most important measure is improvement in the ability to live (i.e., to work, participate in family life, attend important events, and enjoy daily activities). With each patient, the care team identifies capabilities that are motivating and meaningful and track their improvement. While these measures require greater effort to quantify, they are often the drivers of people's long?term commitment to lifestyle change and health.

Patients have responded incredibly well. A recent patient entered the program hoping to improve his health, get off regular insulin and lose about 60 lbs. With the diabetes team's help, he understood the need to deny barriers and stressors, such as fast food and sugary drinks, and was very successful.

Through the program, he increased glucose monitoring from to three to four times daily; went from not exercising at all to exercising four times a week at the facility we recommended to him; attended all prescribed education opportunities and shared medical group appointments; and engaged often with our dietician. While he hasn't yet reached all his top-level goals, he lost more than 45 lbs., reduced his BMI from 33.7 to 27.5 and his waist size from 44 to 36, and no longer needs mealtime insulin coverage.

The most successful patients are the ones who receive a continuum of care from the clinic to their community. Our model improves a physician's capability by bringing all of the necessary community resources together. Research shows that what happens outside the doctor's office can have a major impact — either positive or negative — on our health. That's why we began the Diabetes IPU model and why we'll continue using it to fight obesity and improve the care of individuals with prediabetes or diabetes.

Notes

1 Robert Wood Johnson Foundation. Time to Act: Investing in the Health of Our Children and Communities. Princeton, NJ: RWJF, 2014 (accessed May 2014).

2 Robert Wood Johnson Foundation. Time to Act: Investing in the Health of Our Children and Communities. Princeton, NJ: RWJF, 2014 (accessed May 2014).

3 State Health Care Cost Containment Commission. Cracking the Code on Health Care Costs. Charlottesville, VA: Miller Center, University of Virginia, 2014 (accessed May 2014).

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

5 Accountable Care Organizations (ACO). In Centers for Medicare and Medicaid Services (accessed May 2014).

6 Healthier by Design: Creating Accountable Care Communities. In Accountable Care Community (accessed May 2014).

7 National Diabetes Prevention Program. In Centers for Disease Control and Prevention (accessed May 2014).

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

9 The Hilltop Institute. What are Hospital Community Benefits? 2013 (accessed May 2014).

10 Chronic Disease Self-Management Program (Better Choices, Better Health Workshop). In Stanford Patient Education Resource Center (accessed May 2014).

11 City of Boston, Boston Bikes. State of the Hub: Boston Bikes 2013 Update Presented March 2014 (accessed April 2014).