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New approaches and unique partnerships take on childhood obesity

There is little doubt that healthcare policy-makers and providers understand the growing threat that obesity poses to the nation’s health. Numerous studies point out that healthcare costs are roughly 30% higher in overweight individuals, and excess pounds are a key risk factor for many chronic diseases including diabetes, hypertension, cardiovascular disease, and some cancers.

Despite the compelling data, however, payers have been reluctant to take on obesity with funding or interventions because of the scant evidence showing any treatment strategy—short of surgical intervention—would succeed. Fortunately though, a few pioneering organizations have begun to develop the kind of comprehensive approach that many experts maintain is essential to fighting a stubborn problem that requires fundamental alterations in lifestyle.

In fact, given that preventing obesity or excess weight offers tremendous advantages over the long term, a number of organizations are now attempting to tackle the issue in children. Although working with the pediatric population poses unique challenges, many experts believe that addressing the problem at this early stage offers the best chance of achieving meaningful behavior change.

Data prompt action

Armed with data showing that one-third of its covered pediatric population is overweight or at risk for becoming overweight, BlueCross and BlueShield of North Carolina (BCBSNC) has unveiled a pilot program that it hopes will provide families and children with the information and resources they need to move toward healthier eating habits, higher activity levels, and more appropriate body mass indexes.

The approach is modeled after BCBSNC’s Healthy Lifestyle’s ChoicesTM Program for adult members, which was launched in 2004. The adult program incorporated new tools for providers to discuss weight management with patients, six nutritional therapy visits per year for patients, and mail-based/online program materials for patients. Patient-reported data suggest that the multipronged design is effective. According to surveys conducted before program implementation and at six months following enrollment,

  • 47% of participants who indicated that they wanted to lose weight lost an average of 9.5 lbs
  • 83% of participants with either stage 1 hypertension or prehypertension moved to a lower-severity hypertension category
  • 46% of participants reported an increase in days of exercise
  • 90% of participants reported being satisfied or very satisfied with the program

    More rigorous measurement of clinical and financial outcomes is planned, but the early data were enough to convince BCBSNC that a pediatric program equipped with the same types of education and interventions—modified as appropriate for families and children—made good sense.

    Program begins with education

    Beginning in January, the first of 500–700 families will be invited to participate in the pilot effort. These will include the families of children who have been diagnosed with asthma or diabetes as well as those who have expressed interest via survey in participating in the program. These families will be invited to complete an enrollment survey that enables program administrators to collect baseline data for later use to gauge participants’ progress.

    Families that complete and return the survey will then receive a series of educational mailings designed to help families make appropriate changes in their nutritional habits and look at healthy ways to increase physical activity. For example, every family that returns the survey will receive a “health organizer” that includes food and activity trackers, guidance on how to use them, and information on how to communicate effectively with providers.

    “Subsequently, in the second mailing, we will get more specific about physical activity and nutrition,” says Dawn Porter, MPH, the program innovation manager at BCBSNC. Further, recognizing that there are vast differences between toddlers and 16-year-olds, Porter explains that the materials have been designed for three age groupings: two to four-year-olds, five- to 11-year-olds, and 12–17-year-olds.

    A third mailing, which is also organized by age group, will include additional information and tools focused on nutrition and physical activity. This mailing will be followed by an evaluation survey for the family to complete, offering their insights on the effectiveness of the program.

    In addition, families will have the option to work with a telephonic health coach. “The health coach will assess their readiness to change and what the person’s needs are in order to go to the next step,” says Porter. “And then [he or she] will provide ongoing support—as much or as little support as the family needs, whether that involves just one or two phone calls or several more intensive calls.”

    This is one area in which the pediatric program differs from the adult program, because the health coach will often be working with a parent as opposed to the child or some combination of the two. “It is hard to have a template for everybody because it is going to be different, case by case, depending on what the complicating issues may be,” says Porter, adding that the health coaches are all registered nurses, but there are also nutritionists on staff for consultation as needed.

    Additionally, although pediatricians are not involved with the health coaches or the program materials, they receive the same types of benefits and materials that are incorporated into the Healthy Lifestyle Changes program for adults. These include

  • physician toolkits that include support tools and guidance that clinicians can use to address issues related to weight management in their practice
  • the ability to refer patients to up to six visits per year with a nutritionist
  • reimbursement for an office visit related to the diagnosis of obesity

    The pediatric program is just beginning its pilot phase, but Porter emphasizes that BCBSNC plans to move quickly to evaluate the program, make any needed changes, and make it available to the health plan’s larger population as early as 2008.

    PHS designs community-based program

    Also shifting into high gear this month is a unique effort in Arkansas. The state is working with New York City–based Pfizer Health Solutions (PHS) on a community-based initiative that developers hope will show promise in reversing, or at least slowing down, the escalating incidence of obesity and its associated costs. Statistics from the Centers for Disease Control and Prevention suggest that obesity rates are particularly high in a handful of states including Arkansas, and Governor Mike Huckabee—who has publicly dropped more than 110 lbs through difficult lifestyle changes—has made tackling the problem a top priority of the state.

    The approach, dubbed “Balance it Out: Arkansas,” was designed by PHS, but will be implemented in partnership with various state agencies, including Medicaid and an advocacy group called Arkansas Advocates for Children and Families. “We will work first through the school systems and then very quickly thereafter through the families to not only prevent disease, but also to help educate and work with those who have disease today so they don’t exacerbate and develop more complications down the road,” says John Sory, vice president of PHS.

    The effort began in late 2006 with PHS conducting a series of health screenings with Arkansas’ Department of Education to gain insight about the underlying risk factors for obesity and to identify individuals at risk so they can be brought into the health system for intervention. However, the larger effort begins in January and is concentrated on children and families within three primary school districts.

    Program administrators are conducting both school- and community-based health screenings and behavior assessments so more intensive interventions can be directed toward at-risk families. “For those who need more support—we estimate about 300 Medicaid families with chronic illnesses—they will receive not only prevention and wellness education, but also health coaching to really work on their chronic care needs,” says Sory.

    The program is designed to curb obesity, but Sory says the conversation with families is always focused on what steps they can take to improve their overall health. “Then you begin to tailor the intervention specifically to the family environment and the individual,” he says. “These are three very distinct communities in Arkansas, so like any good care management program, the interventions are going to be specific to the person, making sure that we speak to people in their language.”

    Sory underscores the point that the program is community-based—involving nurses, care managers, health coaches, and educational materials that are all supplied through Arkansas. “We are working with partners there who are on the ground. These are community health workers who understand how to go into a person’s home, identify local resources, and help make them see and understand the steps that they can take because the [health workers] are right there with the person,” he says.

    For the time being, the Arkansas program is a three-year initiative limited to three districts, but PHS hopes to produce positive interim results within the year. Sory anticipates that the approach will be expanded to include the entire state. “One of the reasons Medicaid is our partner here is we have claims information that comes through the Medicaid system, so for those patients whose medical costs are covered by Medicaid, we will be able to track their claims information and see if this intervention actually helped to improve their health and reduce their overall costs,” says Sory. “We believe strongly that the total cost will be reduced and that risk will be reduced, and access to that claims information will really be able to tell the story.”