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A Health Plan’s Active Measures to Curb the Disease

Overweight and obesity affect all of us, whether it is a personal struggle or trying to support family and friends. Despite evidence that obesity rates in children continue to rise, many clinicians and payers are not equipped to address this issue with their patients and members. This article will explore the financial and individual health costs of obesity and explore an innovative approach one Medicaid health plan is using to impact this condition.

National data from the 2003 Survey of Children’s Health shows that 31 percent of children are overweight or obese. More alarming, 40 percent of children on public insurance are overweight or obese. The numbers are worse for adults: 65 percent of American adults are overweight or obese (NHANES 1999-2002).

Defining overweight and obesity is different for adults and children. For adults, body mass index (BMI) determines their weight category. However, for children (2-20 years old) BMI, gender, and age are considered when determining their weight category. This information is plotted on a growth chart to determine their BMI percentile. (See Chart 1 on the next page.)

It is important to remember that BMI is a screening tool. Some individuals with an elevated BMI have increased muscle mass. When treating female adolescents, for example, it is especially imperative to monitor their BMI trend. During growth periods, girls will gain weight before they grow taller, which presents as elevated BMI. Without monitoring BMI trends, overweight or obesity may be misdiagnosed. Screening for overweight and obesity risk factors is also helpful when evaluating weight trends, especially during critical growth periods of adolescents.

Pediatric obesity has been described as a family problem that requires a family approach for sustainable success. There has been much research on risk factors for pediatric obesity. Expert committee recommendations include screening for obesity risk factors at least annually. Many providers choose to include this screening in well child exams. Recommendations for reducing risk factors of pediatric overweight and obesity include:

• Limiting consumption of sugar-sweetened beverages (juice, soda, sweetened milk, etc.).
• Consuming recommended quantities of fruits and vegetables. (Currently, USDA recommends nine servings/day. Many programs recommend starting at five servings/day.)
• Limit screen time (TV, video games, computer) to two hours/day or less.
• Eat breakfast daily.
• Consume family meals at home.
• Be active at least 60 minutes/day.

After screening for risk factors, the most effective treatment method is to help the family select one area to focus on and set a goal to make a behavior change in that area. Follow up is recommended at least every three to six months. Many providers find greater success when they let the family choose their goal and follow-up schedule.

The Cost of Obesity

It is estimated that Americans spent $147 billion on obesity-related medical costs in 2006. Per capita, obese adults spend 42 percent more ($1,429) on medical expenses than their normal-weight peers. In 1998 the percent difference in per capita medical spending compared to normal weight adults was 37 percent. The increasing cost and prevalence of obesity paint a grim picture of the viability of the health care system.

Elevated BMI is linked to increased risk for co-morbidities such as diabetes. Pediatric diabetes and pre-diabetes are increasingly concerning as a result of the increasing prevalence of overweight and obesity. The prevalence of pediatric type 2 diabetes is relatively low and more often found in older youth. However, the incidence of type 2 diabetes is increasing in the pediatric population, according to recent data.

The American Diabetes Association has defined pediatric screening criteria as the following: Children should be screened for elevated fasting plasma glucose (FPG) at 10 years old or at the onset of puberty if they have a BMI in the 95th percentile or greater, or a BMI  in the 85-94 percentile with at least two risk factors. Diabetes pediatric screening in the at-risk population should be done biannually. 
Risk factors include:

• Family history of type 2 diabetes in first or second-degree relative.
• Race/ethnicity (e.g., Native American, African American, Latino, Asian American, and Pacific Islander).
• Signs of insulin resistance or conditions associated with insulin resistance (e.g., acanthosis nigricans, hypertension, dyslipidemia or PCOS).
• Maternal history of diabetes or GDM. (See chart 2.)

Promoting Prevention and Treatment: A Health Plan’s Role

Children’s Mercy Family Health Partners (CMFHP) is a not-for-profit safety net health plan owned by Children’s Mercy Hospitals and Clinics. CMFHP provides health insurance to children and adults eligible for Medicaid or State Children’s Health Insurance Plan in Kansas and Missouri. Like many health plans, CMFHP is committed to investing in the communities it serves and improving the quality, access and efficiency of health care within those communities. Eighty percent of members on the plan are children.

When community providers expressed a lack of knowledge in treating pediatric obesity and a desire to improve in this area, CMFHP embarked on a plan to provide physician education and support to members in making healthy lifestyle changes. The Healthy Lifestyles Program (HeLP) was implemented in community practices in 2007. To date, 46 pediatric and family medicine practices have completed the program.

Through empowering the provider and the member, the ultimate goals are increased quality of life, improved quality of care, and improved self-management of chronic diseases. The partnership between the provider, member and health plan is key for inducing sustainable behavior change in the member.  Reinforcement and empowerment can happen at either level or simultaneously as the member works with the provider or health coach through the health plan.

The physician education component consists of didactic modules taught in the clinic setting to providers and their staff. CMFHP’s goal for providers is to empower them to diagnose, treat and prevent childhood obesity. Topics covered include:

• Diagnosing overweight and obesity.
• Motivational interviewing strategies.
• Teaching healthy lifestyle topics.
• Prevention strategies for obesity.

Shadow time is also offered where the educator works side by side with staff and providers to demonstrate and reinforce teaching methods using motivational interviewing strategies to support behavior change in patients. Each practice receives a toolbox filled with healthy lifestyles handouts. CMFHP also provides a screening tool, Health Habits Assessment, which can be used to identify behaviors linked to pediatric obesity. The Health Habits Assessment is designed for prevention and intervention. However, most practices initially use it for children with a BMI in the 85th percentile or greater. All Healthy Lifestyle Program materials can be accessed at www.fhp.org/help.

Once the clinic has completed the program, CMFHP offers an additional $25 reimbursement each time they provide healthy lifestyles education to members.  Initially, additional reimbursement is a strong motivator for practices to complete the education. However, many practices do not bill the health plan for education despite documented education and reminders regarding the availability of reimbursement.

CMFHP educators complete pre-program and semiannual chart reviews at each participating clinic to track the clinic’s progress. The reviews measure:

• BMI and BMI percentile.
• Diagnosis of overweight and obesity.
• Health habits assessment completed for well child visits.
• Documentation of Healthy Lifestyles Education and follow up plan for overweight and obese patients.

The results of the reviews are shared with the clinics at biannual follow-up visits. By going back into each clinic twice a year, the staff and providers receive positive reinforcement for the behavior changes they have made to address pediatric obesity. It also provides a platform for the clinic to decide what additional changes they want to make to improve their clinic flow, education techniques or patient outcomes.

Health coaching is offered for members who require additional education or resources to implement a healthy lifestyle. Health coaches have clinical backgrounds and extensive training in motivational interviewing techniques. They are certified well coaches through the American College of Sports Medicine. Health coaches receive referrals from providers, care managers and members.

If the member agrees to enter into a health coaching partnership, the coach will meet them telephonically or face-to-face in their clinic, home or a community setting. HeLP health coaches provide services that meet the level of need and motivation of the member. Health coaching relationships typically last between three months to a year. Health coaches send quarterly updates to the member’s primary care provider to update them on the member’s progress. This has proven to be an extremely effective way to partner with providers and members to improve their health outcomes.

The ultimate goal of health coaching is for members to be able to sustain behavior change and continue to make additional behavior changes toward a healthier lifestyle independently. One member described the health coaching process as “the push to get going.” The member’s parent thought that the support from CMFHP’s Health Coach motivated her child to make changes because “he feels like someone really cares.”

Although CMFHP will not likely see a decrease in utilization as an outcome of this program due to serving primarily pediatric members, CMFHP understands that supporting efforts to reduce childhood obesity will improve the quality of life of members, minimize co-morbidities and ultimately decrease utilization of health care resources for preventable conditions. If we all take steps toward preventive strategies, over time we can change the long-term health outcomes of our members and the communities they live in.

Beth Wilkes, RD/LD, is a Registered Dietitian and Education Coordinator for the Healthy Lifestyles Program at Children’s Mercy Family Health Partners, specializing in obesity education. Beth’s mission is to promote healthy lifestyles and prevent chronic diseases associated with obesity. ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )