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.
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
- 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.
- Transforming Health By Developing an Accountable Care Community. J. Janosky. Austen BioInnovation Institute in Akron
- Total Health: Public Health and Healthcare in Action Case Study. T. Norris. Kaiser Permanente
- Hospital Community Benefits after the ACA: Present Posture, Future Challenges. The Hilltop Institute Hospital Community Benefit Program
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).